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While many of us would agree with the president-elect's objectives for healthcare reform, we would be remiss not to question how realistic they are. How can the U.S., which is mired in an increasingly deep recession, faced with growing numbers of uninsured and underinsured, hamstrung by lower federal tax revenues as national productivity falters and a spiraling national debt fueled by the critical need for trillion(s) to fund recovery programs afford healthcare reform now?
Within the health policy community there is no shortage of ideas for reform. And the Obama nominee for secretary of health and human services, former U.S. Senator Tom Daschle, even held small community meetings around the country during December to hear from the public about their experiences in the healthcare system and what they would like to see changed.
From my point of view, among the more interesting policy recommendations are in a white paper released last month by The Dartmouth Institute for Health Policy & Clinical Practice. The white paper is informed by years of research and data gathering by the institute's Dartmouth Atlas Project, which has assiduously documented a 2.5-fold variation in Medicare spending across the country, even after adjusting for local price differences and the underlying health conditions, age and race of the populations studied. Their conclusion: "Patients who live in areas where Medicare spends more per capita are neither sicker than those living in regions where Medicare spends less, nor do they prefer more care. Perhaps more surprising they show no evidence of better health outcomes. These insights, therefore, overturn the conventional views that more spending on healthcare translates automatically into better health outcomes."
There is no reason to believe that the same isn't true for the non-Medicare population as well. It's just easier to study patterns of care and health outcomes for Medicare beneficiaries, because all of the relevant data reside in one place: the federal Centers for Medicare and Medicaid Services (CMS). The availability of information on cost and benefit is one advantage of a single-payer healthcare system.
The Dartmouth Atlas Project research has shown time and again that many, if not most, of the clinical decisions made by doctors are driven by opinion of local physician leadership, as well as the locality's supply of medical resources (hospital beds, number of surgeons, for example) rather than by scientific evidence and the needs and preferences of well-informed patients. The result is what the Dartmouth researchers label as "supply-sensitive" care. For example, regions with more hospital beds have more hospitalizations; more surgeons means more surgery, resulting in "unwarranted variation" in resource use and, thus, higher comparative costs across regions.
In New York State, Medicare spending per beneficiary varies exactly according to these principles. In Metropolitan New York City, including Long Island and counties immediately to the north, Medicare spending per beneficiary is in the nation's most costly tier ($8,600 to $14,360), while upstate, in counties without large medical centers and lacking a plethora of specialists, spending is in the lowest tier ($5,280 to $6,600)--a more than two-fold difference. For those New Yorkers living in low cost areas and perhaps unwilling to accept the fact that they may just be better off than their high-cost neighbors, the white paper offers some reassurance: "Chronically ill patients are at greater risk of dying in regions where the healthcare system delivers more supply-sensitive care."
A second factor in the unwarranted variation across regions is what The Dartmouth Atlas Project describes as "preference-sensitive" care. This is care for conditions where alternative treatments are available that involve tradeoffs in quality or length of life and where informed patient choice should guide treatment. Often the evidence is equivocal, and no one treatment has a clear clinical advantage. Here too, irrationally large variation in practice occurs across regions. In Fort Myers, Fla., for example, Medicare beneficiaries are more than twice as likely to have a knee replacement than are their neighbors in Miami; seniors in Palo Alto, Calif., are over two times more likely to have back surgery than their neighbors to the north in San Francisco. These variations arise because most patients delegate decision-making to physicians based on the assumption that "doctor knows best" about treating the condition and that particular patient. Apparently nothing could be farther from the truth. There is strong evidence that where informed patient choice is encouraged and supported, the rate of elective surgery can be considerably reduced.
The white paper makes a number of recommendations to the incoming administration. These include promoting so-called "organized systems of care," good examples of which are Kaiser Permanente in California, Geisinger Clinic in Pennsylvania and the Mayo Clinic in Minnesota. Using group practices and integrated hospital systems, these providers have managed to improve the quality of the care they provide and reduce costs at the same time without denying members needed, effective treatment. This recommendation for efficient, high performance systems of care is not unique to the Dartmouth white paper; many policy experts see it as the only way forward for meaningful, affordable reform.
A second recommendation is for the federal government to adequately fund medical effectiveness research. We have a lot to learn about what works and what doesn't in healthcare. Some proposals for programs that move in this direction have been kicking around Congress the past year, but none have emerged yet from committee.
A third suggestion is to require that federal health programs like Medicare encourage and support shared decision-making by patients and their caregivers. The authors argue that such an approach to "preference-sensitive care" could help achieve meaningful reductions in the current levels of unnecessary and unwanted care that wastes resources without improving outcomes.
While the paper focuses on quality and efficiency, its authors believe their recommended policy reforms will also work to contain costs. But they warn that while most regions in the country already can meet increased demand from both aging baby boomers and Americans who currently uninsured or underinsured, "in virtually every region of the country, the supply of medical specialists, ICU beds and other medical resources such as imaging machines is increasing." And the paper says that this increase "is rising fastest in the regions that already overuse supply-sensitive services the most."
The answer, the authors suggest, is to hold the line on new physician specialists, technology and acute-care hospital capacity.
The medical-industrial complex will fight hard against proposals to curtail its growth and, thus, its profitability. If these recommendations are to ever be incorporated into President-elect Obama's healthcare reforms, they must gain the support of ordinary citizens. That's not an easy task considering the decades of consumer marketing from private companies (drug and device makers) and the public sector (voluntary health organizations like the American Cancer Society), which has encouraged the consumption of medical services. But disabusing Americans of the belief that more spending on healthcare translates automatically into better health outcomes is essential to achieving meaningful, affordable healthcare reform.
Arthur Levin, MPH, is director of the Center for Medical Consumers in New York City and a part-time Hudson Valley resident.
