OP-ED

Are New Yorkers Sicker Than Patients in Atlanta–or Are They Just More Likely To Be Diagnosed?

At a dinner party in Manhattan, someone mentions the problems he has been having with his sinuses, and his doctor’s diagnosis. Since everyone at the table is over 40, his comment quickly leads to a lively discussion of back pain, rotator cuffs, high blood pressure, skin cancer, and diverticulitis. It seems that everyone in the room has been diagnosed with something. Finally, someone asks “Are we really that old? Can’t we talk about something else?” Everyone laughs and the conversation turns to politics.

I couldn’t help but recall that evening while reading an article in the May 12 New England Journal of Medicine (NEJM) titled “Regional Variations in Diagnostic Practices” written by a team of investigators at Dartmouth.

Earlier work done by researchers at Dartmouth has shown that patients in some regions receive moretreatment than others. This newest study, written by Yunje Song, senior author Elliott Fisher, and colleagues, goes further, to suggest that patients in places such as Miami, New York or McAllen, Texas are more likely to be diagnosed in the first place. “Their doctors order more tests and refer more patients to sub-specialists than doctors in Atlanta, Phoenix or Jackson, Mississippi,” explains Jonathan Skinner, one of the co-authors, “and so they discover more disease.”

At first glance, this might suggest that physicians in Atlanta should devote more time to testing, so that their patients can enjoy the benefits of early detection. But when the Dartmouth team looked at survival rates, they found that in regions where there is more testing and more diagnosis, patients fare no better. This suggests that our enthusiasm for diagnostic imaging has led to “early detection” of what some doctors call “pseudo disease” –small breast lesions that will disappear, without every leading to breast cancer, or lower back pain that, with time, will vanish on its own, without any need for surgery.

As Dartmouth’s Dr. Gilbert Welch points out, the explosion of medical testing has created an “epidemic of diagnosis:” “Exactly what are we doing to our children,” he asks, “when 40 percent of summer campers are on one or more chronic prescription medications?”

Given Regional Variation in Diagnosis, How Can Reformers Adjust For Risk?

Nevertheless, once the diagnosis is recorded in a patient’s medical record, it becomes a fact. The New Yorker who has been diagnosed with early stage prostate cancer now appears sicker than his cousin in Atlanta, who has never had a PSA test. The New Yorker may never experience symptoms, but he is now listed as a cancer patient.

This poses an enormous problem for health care reformers who hope to adjust for risk when deciding how much to pay hospitals and doctors. Under the new legislation, Medicare plans to begin rewarding providers for the quality of the care they offer—paying more for better outcomes. But Medicare recognizes that some providers care for sicker patients, and in those cases, outcomes won’t be as good. Obviously, hospitals shouldn’t be penalized because they treat more vulnerable population. They, too, should be eligible for bonuses.

Reformers who plan to compare the effectiveness of various products and services, also need to adjust for risk. If a patient suffers from two or three diseases, this could explain why he is not responding to a new cancer drug.

Clearly, regional variations in diagnoses could wreak havoc with risk-adjustment. As the authors of the study note: “Risk adjustment is only as good as the information on which it is based. Current risk-adjustment methods depend on the diagnoses that are recorded by physicians in medical record. . . or are coded by medical-records personnel and billing staff in hospital discharge abstracts and physician claims…” “If physicians have substantial and systematic differences in their diagnostic practices that are unrelated to the underlying health of their patients but are related to institutional or regional practice patterns, biases in risk adjustment will result.”

Testing the Hypothesis

To test their theory, investigators began by comparing trends in laboratory testing, imaging and diagnosis in different “hospital referral regions” (HRRs) across the nation. They grouped these regions into five quintiles based on the intensity of hospital and physician services in the HRRs, ranging from the 1st quintile (least aggressive) to the 5th (most aggressive).

They then identified 5,589,741 Medicare beneficiaries who received Medicare from 2001 to 2003, zeroing in on the 255,264 individuals in that group who moved sometime during those three years. Some migrated to a city in the 5th quintile where physicians do more tests; others moved to a place where diagnostic imaging is not as popular. The researchers asked two questions: Would seniors be diagnosed with more diseases simply because their address had changed? What would happen to those who didn’t move? (Researchers excluded beneficiaries who died during those three years because, wherever they moved, as their health deteriorated, they would have been likely to see more doctors and undergo more testing.)

The Results of the Study

As the table below reveals, a change of place made all of the difference.

