“The rich geographical diversity of the United States is part of its appeal. The diverse performance of the health care system across the U.S., however, is not,” notes The Commonwealth Fund in “Aiming Higher: Results from a State Scorecard on Health System Performance.”
This comparative state-by-state study of care in the U.S. pops off the page as part of a report released this month, “Health Policy Reform: Beyond the 2008 Elections,” and explodes some myths about where the best care can be found.
Find your state on the map below. You may be surprised to discover that when it comes to overall performance, health care systems in states such as New York, California and Texas—places known for being home to some world-class academic medical centers—don’t turn up in the top quartile. (States that do rank in the top 25 percent appear in white).
Reputation is one thing; medical evidence about quality of care, access to care, unnecessary treatments, excessive costs and bad outcomes is another. U.S. News & World Report is good at many things; ranking hospitals is not one of them.
How did the researchers who drew this map rank states? They used the 32 indicators listed on the table below (click to open a larger version in a new window) which measure:
- “Access” (based on how many of the state’s adults and children have no insurance, and how many went without needed care)
- “Quality” (measured by yardsticks such as the percent of adults and children who receive recommended preventive care; the share of hospitalized patients who received recommended care for acute myocardial infarction, congestive heart failure, and pneumonia; the percent of surgical patients who received antibiotics at the right time to prevent infections; the share of Medicare patients who gave the treatment they received high marks and said their provider listened to them, explained, and showed respect; the percent of nursing home patients suffering from bed sores resulting from not having been turned often enough; and the share of nursing home patients who were strapped to their beds)
- “Potentially Avoidable Use of Hospitals and Cost of Care” (measuring how many patients were hospitalized who might not have needed hospitalization if they had received proper care in the first place– and the cost of those unnecessary hospitalizations)
- “Healthy Lives” (indicating the chance of living a long and healthy life in a given state based on the percent of deaths that might have been prevented if the patient had received good care, the percent of breast cancer deaths, colorectal cancer deaths, infant mortalities, and the share of seniors whose activities are limited due to physical, emotional or mental health problems)
Let me be clear: these 32 indicators are not the be-all and end-all
of assessing the quality of care in each state. Some are extremely
subjective. For example, did your health care provider show “respect”?
Others measure only one small corner of care, i.e. did surgical
patients receive antibiotics at the right time? There are many other
things that can go wrong during surgery. And one might wish for a
broader measure of the risk of infection. For instance, it would be
useful to know the percent of patients who suffered from infections as
a result of being hospitalized. But at this point in time, such numbers
are difficult to obtain.
Ultimately, “outcomes” may well be the best overall measure of
performance, making “mortalities amendable to health care” (i.e.,
percent of people who died from diseases that are treatable) a
particularly interesting number.
In truth, we are just beginning to learn how to measure the quality
of healthcare. Nevertheless, the pool of hospitals and patients
involved in this report is large enough, the number of indicators broad
enough, and the differences between states sharp enough, to provide an
overview of U.S. healthcare that is definitely worth our attention.
Moreover, the Commonwealth Fund, an independent, private foundation
that uses experienced medical researchers, is a much more reliable
source than most. (In particular, be wary of ratings provided by
companies that are paid by the health care providers who are being
graded. If a for-profit company says it can rank the best hospitals or
doctors, ask how it makes its profits. Who buys its research? If its
customers are also the subjects of its research, conflict of interest
is all but inevitable).
Highlights of the Report
What is striking is just how wide the range of performance is across
states, with a two- to threefold spread from top to bottom. Moreover,
leading states consistently outperform lagging states on most of the 32
“indicators” of performance. This is one reason why we don’t want to
leave health care reform up to the states: a third of the nation could
easily be left behind.
Thirteen states—Hawaii, Iowa, New Hampshire, Vermont, Maine, Rhode
Island, Connecticut, Massachusetts, Wisconsin, South Dakota, Minnesota,
Nebraska, and North Dakota—emerge in the top quartile of the overall
performance rankings. And states that earn top scores in “access” and
“quality” tend to outperform in the other three categories as well.
Iowa, for instance, ranks in the top 25 percent in all five categories
while New Hampshire places in the top quartile in all but one category.
Meanwhile, the 13 states at the bottom quartile of the overall
performance ranking—California, Tennessee, Alabama, Georgia, Florida,
West Virginia, Kentucky, Louisiana, Nevada, Arkansas, Texas,
Mississippi, and Oklahoma—lag well behind their peers in many areas,
with Mississippi, Oklahoma and Arkansas placing in the bottom quarter
in all areas. Texas falls into the lowest 25 percent in all but one
category.
In the middle, New York ranks in the lowest quarter when it comes to
“avoidable hospital use” –which means that New Yorkers are more likely
to be exposed to the risks as well as the cost of unnecessary
hospitalizations. The state places in the top quintile only in
“access”—in large part, no doubt, because in New York, private insurers
are not allowed to shun customers because of pre-existing conditions.
Nor can insurers charge a cancer patient more. In NY, state law
insists that everyone in a given community pays the same premiums for
the same policy, whether they are sick or well, young or old.
Stepping back from the map, and taking a look at the larger picture,
it becomes apparent that states in the Northeast and the northern part
of the Midwest (areas that some healthcare experts refer to as “Canada
South”) rank near the top of the scale on most measures. States at the
bottom of the performance ladder tend to be concentrated in the South.
Higher Quality Goes Hand in Hand with Lower Costs
Surprisingly, there is no clear connection between higher quality
and increased spending. “Annual costs of care vary widely across
states,” the report observes, “with no systematic relationship to
median incomes.” And people in wealthier states do not necessarily
receive better care. As the report points out, “there is no systematic
relationship between the cost of care and quality across states.” Iowa,
Vermont, Minnesota and Nebraska manage to deliver top quality care at
significantly lower costs than most of the nation.
