December 04, 2008

Don't Just Do Something, Sit There

All over the country, hospitals are setting up “rapid response teams.” The idea is to intervene quickly when a patient looks as though he might be going downhill—for example if his blood pressure is falling or he’s breathing very rapidly. The expectation is that this preventive approach will avoid cardiac arrests, emergencies in which a patient’s heart stops and respiration ceases. Massachusetts recently passed a law that requires hospitals to put rapid response teams in place (The Act to Promote Cost Containment, Transparency, and Efficiency in the Delivery of Quality Health Care). The only problem is that there is now pretty good evidence that the teams don’t save lives.

A study in this week’s Journal of the American Medical Association is the first large, carefully conducted study of the effect of a rapid response team, taking into consideration normal seasonal variability in the rate of cardiac arrest and death. Carried out at a medium sized tertiary care hospital in Kansas City, Missouri, the investigators found there was no decrease in the frequency of cardiac arrest after the intervention was introduced and no change in the mortality rate at the hospital.

What was particularly striking about the study is that at first glance, it looked as though the rapid response teams were effective: the crude code rate (number of cardiac arrests per 1000 hospital admissions) fell from 11.2/1000 to 7.5/1000. But when the physicians carrying out the study adjusted for normal month-to-month changes in the frequency of cardiac arrests, the differences vanished. Failure to look at the consequences of rapid response teams over a long enough period of time and to calculate the effect of seasonal changes may have accounted for the positive results in earlier, preliminary studies.

The other startling finding in this study is that of the 70 patients who died despite the rapid response team interventions, fully 46 decided on a do-not-resuscitate status after their evaluation. In other words, the rapid response team stimulated a discussion among physicians, patients, and families about the fact that the patient was very ill and doing poorly. The result of this discussion, in many cases, was an explicit decision to limit invasive and painful interventions that had only a small chance of success.

What can we learn from this provocative study? The first is that it’s a bad idea to institute sweeping changes in medicine without good evidence that the changes will have the desired effect. Several physicians expressed skepticism about rapid response teams when they were becoming the vogue (for example, "Rapid Response Teams—Walk Don’t Run," JAMA 2006). A review of the subject done by the Cochrane Collaborative, a group that undertakes systematic reviews of all kinds of questions in medicine to determine whether the preponderance of evidence support their use, found no evidence of benefit from rapid response teams. But despite these calls for caution, the Institute for Healthcare Improvement recommended that all hospitals adopt rapid response teams. The intervention may turn out to be more effective than the current study suggests—the JAMA study was at a single hospital and used a particular combination of two ICU nurses and a respiratory therapist with ICU physician backup; other institutions using other types of clinicians may achieve different results. But what is clear is that sweeping policy changes in medicine, changes that involve many resources and great expense, should be preceded by correspondingly extensive evaluation.

The second conclusion to be drawn is that the best time to engage patients and families in advance care planning—talking about what approach to medical care they want if they are extremely ill—may not be when they are doing well and may not be when they are in the middle of a crisis. Rather, the best time to consider what they hope treatment will accomplish for them, and what treatments are consistent with their goals, may be when they have just come through a serious illness. We know, for example, that patients are particularly susceptible to advice to stop smoking right after they had had a heart attack. That, of course, is a bit late, but a recent study found that after any hospitalization, whatever the medical problem, patients are good candidates for giving up smoking (Rigotti et al, “Smoking Cessation Intervention for Hospitalized Smokers," Archives of Internal Medicine, October 2008). While it would be premature to conclude that advance care planning is best done right after a close call—just as it was premature to conclude that rapid response teams are the way to go based on very preliminary data—it’s an area to explore further.

