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QUALITY: Are we getting our money’s worth?

On the very day that a fascinating article confirms that high spending does not equal high quality overall care, Pfizer-sponsored doc Mike Magee has a new presentation out based on the industry report which suggested that every dollar spent on health care returned several dollars back to society. THCB regulars will remember me losing my cool over the methodology and PR behind that report. Incidentally the PR was put together by the same actors (and I mean that literally) who were involved in faked "news releases" that promoted the Bush Medicare bill.

But there is the tacit acceptance in healthcare that more technology is better, and similarly that more specialist-based care required to use that technology is better. There’s never really been an answer to Larry Weed’s question — "if the radical prostatectomy rate in Denver is 3 times what it is in Salt Lake City, should you move to Denver to get your cancer taken care of properly or should you move to Salt Lake to avoid unneccessary surgery."

However, for the first time I’ve seen, someone has now come out and answered the question. And of course the someones are the folks from Dartmouth, who’s leader and guru Jack Wennberg really deserves much greater recognition for his pioneering work in area practice variation.

For many years it has been known that in some states Medicare (and by extension) other payers, are spending more, by a factor of up to three, on similar populations than in other states. This Wennberg presentations from 2000 shows that spending on patients in the last 6 months of life varies dramatically, with South Florida’s costs being up to three times those in Minnesota. Now Wennberg’s colleagues Katherine Baicker and Amitabh Chandra have a new Health Affairs article which shows that there is at the least an inverse relationship between spending levels and general care quality measures. Their conclusion is pretty brutal:

    Higher spending is associated with lower quality of care…..These relationships are statistically significant: Spending is not merely uncorrelated with the quality of care provided. Exhibit 1 quantifies the relationship between an increase in spending of $1,000 per beneficiary (roughly the rise in average spending from 1995 to 1999) and the twenty-four individual quality measures, as well as end-of-life care and patient satisfaction……The effect of increased spending on fifteen of the measures is estimated to be negative and statistically significant, and there is no statistical effect on the remaining nine. The first row demonstrates that a state spending $1,000 more per beneficiary dropped almost ten positions in overall quality ranking (p < .001). Similarly, states spending $1,000 more per Medicare beneficiary had beta-blocker usage rates at discharge that were 3.5 percentage points lower (p < .02), and mammography rates that were 2.1 percentage points lower (p < .01) than the average usage in 2000.

They can’t overall prove that commonly accepted quality processes, such as prescribing of beta-blockers and ACE inhibitors for post-MI patients, are not being followed because spending is higher, and in fact it’s probably circular, as the patients end up back in the hospital because their follow-up care wasn’t good. But if they can’t show the cause, they certainly point out the striking collinearity. And it’s what the Enthoven’s of the world have been saying forever–poor quality care costs more money. Why? Well among other things there is of course the incentive that performing heroic interventions at the last moment is much better rewarded than good quality primary preventative care. And of course that is related to the greater pre-ponderance of specialists (as a proxy for expensive technology), which the article says is responsible for 42% of the difference in spending.

No one is going to pretend that this will be easy to change. We have a structural preponderance of specialists and a Medicare payment schedule that continues to favor increased reimbursements for procedures on the very sick rather than improving care processes for the near-sick. (To be fair MedPAC has been advising changing this for some time). And we have GOGME calling for more specialists in the future. Plus, if you hadn’t noticed, specialists make a heck of a lot more money than generalists, so why would a smart young doc become a generalist?

But this research is a clarion call for the improvement of care processes and evidence-based medicine. And it is a counter-weight to ill-informed trumpeting of the benefits of technology from health care industry groups, who should be spending much less on their PR and more on helping clinicians improve the quality of the care they deliver. In the meantime, if you intend to get old, move to New Hampshire.

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