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Jamachart518 Percent Increase in the Number of Major Diagnoses, Diagnostic Tests, and Imaging Services among Medicare Beneficiaries, According to the Intensity of Practice in the Hospital Referral Region (HRR) in Which They Lived.

The investigators had expected that, as Medicare patients aged, they would be diagnosed with more major diseases. And indeed, they were. The top line of the table shows that those who lived in a town like Phoenix (in the 1st quintile) and stayed put, nevertheless watched their diagnosis rate rise by 65 percent over the course of three years.

But what is striking is what happened to those who moved from a 1st quintile region to a 5th quintile city such as Miami. Over the same span, their diagnosis rate jumped by more than 100%. (See the third line of the table). Suddenly they appeared much sicker than friends who stayed at home–at least according to their medical records. As the third and fourth columns show, their doctors ordered many more tests. Seek and ye shall find.

“It’s not hard to understand how this happens,” says Skinner. “As Jack Wennberg [the father of the Dartmouth research] has said: ‘Older people are vast reservoirs of disease.’ It’s relatively easy to diagnose any Medicare patient if you look hard enough.”

What about patients who moved to an area where care is more conservative? The bottom two lines on the table show that those who moved from a 5th quintile town such McAllen, Texas to a town more like Atlanta or Jacksonville, Mississippi (both in the 1st quintile) appear healthier (at least on paper), after making the move. If they had stayed in a 5th quintile region, their diagnosis rate would have risen by 55% over three years; those who moved to a place where doctors are less assiduous saw diagnosis rise by only about 43%.

Still, many Americans would find it hard to believe that Atlanta physicians aren’t short-changing their patients. Hundreds of millions of dollars are spent every year on hospital ads indoctrinating us to believe that more lab tests and earlier diagnosis will lengthen our lives.

And, in fact, sometimes this is true. But when Dartmouth’s researchers compared 1-year and 3-year rates of death after Medicare patients moved– adjusting for differences in age, sex, and race– they found no evidence of a survival benefit among those who moved to a region where doctors find more disease.

The only difference is that when the discussion turns to health problems at a dinner party, New Yorkers have more to brag about— the number of doctors they see, the number of diseases diagnosed, the number of treatments, the cost of all of the above….

More work needs to be done examining when and where more diagnostic imaging and lab tests will actually save lives. As the Dartmouth team acknowledges: “Although our study did not show a significantly higher rate of survival among beneficiaries who moved to regions with higher-intensity practices, this result should not be interpreted as implying that greater diagnostic intensity offers no benefits. Rather, it underscores the need for research to determine the specific clinical settings in which greater diagnostic intensity does — or does not — confer a benefit.”

Implications for Reform

If, under reform, we try to pay for quality, and “payments to health care providers are based on risk-adjusted costs and risk-adjusted outcomes, those who diagnose more will have a double advantage,” Skinner observes. “Every time a hospital enters new diagnoses for its patients, reimbursements will go up because” Medicare will assume that it is more expensive for a hospital to care for patients suffering from more diseases. Meanwhile, in places such as Miami, doctors’ risk-adjusted outcomes will look better; even if their outcomes are only average, because it will appear that they are doing better than other doctors while treating much more vulnerable patients. “The temptation to diagnose more and more disease will be irresistible,” Skinner concludes.

The Dartmouth team estimates that variations in diagnoses could mean that “reimbursement rates would be as much as 19% higher in the high-intensity regions solely because of bias related to diagnostic practice. Alternatively,” in regions where doctors are not so quick to order a Cat-scan, “risk-adjustment models could fail to account for the difficulty of caring for truly high-risk patients or those whose care is made more difficult owing to challenges such as language barriers, poor health literacy, or lack of social support, encouraging some providers to avoid or stop providing care for such patients.”

“Risk-adjustment is going to be more difficult than we thought,” Skinner admits. “The challenges are going to be to measure risk in more objective ways by focusing on more detailed measures.”

The Dartmouth investigators end their study by focusing on the problems that geographic variations in diagnoses pose for reformers trying to measure quality, and they offer some solutions. “These challenges could become more manageable as comprehensive electronic health records are implemented,” they write. They go on to suggests that when these electronic records are used to identify sicker patients, they should include not just clinical diagnoses, but “nonclinical factors that may predict a patient’s lack of adherence to clinical advice (e.g., homelessness or poverty).”