By contrast, in New York, New Jersey, District of Columbia, Texas,
Louisiana and Illinois we spend more on healthcare, without meeting the
benchmarks established by Minnesota, Iowa and Vermont. The
lower-ranked states also show higher rates of preventable
hospitalization; too often, patients suffering from treatable diseases
like diabetes and asthma wind up in a hospital bed.
But do such differences really tell us anything about the quality of
the healthcare system in these states? One could reasonably argue that
people in Iowa and Minnesota are simply healthier than the citizens of
New York, New Jersey, and Louisiana. I could think of at least a dozen
reasons why this might be so.
Yet as regular readers of this blog know, three decades of research from Dartmouth Medical School
show virtually the same results as the Commonwealth report. And, as I
have noted in the past, Dartmouth’s researchers adjust for differences
in race, age, sex—and the underlying health of the population.
For example, Dartmouth’s researchers knew that salubrious conditions
in Grand Junction, Colo., mean that per capita outlays for healthcare
in that town will probably be about 20 percent below the national
average, and they adjust for that fact. By contrast, the comparatively
poor health of the citizens of Birmingham, Ala. (one of the nation’s
least healthy communities), suggests that spending there should be
nearly 25 percent above the national average. But even after factoring
in these differences, the Dartmouth researchers find that per capita
spending on healthcare remains twice as high in some areas than in
others. Meanwhile outcomes in high-spending states like Florida and New
York are no better—frequently they are worse.
Dartmouth’s work also shows that we tend to spend lavishly in places
like New York City, Florida and Louisiana—where there are more
hospital beds—and more specialists. (Yes, even in Louisiana, before
Katrina hit, there were more beds and specialists per capita than in
states like Iowa or Minnesota.) It turns out that if the beds are
there, and the state boasts enough specialists to see more patients
more often, the beds will be filled. Yet more aggressive, expensive
care does not necessarily lead to fewer deaths.
The Commonwealth study confirms that more care is not necessarily
better care—sometimes it is worse. This is in part because patients who
are hospitalized are exposed all of the dangers of a hospital—including
hospital-acquired infections and errors. As one of Dartmouth’s
researchers points out, “Hospitals are dangerous places, especially if
you don’t need to be there.”
In states where patients receive more expensive, intensive care,
those patients also are more likely to be re-admitted to the hospital
within a month of being discharged. For example, in New York, where
Medicare spends over 50 percent more per patient than it spends in
Oregon and Iowa, 18 percent of hospitalized patients will have to be
re-admitted to the hospital within 30 days, vs. 13 percent in Oregon
and Iowa. Lower costs go hand in hand with higher quality care.
Would-be health care reformers should pay attention to these states. As
the Commonwealth report observes: “Reducing the use of expensive
hospital care by preventing complications, controlling chronic
conditions, and providing effective transitional care following
discharge has the potential to improve outcomes and lower costs…Benchmarks set by leading states, show that there are broad
opportunities to improve and achieve better and more affordable health
care”.
Insurance Matters
The Commonwealth study also shows that access is key. Sometimes
readers commenting on this blog have noted: Americans don’t need
health insurance; they need health care. This certainly is true—having
insurance is no guarantee that you will receive superior care.
But without comprehensive insurance your chances of receiving the
care that you need—when you need it—fades. As the report emphasizes:
insurance matters. Across states, better access to care and higher
rates of insured citizens are closely associated with better quality
Again the differences are stark. The percent of adults under age 65
who were uninsured in 2004–2005 ranged from a low of 11 percent in
Minnesota to a high of 30 percent in Texas. The percent of uninsured
children varies fourfold, from 5 percent in Vermont to 20 percent in
Texas. As one Houston doctor said to me when I was writing Money-Driven
Medicine, “Texas is a state that never has, and never will take care of
its poor.” Though perhaps, with national health reform, that could
change.
Not surprisingly, states with the lowest rates of uninsured
residents tend to score highest on measures of preventive care and
management of chronic diseases. Four of the five states that rank
highest in terms of access —Massachusetts, Iowa, Rhode Island, and
Maine—also place among the top five states in terms of quality.
How Much Could We Save?
One can’t help but wonder how much we could save—both in dollars,
and more importantly, in lives —if the lowest-ranked states covered
their uninsured, and if health care providers in those states learned
to practice medicine the way it is practiced in Iowa and Minnesota.
Reformers take note: “If insurance rates nationwide reached that of
the top states, the nation’s uninsured population would be halved,” the
Commonwealth report observes. “If all states could approach the low
levels of mortality from conditions amenable to care achieved by the
top state, nearly 90,000 fewer deaths before the age of 75 would occur
annually. Matching the performance of the best states on chronic care
would enable close to four million more diabetics across the nation to
receive basic recommended care and avoid preventable complications,
such as renal failure or limb amputation. By matching levels achieved
in the best-performing states, the nation could save billions of
dollars a year by reducing potentially preventable hospitalizations or
readmissions, and by improving care for frail nursing home residents.
If annual per-person costs for Medicare in higher-cost states came down
to median rates or those achieved in the lowest quartile of states, the
nation would save $22 billion to $38 billion per year. While some
savings would be offset by the costs of interventions and insurance
coverage expansions, there would be a net gain in value from a
higher-performing health care system.”
It is important to understand
that those billions in savings would come over time. By contrast, the
funding required both to expand insurance coverage and to improve
preventive care and disease management will be needed up front. But
over a period of years, the savings generated by a more efficient,
high-quality health care system will outstrip costs. It is important
that reformers acknowledge these facts.
Here, we can learn from the experience of other countries. As I
write this, I am in Berlin, attending the 2008 World Health Care
Congress. Just an hour ago, I heard David Nicholson, the chief
executive of the United Kingdom’s National Health Care System, speak,
followed by Richard Alarez, president and CEO of Canada Health Infoway,
a not-for-profit private-sector corporation responsible for installing
and coordinating healthcare care information technology in Canada. Both
Nicholson and Alvarez are involved in major overhauls of their nation’s
healthcare systems, and after they spoke, the moderator asked them:
“What is the biggest challenge that you face?”
