Variation mat­ters

But its elim­i­na­tion is more crit­i­cal to im­prove out­comes than sav­ing money


One of the most fre­quently trum­peted “truths” in health­care pol­icy re­search is that the sys­tem is larded with waste, per­haps as much as 30% of all spend­ing. The Dart­mouth In­sti­tute for Health Pol­icy & Clin­i­cal Prac­tice, now led by Dr. El­liott Fisher, ini­tially de­vel­oped that in­sight af­ter find­ing wide dis­par­i­ties in Medi­care spend­ing in dif­fer­ent parts of the coun­try. Its Dart­mouth At­las of Health has re­peat­edly found that variation in provider prac­tice pat­terns is driv­ing those spend­ing dif­fer­ences, not the level of ill­ness among pa­tients.

McAllen, Texas, be­came the poster child for overuti­liza­tion af­ter Dr. Atul Gawande painted an un­flat­ter­ing por­trait of the city’s physi­cian and hos­pi­tal prac­tices in a New Yorker mag­a­zine pro­file. The idea even­tu­ally re­ceived the of­fi­cial im­pri­matur of the In­sti­tute of Medicine, which agreed that over­all spend­ing could be slashed by $690 bil­lion a year if ev­ery health­care sys­tem de­liv­ered care with the ef­fi­ciency of the low­est-cost providers.

But last week a re­search team as­so­ci­ated with the Wash­ing­ton-based Cen­ter for Study­ing Health Sys­tem Change launched a frontal as­sault on the Dart­mouth At­las the­sis. Their study, pub­lished in Medi­care Care Re­search and Re­view, found that over­all pop­u­la­tion health, that is, how sick the peo­ple were in dif­fer­ent re­gions of the coun­try or even within a re­gion, ac­counted for as much as 75% to 85% of the dif­fer­ence in spend­ing be­tween high-cost and low-cost ar­eas.

To drive that point home, they looked at di­ag­noses where physi­cians had very lit­tle dis­cre­tion in how they treated pa­tients: hip frac­tures, trau­matic am­pu­ta­tion, heart at­tacks and strokes, for in­stance. They found the high-cost ar­eas had in­ci­dences of those acute events that were 73%, 91%, 84% and 74% higher than low-cost ar­eas, re­spec­tively.

They took their anal­y­sis one step farther by look­ing at end-of-life care, which the Dart­mouth re­searchers have re­peat­edly iden­ti­fied as a ma­jor driver of higher costs in some ar­eas. No, the study ar­gued. Peo­ple in high­cost ar­eas tended to have more chronic con­di­tions as they neared the end of life com­pared to peo­ple in low-cost ar­eas, which meant they were be­ing treated for more ill­nesses and hence were more costly.

The study down­played the role of in­come and poverty in driv­ing health sta­tus and hence spend­ing. But other skep­tics have re­peat­edly made that point in chal­leng­ing the va­lid­ity of the Dart­mouth anal­y­sis. Want to know where high-spend­ing ar­eas are lo­cated? All you have to do is look at the cen­sus tracts where the poor and ill-ed­u­cated are con­cen­trated. They are the ones who en­ter their Medi­care years with mul­ti­ple chronic con­di­tions, and hence wind up cost­ing a lot more as they move to­ward end-of-life care.

The Dart­mouth re­searchers fired back, of course, claim­ing the re­search couldn’t be repli­cated. But they make a big mis­take by not en­gag­ing their crit­ics.

Ev­ery­one un­der­stands there are huge vari­a­tions in prac­tice pat­terns. But those dif­fer­ences are just as likely to ex­ist be­tween doc­tors within a hos­pi­tal or a physi­cian prac­tice as be­tween re­gions of the coun­try. Even the re­searchers be­hind this lat­est study ad­mit vari­a­tions in prac­tice pat­terns drive costs higher. But it is nowhere near the level that jus­ti­fies claims of 30% of health­care spend­ing be­ing wasted.

There’s an im­por­tant les­son in this de­bate for health­care providers. What makes those prac­tice vari­a­tions im­por­tant is not only the waste they rep­re­sent, which is prob­a­bly much less than the bal­ly­hooed 30%, but the like­li­hood that much of that un­nec­es­sary uti­liza­tion is lead­ing to lower qual­ity care. By elim­i­nat­ing un­nec­es­sary variation, the sys­tem will save some money, of course. But more im­por­tantly, it will lead to bet­ter out­comes, which ul­ti­mately mat­ter more.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.