This makes sense. When allocating bonuses, Medicare should recognize that low-income patients are harder to treat, not only because they suffer from more chronic diseases, but because a lack of education combined with a high-stress life makes it less likely that they will comply with their doctors’ recommendations. That said, providers who care for poorer patients should receive extra compensation only if treatment leads to some improvement in heath and survival rates, not simply because the physician correctly diagnoses more diseases.

Too often, a Medicaid patient’s health problems are recognized, but he or she still doesn’t receive recommended care. For example, the California Breast Cancer Research Program has found that while poorer women are more likely to be diagnosed with breast cancer, they are less likely to receive standard treatment. This is why, as I noted in a recent post, poor women are about twice as likely to die of breast cancer as wealthier women. They receive less medical care, and less sophisticated care, explains Otis Brawley, MD, associate director of the Winship Cancer Institute at Emory University. The same pattern holds true for other diseases. In general, even when they are on Medicaid, poorer patients face more hurdles in getting access to the right care at the right time.

The Dartmouth team also recommends that when adjusting for risk, reformers should focus on “clinical data that are less subject to bias that is due to differences in diagnostic practices.” Rather than simply assuming that all patients diagnosed with cancer are “at risk,” they should use “data that includes stage and grade of the cancer.” For example, the vast majority of men who are told that they have early-stage prostate cancer will never experience symptoms.They are far healthier than patients diagnosed with a more aggressive cancer. Similarly, the researchers suggest, that “in the case of those with congestive heart failure, researchers should pay attention to ejection fraction” (the percentage of blood pumped out of the heart with each beat) which is an important measure of how serious the problem is.

Finally, they note, it’s always worth listening to the patient: “measures of health risks reported by patients (e.g., smoking and exercise patterns) and functional status (physical, social, and role function) could be incorporated in risk-adjustment models.”

I am glad that researchers at Dartmouth are taking a hard and honest look at the challenges that we will face now, more than three years before full-scale reform becomes a reality. As I have said in the past, mending our broken health care system will require constant “re-visioning,” as we learn more about how to assure that we are getting value for our health care dollars. My guess is that it will take a decade to restructure the system, changing how we pay for care, what we pay for, and how care is delivered.

But I also believe that we can “break the curve” of health care inflation in the next three or four years by beginning to squeeze the hazardous waste out of the system. As I have suggested in the past, much of that waste is easy to spot. Some of it takes the form of over-testing which then leads to an “epidemic of diagnosis.” But we cannot simply assume that all providers in a region where care tends to be more aggressive are diagnosing “pseudo-disease.” The Dartmouth team cautions that in order to assess benefit to the patient, Medicare will have to hone in on individual hospitals and doctor/hospital networks where patients seem to be undergoing an unusually high number of tests and procedures. Only then can Medicare begin to use financial carrots and sticks, on a hospital-by-hospital basis to encourage higher quality, less costly care. Take a look at the proposals for pilot projects in the reform legislation, and you will discover that this is precisely what Medicare plans to do.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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Jamesbev M.D.Tom LeithjdExhaustedMD Recent comment authors
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ExhaustedMD
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ExhaustedMD

I am talking about Paul Levy and Dr Wachter’s post of a couple of days ago bringing attention at this site about questionable behaviors and Dr Wachter’s defense of them. Not the kind of press you want when you are running a blog trying to educate and enlighten about health care concerns and hopeful improvements.
EH!?!?

jd
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jd

And yes, there are fans in trenches. Mixed metaphors rock.

jd
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jd

ExhaustedMD, I have no idea what you are talking about. Nate, it’s too early to say (or at least for me to say) how different it is going to be this time. I am certain that there is a lot more understanding of the complexity of assessing risk. 15 years ago, those who are now in their 50s and 60s running organizations were mostly in their 40s, slogging in the trenches as the Sh-t hit the fan. The only thing that gives me any cause for concern as far as providers taking too much risk or pricing it badly is… Read more »

ExhaustedMD
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ExhaustedMD

Man, who are these people who just promote this attitude that doctors are overpaid scum who need to be put in their place like a misbehaving child? People who have an agenda to see this legislation come to fruition. And I’ll keep saying this until everyone puts in their honest and documentable disclaimer that they are not tainted by this legislative insult: there is a buck to be made or fatal optimism will play out as labeled! Now you read how another commenter has “issues” with the way he handles his job. Not the kind of press you want if… Read more »

MD as HELL
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MD as HELL

“Bottom line: in many situations,care would be better if docs were on salary.”
Like at the VA?