Nicholson didn’t hesitate: “You have to invest a lot of time and
money with no immediate payback. Meanwhile, a politician’s horizon is
short. If he backs reform he has to take a huge amount of criticism
for spending the money when people can’t see any immediate benefit.”
Alvarez agreed: “Politicians live in four-year cycles. You can’t
show a nationwide benefit in four years. Keeping the politicians
focused is a huge problem. You have to find individual patients who
have been helped by pockets of reform and bring them to the forefront.
You’re constantly looking for newspaper stories.”
In the U.S. those who lead health care reform will need to level
with the public. They must be candid in acknowledging that the upfront
cost of providing universal access to high quality care will seem
steep. Anyone who says that reform won’t cost us anything—or that
healthcare will magically become less expensive in the first few years
of reform– simply isn’t telling the truth. We will be covering
millions of uninsured and underinsured Americans—many of whom have
postponed needed care. And even well-insured Americans need better
preventive care, along with the electronic medical records that many
nations in Europe already have. Playing catch-up will be expensive. But
I think taxpayers can understand that the money needed at the outset is
“seed money.” If we make the investment now, over the long term, the
nation stands to reap rewards that will more than make up for the
costs.
Anyone with any experience in health care analysis will cite (1) the national VA studies that could not account for outcome variance despite being one unified HC system and (2) studies that showed that even though NYC and BOS had high per-cap health care spending, there was NSD in outcomes compared to other, lower-spending regions.
In other words — just spending more money cannot be a sole contributing factor to health care. There are other factors. And anyone who thinks otherwise ought to be required to spend their own money first, to see if they can prove otherwise. I seriously doubt they can.
Excellent point here, Maggie: “They must be candid in acknowledging that the upfront cost of providing universal access to high quality care will seem steep. Anyone who says that reform won’t cost us anything—or that healthcare will magically become less expensive in the first few years of reform– simply isn’t telling the truth. We will be covering millions of uninsured and underinsured Americans—many of whom have postponed needed care.”
I think insurance executives already know this. I have listened to quarterly conference calls of publicly traded Medicaid health plans (Centene, Amerigroup, Molina, WellCare) and the CEOs and CFOs all have to explain the same thing to Wall Street analysts. When these companies and their HMOs absorb “newly managed populations,” they point out that the MLRs go up for at least three or four quarters. They only come down once the populations are under management, and their chronic conditions are controlled.
When we begin really attacking the ranks of the uninsured, we will see the same effect. There will be the upfront costs of infrastructure which will yield no results until members are enrolled. Then once members are enrolled, the costs will go up as previously unmanaged conditions are brought to heel. The fact that this will happen needs to be communicated beforehand and understood.
The problem is, we need a 5-year or a 10-year plan, but we live in a country where 30-second sound bites, 23-minute TV shows, and quarterly financial reports are the benchmarks around which most thinking is done.
New Hampshire #3 in the country
According to The Commonwealth Fund ranking states on health system performance. I’m happy to be a part of that.
I think it’s fair to conclude that it’s access (as opposed to ‘just’ insurance) that matters. And I also agree that insurance is positively correlated with access, but I would add: ‘in the current system’.
While some may disagree, I think that there are systems (or really, lack of ‘systems’) in which access and insurance would have a weaker association. Whether or not such a situation is attainable is something about which reasonable people may disagree, and I only point this out to counter the idea that the only way to improve access is to set up some sort of ‘Universal Insurance’ program.
The question I have for those who see these data as supporting the utility of a National Universal Insurance program is: By what mechanism will you ration health care spending?
Without adjusting for the demographic makeup of the population one can easily come to the wrong conclusions.
Obvious factors that need to be considered include percentage of immigrants (legal and “illegal”), percentage of those below the poverty line, or in single parent families, or homeless, or unemployed, etc.
Also there needs to be some consideration for the overall health and lifestyle of the population. I’m sure there are many more hard drug users (per capita) in NYC than in Bismark, ND. Even the cultural background of the population needs to be examined. What are the health expectations of the influx of people from west Africa that have landed in NYC? Do they tend to seek informal or traditional types of care rather than approaching western style facilities as quickly as readily as WASP’s?
I have no idea, but failure to normalize the data makes their conclusions less trustworthy than one would like.
Thank you all for your comments.
Robert,
Please see the section of my post that begins: “Yet as regular readers of this blog know, three decades of research from Dartmouth Medical School show virtually the same results as the Commonwealth report. And, as I have noted in the past, Dartmouth’s researchers adjust for differences in race, age, sex—and the underlying health of the population.
“For example, Dartmouth’s researchers knew that salubrious conditions in Grand Junction, Colo., mean that per capita outlays for healthcare in that town will probably be about 20 percent below the national average, and they . . . ”
Unfortunately, adjusting for “race” pretty well covers adjusting for poverty, unemployment, etc.
Illegal immigrants aren’t included in the mix because this is Medicare data.
(I’m pretty sure the Commonwealth fund also adjusted for variables like race, income, underlying health of the population but since I couldn’t find a place where they talked about methodology, I didn’t want to assume they had.)
The important point is that Dartmouth has been conducting these studies for over 3 decades and has “adjusted” the numbers to cover everything you or I might imagine.
You may have started reading this blog after I wrote several pieces about the Dartmouth research. . IF so, click on “from Dartmouth medical school” and it will take you to an article I’ve written about Dartmouth’s work. I think you’ll find it interesting.
For the past 10 years or so, virtually no one among the medical cognoscenti has tried to
question the validity of their findings. It’s now generally accepted that spending is higher in areas where there are more beds and specailists–supply creates demand–“build the beds and they will come.”
The only questions is: what do we do about it?