October 28, 2008

Medicare for More

The next administration will have an historic opportunity to reform the American health care system. The federal government might actually do something about the fact that 45 million Americans are uninsured, that health care costs are soaring (with spending on Medicare and Medicaid alone now accounting for 4.6% of GDP and on track to reach 20% by 2050), and that despite our extraordinary level of expenditure on health care, the U.S. ranks in last place among 19 industrialized nations in terms of quality of care (see my posting ‘F’ is for Failure on 7/22/08). Unfortunately, neither Obama nor McCain has put forward a plan that is likely to solve our problems.

What would fix the situation would be to expand Medicare to cover all Americans, as proposed by Senator Edward Kennedy (see “Kennedy and Dingell Fight for Medicare for All,” http:/ This approach has the potential to insure everyone while reducing costs and enhancing quality. And it would finally bring the U.S. in line with all other developed nations: countries such as Australia, England, France, Germany, and Canada all provide some form of mandatory universal health insurance for their citizens. They also all have lower infant mortality rates, lower rates of preventable death in people under 75—at a per capita cost half that of the U.S.

When Congress created the Medicare program in 1965, it acted in the belief that older people were somehow exceptional—they were sicker, they lived on fixed incomes, and they did not have employer-based health insurance. While some physicians, politicians, and economists hoped that Medicare would be the wedge opening the door to health insurance for all, Medicare was passed precisely because it did not promise mandatory health insurance (see the chapter, “Medicare for the Middle Class” in David Rothman’s insightful book, Beginnings Count: The Technological Imperative in American Health Care, NY: Oxford University Press, 1997). Single payer insurance was touted then and continues to be seen today as “socialized medicine,” but the expansion of Medicare does not imply a government-run system. While Medicare is publicly financed, it is a private health care system administered by private intermediaries that gives patients an extensive array of choices of physicians and hospitals.

Ironically, there is one part of the health care system in which government is actually in the business of providing medical care, and it’s a part of U.S. health care that McCain vigorously supports. That’s the Veterans Health Administration. The VHA operates the largest integrated health care system in America, which includes hospitals, outpatient clinics, nursing homes, and rehabilitation facilities. A uniform medical benefits package is available to all veterans and covers primary care, outpatient and inpatient services, and prescription drugs. Additional benefits, such as nursing home care and dental care, are available to some vets, depending on their “priority level.” The VA system is known for its pioneering work in managing chronic conditions, for its comprehensive electronic medical record, and for other quality improvement measures.

No one is recommending expansion of the VA system—it’s just not a politically tenable solution. But expanding Medicare, while clearly a difficult sell, would make a great deal of sense. Medicare is far more efficient than private health insurance plans: Medicare’s overhead is about 2%, whereas private insurers take an average of 13% of premium dollars for overhead and profit, with large managed care plans taking as much as 30% (see David Himmelstein and Steffie Woollhandler, “Why the US Needs a Single Payer Health System,” Not only would it be simple and efficient, but paradoxically, the existing Medicare program would do a better job serving the non-elderly than it does with those it currently covers.

Medicare was established to cover acute, time-limited illness. By far the largest component of Medicare expenses continues to be for hospitalization. Of the $402 billion spent by Medicare in 2006, 29% went to inpatient care, compared to 15% for physicians, 12% for outpatient drugs, and 3% for home health care (see the MedPac report, Medicare was designed to address a disease such as pneumonia in which the patient rapidly develops a significant illness, is hospitalized for a week or so (covered after a deductible), and is then discharged home to complete his treatment by taking a few days’ worth of oral antibiotics. By contrast, the typical Medicare patient today has multiple chronic conditions, which are best cared for using a model of chronic disease management: 75% of the elderly have at least one chronic disease and 50% have two or more chronic illnesses. While the Medicare Modernization Act of 2003 addressed some of the needs of today’s older patients, principally by offering a prescription drug plan, the program is still heavily weighted toward the treatment of acute illness. Its incentives, for example, promote hospital care rather than treatment in the home or the nursing home (see chapter 4, “The Trouble with Medicare,” in my book, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, Cambridge, MA: Harvard University Press, 2006). But this focus on acute care is precisely what most younger, healthier patients need. Some middle aged individuals have congestive heart failure or chronic obstructive pulmonary disease and similarly, some children suffer from chronic conditions such as asthma or diabetes; the majority do not.

