Quantity of Medical Care Doesn’t Guarantee Quality

More medical care does not necessarily mean better medical care. That’s what researchers at Dartmouth School of Medicine have concluded from a nationwide study looking at variation in spending, along with health outcomes and patient satisfaction. Their report, “The Implications of Regional Variations in Medicare Spending,” appears in the February 18 Annals of Internal Medicine.

Lead author Elliott S. Fisher, M.D., told Psychiatric News that the study confirms many previous reports demonstrating wide variation in health care utilization and spending from region to region and within states.

“We have known for 30 years that there are big differences across regions and in neighboring communities in the amount of care provided to similar populations,” Fisher said. “What we haven’t known is what this means in terms of outcome for those who are receiving less or more.”

He is co-director of the Veterans Administration Outcome Group and professor of medicine at Dartmouth School of Medicine.

What Fisher and colleagues found would appear to turn conventional wisdom on its head: people in higher-spending regions received approximately 60 percent more care than those in other regions, but this increased medical care did not result in better satisfaction or health outcomes.

“It contradicts the general assumption that more medical care means better medical care,” Fisher told Psychiatric News.

In the study, Fisher and colleagues looked at care of Medicare patients hospitalized from 1993 to 1995 for hip fracture, colorectal cancer, or myocardial infarction, and of a representative sample drawn from the Medicare Current Beneficiary Survey.

They examined the frequency and type of services received, quality of care based on recommended best practices—such as whether patients received flu vaccine or were given aspirin after a heart attack—and access to care.

The average baseline health status of the cohort was similar across regions of differing spending levels, but patients in higher-spending regions received 60 percent more care.

The researchers were able to compare the actual amount of care being provided in different regions, independent of the variation in cost services from region to region. They did this by using the End-of-Life Expenditure Index, a measure reflecting the regional-variation component in Medicare that is due to physician practice rather than regional differences in illness or price.

Fisher reports that the increased utilization in higher spending regions is attributable to more frequent physician visits, especially in the inpatient setting, more frequent tests and minor procedures, and increased use of specialists and hospitals.

“What we see is that in the higher-spending regions, the additional services are almost entirely discretionary,” Fisher said.

Higher-spending regions also had more frequent psychotherapy visits—nearly three times more than other regions. “Our hypothesis is that there are more therapists in those regions,” Fisher said. “The higher-spending regions are those that typically have more specialists.”

But APA Vice President Steven Sharfstein, M.D., an expert in health care economics, said the continuing discriminatory coverage of mental illness—in both the Medicare and private pay markets—makes it difficult to apply the study’s lessons to psychiatry.

“It has been well known for a long time that the supply of medical and psychiatric care has an important influence on the cost of care,” Sharfstein said. “But the major problem for psychiatry is the continuing discriminatory coverage under Medicare.”

Sharfstein cited the 50 percent copayment for psychiatric care—in contrast to 20 percent for medicine—and the 190-day lifetime limit for psychiatric hospitalization as particular burdens for those who are seriously and persistently mentally ill.

“Underinsurance for psychiatric care remains the number one public policy issue for our patients today,” he said.

Yet quality of care in the regions where people received more care was no better on most measures. For instance, patients were no more likely to receive aspirin after a heart attack or receive a beta-blocker upon discharge, or to receive flu and pneumonia vaccines.

High technology, end-of-life care is often assumed to drive health care spending, but Fisher said that people in the regions where people received more care did not necessarily receive more major procedures—such as bone marrow transplants and bypass surgeries—to extend life.

“What we do see is much more aggressive use of the intensive care unit and a greater likelihood for the use of feeding tubes and intubation,” Fisher said.

Again, the regions where people received more care did not see a gain in survival. Remarkably, Fisher said the study found a 2 percent to 5 percent higher increased risk of death in regions that provide more care.

Can the findings reasonably be applied to the private-pay population?

Fisher believes so. “Medicare practice patterns are highly correlated with practice patterns for the care of those under 65,” he said.

If so, reduction in variation and adoption of conservative practice patterns typical of lower-spending regions would have enormous consequences for the nation’s health care system.

“It suggests that 30 percent of all spending is at stake, and potentially we could be saving up to $400 billion a year if we could practice more conservatively,” Fisher said.

The barriers to achieving such savings are significant, he added. Principal among them is the pervasive cultural belief that more care means better care. “The press and commercial messages from the drug and device industries all strongly reinforce the notion that more medical care means better care,” Fisher said.

Moreover, incentives to provide more care—rather than more efficient or better-quality care—are built into reimbursement structures. “We currently pay physicians and hospitals to provide more care, not to provide better care,” Fisher said. “So any solution will require rethinking the financial incentives built into the system.”

In the meantime, Fisher said the findings suggest at least some directions the health care system should avoid. “We should not be thinking about increasing the number of specialists or increasing spending on health care,” Fisher said.

An abstract of “Implications of Regional Variations in Medicare Spending” is posted on the Web at www.annals.org/issues/v138n4/abs/200302180-00006.html. ▪