The higher spending has nothing to do with the medical needs of the community—or even the wealth of the community.
Meanwhile, outcomes in these high-spending are no better.
Tom–All of the Democratic candidates’ plans for reform as well as other independent plans like Jacob Hackers’ call for creating an independent institute to compare the effectiveness of various drugs, devices, and procedures.
If a new product or procedure is no more effective than what we already have–and may be riskier–it wouldn’t be covered.
One might think that we already do this–every other developed country in the world does. But we don’t. Drug-makers, device-makers and some surgeons don’t want their products and servcies tested, head to head, against what we already have.
So in this country, the FDA only requires that the new product or procedure be testted against a placebo–prooving only that it is better than nothing. And we often don’t require the long-term follow- up testing needed to find out whether benefits really outweigh risks.
If insisting that something is effective before agreeing to cover it is “rationing” , so be it. It is estimated that we could save about 1/3 of the $2.2 trillion we now spend on healthcare if we
eliminated the unproven drugs,devices and procedures along with unncessary and ineffective tests and hospitalization.
This isn’t rationing in the sense of taking away something that is beneficial–it is eliminating hazardous waste.
Rick –Thank you.
You wrote: ” There will be the upfront costs of infrastructure which will yield no results until members are enrolled. Then once members are enrolled, the costs will go up as previously unmanaged conditions are brought to heel. The fact that this will happen needs to be communicated beforehand and understood.
“The problem is, we need a 5-year or a 10-year plan, but we live in a country where 30-second sound bites, 23-minute TV shows, and quarterly financial reports are the benchmarks around which most thinking is done.”
Yes, exactly. It is terribly important, I think, that reformers are honest about this upfront, or health care reform could blow up in their faces.
And it doesn’t matter if private insurers or a public sector (single payer) plan is covering everyone: covering all of those uninsured and uninsured people will cost more –much mmore–at the outset. But over time, there will be savings.
Russ–Yes, it’s not just a matter of spending money, it’s a matter of spending money wisely.
Briefly, this means a)not being sucked in by the hype that surrounds many over-priced “bleeding edge”
products and treatments–and insisting on unbiased medical evidence that they work and
b)putting more emphasis on preventive care and chronic disease management (with first dollar coverage–no deductibles or co-pays that
tempt people to skip needed prevent care.)
Maggie,
While the Central Planning and Approval Panel for All New Medications and Devices would likely reduce wasteful spending, I have two thoughts.
1) No matter how much is saved, health care is going to be a scarce resource (in a generally economic sense) regardless. So, there will most certainly be rationing at the level of health care delivery. The question I have is who is going to make those decisions? Hillary-care from the 90’s answered the question with some sort of ‘regional bean-counters’. These folks had a budget and a population. If the budget was reached in November, my understanding is that you’re SOL. So, I’ll ask again…who gets to decide which care gets paid for and which doesn’t?
2) Who makes up the proposed panel? Will they be omnipotent and without bias? How transparent will their decisions be? What happens when they’re opinion runs counter to some ‘scientific consensus’ (as defined by a politician, professional organization, etc)?
I’m really just trying to get a handle both on what the proposals are and how well people are really versed in them.
These results were very similar to a report that describes the state of health care in 2008. The report also had similar color-coded maps with state rankings.
It’ll be interesting to see how all of this plays out in the elections this year, but for now I’m going to be following your blog.
BTW: I found the report I was mentioning earlier. It’s at http://www.health-insurance-2008.org
Tom–
Healthcare really desn’t have to be a scarce resource–not if we
spend money on the things that can be done early on (from pre-natal care to
eye-check ups for diabetics) before problems become serious (and expensive)
As one doctor said to me recently “We’re so enthralled with ‘Sputnik Medicine” (the high-tech things you do when tnings have gotten bad) that we haven’t paid enough attention to the more boring management of chronic diseases.”
In other countries, there is more preventive care–and more doctors doing it–and fewer specialists.
And often, in those countries, their outcomes are better, and costs are much lower.
We spend about twice as much, per person, on healthcare as the average developed country.
Switzerland, for example, spends only about 60 percent of what we do, and they really do have a very good system. Think about everything you know about Switzerland, and this makes sense.
I know– now you are going to say that we have a much more diverse population, with many more poor people and minorities.
But spendigg 40 percent more should be enough to cover that. Morever, if we
covered minorities and our poor from the very beginning (pre-natal care) their health care problems would not be nearly as
expensive.
Finally, you ask (rightly) who sits on the panels who make these decision?
Doctors, medical ethicists, and reserachers who have absolutely no financial interest in the outcome. This is how it works in many other developed countries.
And in other countires, they have electronic medical records that give them a huge databse (with names of patients removed) that allows the decions-makers to analyze what care seems to be effective. (These decisions change as knowledge evolves.)
Can we have high quality care with government oversight?
Germany is, I think, a model in many ways. In Germany there is bot h public-sector, govt’-run
insurance and significantlly more expensive private insurance.
The private insurance covers amenities like a private room in the hospital
But because it is more expensive, only Germans who earn roughly $75,000 a year (individual, not family,) are eligible to buy it)
Yet– and here is the surprising part, more than half of those upper-middle class and upper-class Germans who are eligible to buy the private insurance choose the public sector health care program
Not long ago, I interviewed a German pediatric oncologist in his mid 40s visiting in this country, and he told me that he has chosen teh public-sector plan. He thinks that in terms of getting the highest quality health care, it is just as good.
Now, that is impressive. I’m happy to have people in this country have a choice betwseen private insurance and something like Medicare for all. But \the public sector Medicare for all needs to be so good that well-informed, relatively wealthy people would choose it.
If the Germans can do that, why can’t we?
Maggie,
What I’m saying is that Health Care is a scarce recourse regardless of how much we streamline it. To some extent or another, everything is ‘scarce’ (in that it is not infinite).