Nate
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Nate

Margailt keep talking like that your going to get disinvited from the wine tastings. I think this is where the politics really screw up the whole process. Politicians are trying to score points with “solutions”. There are no perfect solutions or sure fire answers as history has proven. We need to accept that imperfection will still exist and figure out how much of it we can live with. I agree that FFS needs to stay but capitation also needs a place. Its to bad our supposed free market healthcare system is so not free that we can’t try some of… Read more »

James
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James

“In fact, while Texas has had tort reform, it is one of the high intensity areas.” Texas, like the U.S., has wide regional variations. Look at the Central Region for an island of very efficient health care (Waco and Temple). Their costs are about half that of their counterparts in McAllen and Harlingen. The touted benefits of tort reform were an increase in the supply of certain medical specialties, particularly in regions of the state where litigation was more prevelant (the Lower Rio Grande Valley being one). There were also major reductions on the costs of liability insurance and an… Read more »

Margalit Gur-Arie
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Here’s another blasphemy Nate. I’m not entirely certain that the FFS system is so inadequate that it needs to completely go away. Maybe it’s not so much about how we pay, as it is about how much we pay, and maybe some tweaks here and there can make FFS viable, because I can’t really see a clear alternative either.

ExhaustedMD
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ExhaustedMD

Why don’t you compare apples to apples, Dr jd! Doctors don’t spend the time, money, and energy into 12 years plus of training after finishing high school to have the whole profession redesignated one as salaried when the training gives one the opportunity to go solo; yes you have to answer to your boards of specialty and the state boards of ethics and accountability, but what is this argument that pilots, cops, and teachers are synonomous with our field? And by the way, don’t some of them go out on their own and earn a private income if someone is… Read more »

Nate
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Nate

“Time is almost irrelevant in most circumstances.” Except in the numerous codes that specifically outline a time componet. Not all codes are time based, your not going to pay extra if a doctor spends 6 minutes drawing blood instead of 5. At least I hope that isn’t your plan. There are few, in the total count of all CPTs, codes that have significant time differential. Their are already codes for email, and phone calls. The question is how you measure and verify them. I’m not going to take a doctors word it took 12 minutes to write an email. Your… Read more »

jd
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jd

Barry and bev, first let me say what probably goes without saying: I am prognosticating, and of course do not have infallible insights into the future. Second, unfortunately I cannot be all that much more specific about what is happening between payers and health systems right now. This is partly because the conversations are exploratory and not yet public, so I can’t responsibly spill the beans on any details. My direct experience of new activity pertains to the New York market only, though it stands to reason that similar conversations would be happening nationwide. Here is what I can say… Read more »

Margalit Gur-Arie
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No, Nate, that’s not how it works now. You have to document 6 of these and half a dozen of the other and pile up as many ICD9 as you can think of in order to get a certain CPT. Time is almost irrelevant in most circumstances. If you spent half an hour with a patient, and another 15 minutes making phone calls or sending email on their behalf, you should get paid for a base of 45 minutes, plus a little more based on the complexity of the procedure and the level of mastery required to perform whatever you… Read more »

Nate
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Nate

“if you just pay docs for time spent with, and for, patients, instead of CPTs, with proper adjustments for mastery and complexity,” Isn’t this exactly what CPTs do? Measure and differentiate time and complexity? What if we call this new system CPT10 or what ever they are calling the new expanded codes. Will that work? “For-profit insurers moved in– and drove non-profits out of business as for-profits that had made $$$ in other areas of insurance (Aetna, etc.) used their deep pockets to fund price wars, etc.” And things werw going SOOOOO well there for a day. Actually it was… Read more »

bev M.D.
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bev M.D.

I, too, would like to hear jd expand upon his comment about Partners. Certainly we need ways to combat this pernicious method of keeping costs high. Barry, as for bad doctors, please see the post (and especially comments) called “Badness in Baltimore” by Robert Wachter, on both his own blog (wachter’s world) and here on May 14. Also check out the link in his post tied to the word “traditonal”, which refers to an earlier post of his called “Is Peer Review a sham?” As I mentioned in my own comments there, it is clear that the peer review system… Read more »

Barry Carol
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Barry Carol

Maggie – I’m not talking about or advocating executive physicals. In our company with tens of thousands of employees worldwide, there probably aren’t more than two or three dozen executives who get executive physicals at company expense. Insurance generally doesn’t cover those but large self-funded employers often choose to cover them for their own reasons which may not include medical cost-effectiveness. One of the frustrating aspects of health and healthcare is that, for many conditions, when symptoms finally manifest, it can be too late or, at least, treatment will be more complex and expensive than it would have been if… Read more »