Let’s say we stream line the whole system and we eventually decrease spending by 40% (in constant dollars). Do you honestly think that we won’t find something to spend that 40% on? We’ll either shift those tax dollars over to some other government project (which would include paying down the deficit) or we’ll decrease the overall tax burden on the country.
The alternative would be to hypothesize that we can come up with a system wherein I can have whatever I want (i.e., health care is not in any way scarce). Is that the system you’re proposing? I don’t think so. What I think that you system would involve some sort of committee who would determine whether or not I get X, regardless of what I want and I’d have no say in that particular case. After all, you rationalize, Tom doesn’t need that procedure. But what if I want it and you say ‘no’? Is that rationing, or not?
Toom–
Imagine that your girlfriend wanted a necklace that cost $1,000 and wanted you to buy it for her.
You say “no,” saying if you want it, you can buy it. But I don’t think you need it and I’m not going to buy it for you.
Is that rationing?
The point is that if you want a medication or procedure and there is no
medical evidence that you need it (or that it is effective) you can always buy it for yourself, but you can’t expect the rest of us to pay for it.
Maggie,
In regard to your saying: “The point is that if you want a medication or procedure and there is no
medical evidence that you need it (or that it is effective) you can always buy it for yourself, but you can’t expect the rest of us to pay for it. ”
I would agree with you where experimental, cosmetic and “non-essential” procedures are concerned. But I have doubts that this will always be the standard.
The state of Oregon had a public health initiative where they specifically listed a list of medical procedures (about 700, I think) and basically “drew a line” — below this line, there were roughly 200 procedures that will not be covered. And included in the procedures that didn’t make the cut were proven restorative and palliative treatments.
It wasn’t because Oregon didn’t recognize the value of these procedures — it came down to the fact that it cost too much to cover everything, so they had to cut some of the useful procedures seen as “less critical” and perhaps a bit less cost-effective. When medically necessary care is withheld due to financial constraints, yes, I think it’s fair to call that “rationing.”
Tom–
Oregon’s list applied to Medicaid patients only.
And yes, Medicaid has always been a “poor program for the poor.”
This is because when LBJ
finally got Congress to pass Medicare and Medicaid (all part of one piece of legislation), Southeners in Congress refused to vote for it unless Medicaid would pay doctors and hospitals significantly less to treat poor patients than Medicare paid providers to care for elderly patients.
Why? Are poorer patients easier to treat?
No. But Southerners in Congress didn’t want white
hospitals and white doctors treating black patients.
As a result, Oregon didn’t have enough funding for its Medicaid patients to
cover everything that they truly needed. The governor at the time–John Kitzhaber–was also an M.D. (an emergency room doc) and he was furious about this. But he was trying to do the best he could with the little Medicaid money he had.
And, unlike most governors, he wanted to make it perfectly clear: we already ration healthcare in the U.S.–by ability to pay. Poor people get less, and die earlier.
Maggie,
The necklace metaphor does not apply for at least two reasons: jewelry is not something that is ‘necessary’ and there’s no standing monetary cost to her regardless of whether the necklace is bought or not.
A (marginally) more accurate metaphor would be that I’m charging my girlfriend (don’t tell my wife!) a monthly ‘jewelry fee’ of, say, $200 and then I say no to the necklace that she ‘needs’.
Tim makes a good point. I would hope, however, that whatever sort of deal the Universal Insurance side is offering would include experimental treatments. After all, to refuse some dying cancer patient an ‘experimental’ drug would be both inhumane and bad for research.
Maggie:
I’m convinced. Those in the wealthier areas get more “thorough” medical care. This includes tests of marginal necessity, etc.
I just don’t see what can be done about rationalizing the degree of medical care so that it is more uniform nationally, or by demographic sectors.
This country is currently in a “I’m going to get mine” mindset. This can be seen in the way CEO’s and other middlemen are compensated. When one gets gouged by everyone from the plumber to the dentist, then one feels justified in gouging back.
To restrict services would imply some sort of government intervention in exactly what health services would be covered. This is the HMO model which was a complete failure.
If we go to a government-administered plan (like in the UK) then doctors essentially become government employees. This is the dread “socialized medicine” that the GOP is already fighting.
If we go to universal coverage, but through private insurers, then what is the mechanism for controlling the services?
Even passing comprehensive coverage seems difficult, so getting costs under control at the same time seems almost impossible. It would be interesting to hear some wise heads on how the resistance is going to be overcome given the current political realities.
Robert–
Thanks for your comments.
You wrote: “I’m convinced those in the wealthier areas get more ‘thorough’ medical care. This includes tests of marginal necessity, etc.”
But look at the map– the states where people get the most expensive, most aggressive care (dark blue) are not, by and large, the wealthiest states. Look at the South.
(In the South, for-profit hospitals may well have something to do with the degree of over-treatment as they add unneeded beds –and then fill them.
And we’re not talking about more “thorough” care in term of mroe careful care. We are talking about more aggressive care.
In the darker states you are more likely to die in an ICU. You are more likely to undergo not just unncessary tests, but unncessary surgeries. You are more likely to be seen by 10 or more specialists during your final six months of life–many of them “doing” something to you. This is overtreatment that is hazardous to your health. More care is not better care.
Better care (for example the care you get at the Mayo Clinic) tends to be less expensive. (Medicare spends less when a patient is treated at Mayo than when a very similiar patient is treated at UCLA’s hospital, for example)
Again– let me suggest that you take a look at the paragraph that begins “As regular readers” click on “from the Dartmouth Medical School, read the article a nd I think you’ll have a better idea of what I’m talking about.
You also say : “I just don’t see what can be done about rationalizing the degree of medical care so that it is more uniform nationally, or by demographic sectors.”
Medicare is going to begin rationalizing medical care by refusig to pay for unncessary care in areas thar are overspending. The Medicare Payment Advisory Commission is already figuring out how to do this. (The alternative is for Medicare to run out of money, to cut payments to physicians by 20% -or to raise the Medicare taxes taken out of your paycheck by a steep amount. Politicallly, thse are non-starters. )
YOur right that it seems that “This country is currently in a ‘I’m going to get mine’ mindset.” and people are not going to like it when Medicare begins to say no–just as they didn’t like it when HMO’s said no.
But there’s no choice. Health care inflation is too steep; Medicare is running out of money.
The good news is that both the Medicare Payment Advisory Comission and the leading plans for health care reform all call for an independent institute to compare the effectiveness of various products and procedures and then decide what to cover baeed on what medical evidence shows to be most effective (quality) rather than just price (which is how the for-profit HMOs tended to make their decisions in the 1990s.
Once Medicare decides not to cover soemthing, private insurers will follow suit–as they do now.
Meanwhile, the health care system in this country is already changing–even if conservatives don’t like it
Younger doctors coming out of medical school prefer to work for a large organiziation on salary. Most don’t want to try to run their own small business (a small private practice) and they want regular hours.
And the majority of doctors now want to see a complete over-haul of our health care system. MOre than 50% say they want something like “Medicare for All” In this, they are less conservative than he public–because they have a better understanding of the problems in our current system.
Change is always painful–and distruptive.
But change is also inevitable. Things never stay the same.
As Winston Churchill once said “Eventually the Americans always tdo the right thing–after trying everything else.” (For a long time we said we would never get involved in WW II. Finally we did–even though it required enormous sacrifice.)
You’re right that overcoming resistance will be difficult. But as more and more middle-class people find themselves priced out of our health care system–because their employers are no longer able or willing to pay 60% of their premiums–something will have to give.
I am afraid this is a “the worse things get, the better they (eventually) get situation.
Also, while it does seem that we have been going through a period of excess and self-indulgence for the past 20 or 25 years, the history of this country (like the history of the world) tends to consist of pendulum swings.
Many people compare the 1990s to the “gilded age” early in the 20th century–a period of great prosperity for a few.
What followed was the Great Depression begininng with the crash of 1929-1930.
And what followed that was the “New Deal’– Roosevelts reforms, Social
Secuity etc. as we began to take a more collective view of what would be best for the many rather than just for the few..
Right now, we’re in the early stages of a steep recession. I don’t think that it will turn out to be the equivalent of the Great Depression. But I do think there is a very good chance that it will be as bad as the early 1970s–perhaps worse.
This, in turn, could lead to a strong reform movement.
(On economic cycles, you
might want to take a look at my book: “Bull!: A History of the Boom and Bust . . . used copies are available at a low price on Amazon.)
Maggie,
Where did you get the datum that 50% of doctors want to see ‘Medicare for all’. It seems to me (from reading blogs and talking to physicians in my area) that private docs are straining to stay afloat and still take Medicare. So, many of them are dropping it.
As for the idea that we ‘have no choice’, you’re right in the we need to do something. However, as to what that something should be, we certainly do have a choice, we can choose your path, or we can choose a Free Market path.
Tom,
In my state alone we did a survey through the medical society and found 70% were in favor of a single payer system. Don’t trust the blogs to assess doc attitudes, most of us dont have time to blog.
Also, medicare for all or free market are not the only choices, there is socialized medicine, there are many hybrid models out there, look at how the swiss do it. Also, if you read the bill written as “medicare for all” you will see it is a very different animal than the current medicare system.
Tom-
This is a healthcare blog, not a political blog.
And this post is about
variations in care, nationwide, and the Commonwealth Report on the relationship between spending more and quality of care.
Just repeating the same points about the free market and choice really doesn’t advance the discussion.
Fair enough. Here’s a quote from your post that I think might help advance the discussion:
“Moreover, leading states consistently outperform lagging states on most of the 32 “indicators” of performance. This is one reason why we don’t want to leave health care reform up to the states: a third of the nation could easily be left behind.”
I’m not sure why you’re worried about 1/3 of the nation being ‘left behind’. Do you think that California is going to sit idly by while Minnesota takes off into the future of ‘ideal health care’? They have voters, politicians, doctors and taxpayers, right? And if they do, what business is it of mine here on the east coast? I know that we all have a desire to be ‘fair’, but is it fair to Minnesota to take away their apparently great health care system so that we can try to drag California out of the dump?
So, it is and our job to find the best way to go forward from here since we all agree something needs to be done. I think the data referenced in this post provide an as-yet unmentioned opportunity. Since some states are better than others, we have the perfect opportunity for the bottom-performing states to learn something from the top-performers. The top-performers have already gone through a process of trial and error and I can see no reason why the current bottom-performers couldn’t quickly catch up and perhaps even surpass the current top-performers’ current marks.
A typical response to this might be, “Why not just let the federal government do what you’re suggesting and make everyone ‘equal’, wouldn’t that be more fair?” I would respond that the fed gov is a monstrous organization, and to call it such is an insult to all monstrous organizations. It can be good at some things, but given the “…rich geographical diversity of the United States…” what makes anyone think that one central authority is going to be able to solve each individual locality’s difficulties better than the people at the local level? To modify a line from the short-lived TV series Firefly, “They united all the states’ health care under one government, so everyone could be interfered with or ignored equally.”
I know that there are a lot of people who like passing the buck to the federal government in hopes that they’ll find the right answer. Unfortunately, they rarely do. Health care delivery (not just ‘insurance’) is an extremely complex task. It requires knowledge of individual patients and cannot be itemized and pigeonholed into an Excel spreadsheet by some NHS-like agency. I believe that keeping control (and cost) at the most local level possible will allow each locality to deal with the unique problems of their geographical region.
Another thought about the methodology of this study here — I’m not so sure “access” and “potentially avoidable use of hospitals” should really be separate factors, since they seem very intertwined. I would contend that it is the lack of access to basic and preventative care which leads to misuse of the ER for non-emergency care (and minor problems that become major ones because of the lack of early intervention).
As a result, I think those states with “access” problems are pretty much doomed to have a bad rating in “avoidable hospitalization”, and as such this feels like a “double counting” of one factor against these states.
There’s a delicate balance of Medicare reimbursement, quality of care, and defensive medicine. First, let me give of an example where the right balance seems to have been found.
Medicare does not reimburse on an item-by-item, fee-for-service basis. Rather, they have flat payment for what they call “Diagnosis Related Groups” (DRG)
One hospital system with which I work looked at the DRGs on their patient mix. Unfortunately, I can’t remember if the 45% figure that sticks with me was for total cost or percentage of diagnoses. In any event, the DRG for (congestive) heart failure headed the list.
CHF patients were also among the most common in the ICU. There’s little argument that someone on a ventilator, with certain highly invasive sensors, needs to be in the ICU. Their rule, however, was that any patient that was receiving either of two drugs intravenously, they had to stay on the ICU. They thought about that assumption, and started transferring the CHF patients that _only_ needed that specific treatment to stepdown units, and we built an automated tool that alerted all nurses to the close monitoring needed. It worked beautifully, and the hospital took much less of a hit on incredibly expensive ICU beds.
Other rules, on which I’ve posted previously, make less sense. They’ve established a list of 13 complications that they won’t reimburse. Unfortunately, the cheapest medication to treat one condition on the list is most apt to cause one of the other conditions.
The additional marketing cost for me-too drugs is a load on the national budget. From a complexity standpoint, however, a variant drug isn’t always equivalent. One of the nastier cases I’ve seen is within one manufacturer. A widely used and effective drug of theirs does have side effects in many patients. This particular drug has to undergo several chemical transformations in the body before the effective metabolite is present and can work.
The company developed a variant of this drug, in which one of the transformations is done during manufacturing. It appears that by-products of some of the transformations are causing many side effects. They timed release of the second, clearly superior drug, to when the first drug went off patent. In other words, a member of what was, years ago, called the “ethical pharmaceutical industry” deliberately held back a better drug, which should have replaced the old, to maximize their patent monopoly time on both drugs.
Tim, HC Berkowitz, Tom
Tim–You’re right that lack of access and unncessary hospitalizations can go together insofar as a patient who is uninsured (or has a high deductible he can’t afford) may not get regular care until his problem becomes acute, and he lands in a hosptial.
But if you look at the table, you’ll see that unncessary hospitalizatoins is also a problem in states like New York, Mass. and CT. where access is very good. These are states with lots of beds and lots of specialists, and research shows that in these states, patients are often
put in hospitals when they don’t need to be there. (The same is true of Medicare patients in Florida.
HCBerkowtitz–You’re right, Medicare will always have to struggle to find that delicate balance between overtreatment and undertreatment.
Tom-
You write:
“I think the data referenced in this post provide an as-yet unmentioned opportunity. Since some states are better than others, we have the perfect opportunity for the bottom-performing states to learn something from the top-performers. The top-performers have already gone through a process of trial and error and I can see no reason why the current bottom-performers couldn’t quickly catch up and perhaps even surpass the current top-performers’ current marks.”
That’s exactly what we would like to see.
But change is difficult, even when it is from worse to better. People like what is familiar.
Research shows that in states where Medicare patients routinely see 7 or 8 specialists, and rarely see a primary care doctor (which means that no one is co-ordinating their care) they like it that way. This is what they are accustomed to. IF they were told they had to go through a primary care doc who would serve as their medical home,helping them keep their records in order, they would be unhappy.
If you told them that they really don’t need to see an orthopod and get MRIs on that knee that has been bothering them for 20 years (but not really getting any worse), they would be offended.
Similarly, doctors who practice in commmunities where there are lots of hospital beds may think nothing of hospitalizing a frail patient suffering from congestive heart failure because it will be easier, that way, to subject her to a battery of tests (ignoring the dangers of being in a hospital). They feel lthis is the “best” way to practice medicine; they are accustomed to doing things the way they do them.
Differences have to do with supply, but also with tradition. Minnesota’s way of practicing medicine can be traced back to the Mayo Clinic– a collective which has always paid doctors on salary (so there’s no incentive to provide extra services in order to make extra fees) and where doctors work together, as a team (which makes for better co-ordinated care.)
in Southern California, by contrast, more doctors work fee-for-service in solo practices, which makes for less efficient, more expensive care–and increases the chances of hazardous overtreatment.
The “top” doctors who do high volume also make much more than the doctors at the Mayo Clinic.
Why should you care if California ever learns to do it the way they do it in Minnesota? Becaues you are paying for it.
If you live in Minnesota, you are paying the same percentage of your paycheck toward Medicare as someone in California–yet Medicare will spepnd an average of twice as much on him after he turns 65. That’s why your Medicare deductibles are likely to continue to rise.
Clearly, that’s not fair. So why not just make
Medicare a state-by-state program, and let the citizens of each state fund it and spend the money on their own residents?
Because some states are much, much wealthier, per capita, than others. Some, like New York and New Jersey, have a much larger number of poor people than other states. Some, like Alambama and Mississippi are very poor.
But we’re all Americans–which is why many people feel we all have the same basic right to good healthcare. That’s what I mean by “solidarity.”
And the only way to improve the quality and efficiency of health care, nationwide–to reduce waste and curb inflation by improving quality–is if the National Institute of Health (or some other independent body) begins to set guidelines for “best practice”–based on medical evidence–and to question doctors and hospitals that are constantly straying from best practice.
Here I’m not talking about NIH creating rules, but guidelines.
And then Medicare needs to let hosptials and doctors know if they are outliers. (Many don’t realize that the way they are practicing medicine is much more expensive and less efficient–again, it’s what they’re used to.)
Medicare needs to ask these providers why the care they provide is so often more expensive–even though outcomes are no better. This alone will encourage some to improve. (Doctors are competitive)
Others may need a little pressure–i.e. Medicare telling them it that it will no longer reimburse them for repeated treatments that fall outside of what medical evidence shows as “best practice.”
An individual patient here and there might well need to be treated differently (that’s why we need guidelines not hard and fast rules), but if most of a doctor’s practice is costing Medicare twice as much per person as the norm, and the patients are not much sicker, or poorer or older than the norm–something is wrong.
Maggie,
Your proposed NIH ‘guidelines’ sound very nice, warm and fuzzy. Unfortunately, I don’t believe for half a second that they would remain ‘guidelines’ for every long. If hospitals and doctors didn’t shape up, I’m confident the government would replace the carrot with the stick in no time flat.
Other than that, it sounds like your argument is based on two things: 1) the assumption that individuals don’t know what is good for them and they need someone smarter telling them what to do and 2) everyone should be treated based on the average. On these things we’ll likely never agree, and that’s ok.
I find #1 insulting and #2 dangerous. However, my goal here is really only to get everyone’s motivations and basic believes out into the open. I believe that you really want to help people, I just think you’re going about it the wrong way. Thanks for hosting this discussion.
In closing, all I ask is that everyone bear in mind that once a power has been ceded to the government, it is very difficult to take back…even if you don’t like how the original power has morphed in something new.
To Tom — I recognize that it can be difficult to get back a power ceded to the government, but I believe it is even harder to get back powers ceded to interests for which there is no equivalent to throwing an elected individual out of office. Maximizing quarterly stock price is not consistent with the historical quality approach of many pharmaceutical companies, but it’s todays’ reality. I am not wedded to single payor, seeing how well the German system works, but I don’t believe handing all power to essentially unregulated commercial insurers adds value.
And yes, I did go through a phase when I desperately wanted to date Dagny Taggart or Dominique Francon.
Maggie, one thing that often gets ignored in these discussions, but, if not an 800 pound gorilla, it’s a 400 pound smaller ape: EMTALA. In and of itself, for the intended purpose, EMTALA is a good idea. My usual argument for its proper application is when a naked and unconscious Bill Gates rolls into an ER — with no EMTALA, he might die for lack of a visible insurance card.
The problem, of course, is that EMTALA has become a double-barreled unfunded mandate, with the needed funding coming from cost shifting. EMTALA is logical when a gunshot wounded gang-banger (or bystander) rolls in to a trauma center. In some of those cases, the hospital can get the individual on Medicaid, but all too often, they eat the cost.
A definitely unintended consquence of EMTALA was turning ERs into urgent care, or even general medical, clinics. EMTALA funding needs to be in these discussions.
HCBerkowitz:
What power have we ceded to non-governmental organizations?
In response to Tom, and frankly doubting you are being serious, the power of determining what care can be given has significantly been surrendered to medical benefits managers (a broader term than insurers, to include ERISA). There is significant evidence that many of these decisions do not reflect cost-benefit data, but maximization of quarterly process.
A more complex issue is the availability of all clinical trials, regardless of sponsorship. This is not something for which I consider the pharmaceutical industry completely at fault, but it is a reality that new drug approval requests, and timing thereof, are driven by marketing strategies as much as by outcomes research, implementing true improvements and withdrawing therapies of minimal benefit.
I still didn’t get a date with Dagny.
HCBerkowitz:
I was being serious, but I was only wondering exactly what you were referring to. I happen to agree with you, btw.
To be fair, the fact that we only see the results of pharma-sponsored clinical trials doesn’t really set them apart from any other research. It’s called, as I’m sure you’re aware, publication bias.
The issue of third party payers determining treatment decisions is a huge problem. The thing is, I don’t think the problem will be solved by handing over treatment decisions to some benevolent dictatorial government committee. This is evidenced by the difficulty many are having in finding a doctor who will accept Medicaid/Medicare.
I happen to think that the only way to drive down price while maintaining supply is to open up the medical world competition (via the free exchange of goods and services among willing parties)…but that solution finds few supported around these here parts (although it does address the issues of cost/benefit ratio, which you correctly identified as being paramount).
“Reputation is one thing; medical evidence about quality of care, access to care, unnecessary treatments, excessive costs and bad outcomes is another. U.S. News & World Report is good at many things; ranking hospitals is not one of them.”
With regard to US News & World Report, I agree and have written to them several times over the years.
I also agree with the entire paragraph. I also would label this study “accurate” because I live in Houston.
However, I have to wonder, what is the source (“medical evidence”) for the information? In reading the factors that were measured, how did they measure them? Where did the data come from? Medical records are largely inaccurate, hospitals are not required to disclose…almost everything. In reading through the factors measured, I can spot several (quality and unnecessary hospitalization), that in our experience would have rated an “F” for failure. Scientists and researches who study these issues would have no way of knowing or tracking or including our outcome unless they read my book. I’m just curious if their source was voluntary disclosure by hospitals. Also, I think additional key factors to measure quality are infection control, consistency of caregivers, nurse to patient staffing ratios and wholeheartedly feedback from nurses (employee satisfaction) and patients. Again, with the first three we’re dependent on voluntary disclosure, which hardly ensures accuracy and objectivity.
Hey Lisa,
Thanks for your comment and question.
Much of the evidence for what I’m talking about
can be found in the research that Dr. Jack Wennberg and colleagues have been doing at Dartmouth over the past three decades.
Given what you have said in your comments, I suspect you would find their research extremely interesting.
For a in-depth, reader-friendly (I hope) summary of what they have discvered (and who they are) you might want to see
these two pieces that I have written at http://dartmed.dartmouth.edu/spring07/html/atlas.php
and
http://dartmed.dartmouth.edu/winter07/html/braveheart.php
Just cut and paste the URLs If, for some reason, they don’t work,
then just Google my name
and “Dartmouth Medicine and “Spring 2007” and and “Winter 2007”.