The most rational approach to American health care reform is to offer Medicare to everyone, perhaps the existing plan for younger Americans and a modified version for the elderly and the disabled. The U.S. should guarantee health insurance by providing a basic insurance plan (Medicare) paid for out of tax revenues. Patients could choose to exchange their Medicare benefit for a private plan or to supplement their basic plan with a more comprehensive plan for which they would pay directly. A new, expanded Medicare program would be ideally positioned to address the other pressing issue that both Congress and the presidential candidates have largely ignored—the soaring costs of care (see my blog posting, “Going for Broke” on 12/28/2007) by controlling what medical interventions it is willing to cover and how much it will pay for them.

September 04, 2008

Massachusetts Health Care Reform--Act 2

Why isn’t everyone talking about the new Massachusetts Health Care Reform law? Is it that the Governor signed the legislation into law during the dog days of summer? Is it that the act, which introduces cost containment measures and quality improvement measures, isn’t a single issue bill like the first health care reform law, which expanded coverage to almost all Massachusetts residents?
The “Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care,” (S2863) is an important piece of legislation which should be getting a great deal more local and national attention than it has. But for all its virtues, it also has some major flaws—and it won’t make much of a dent in the skyrocketing cost of health care.
The law calls for two new programs: a pharmacy drug detailing program and a health care workforce center. The detailing program is modeled on an intervention proposed by Harvard researchers Jerry Avorn and Stephen Soumerai 25 years ago: they wondered whether the same kind of clever strategies used by drug companies to promote their wares could be used to provide physicians with accurate information about the safety and cost-effectiveness of drugs by using trained pharmacists as “un-sales reps.” Their 4-state randomized trial found that academic detail men were accepted by the overwhelming majority of physicians—and that the program saved $2 for every $1 in costs (Jerome Avorn and Stephen Soumerai, “Improving Drug-Therapy Decisions Through Educational Outreach. A Randomized Controlled Trial of Academically Based ‘Detailing,” New England Journal of Medicine 1983; 308: 1457-63). With the new health reform law, the Massachusetts Department of Public Health has been charged with arranging face to face visits to “inform prescribers about drug marketing intended to circumvent competition from generics.” How effective this strategy will be in 2008 is unclear, now that drug companies are not only targeting physicians but are also pouring money into direct-to-consumer advertising.
The law also calls for the establishment of a Health Care Workforce Center whose main purpose is to increase the number of primary care physicians in the state. Specifically, the program will set up a loan repayment program for doctors who go into primary care. A related part of the bill requires the University of Massachusetts Medical School to increase its enrollment, to add residency slots for primary care, and to waive tuition for applicants who agree to practice in under-served areas. Taking steps to enhance primary care is laudable, but as demonstrated in the recent Institute of Medicine Report, Retooling for An Aging America: Building the Health Care Workforce (see my blog entry, “the Boomers are Coming, the Boomers are Coming,” from May 9, 2008), what we desperately need is not just primary care physicians and nurses, but also a diverse array of individuals equipped to care for our growing geriatric population.
One of the few provisions of the new law that did garner quite a bit of attention is the “gift ban,” which requires health care providers to publicly report any gifts they receive from pharmaceutical or medical device manufacturing companies and which bans certain kinds of gifts altogether. Drug companies protested loudly, but as Dr. Jerome Kassirer argued in his book, On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Life ( NY: Oxford University Press, 2005), the standards promulgated under the law constitute are not radical or draconian: they simply represent a basic, ethically justifiable set of guidelines for corporate and professional conduct.
Massachusetts Health Reform, Act 2 contains a hodgepodge of other provisions designed to improve quality and efficiency of care. It requires hospitals to develop rapid response teams for “deteriorating patients,” a measure that could lead to the installation of “panic buttons” in every patient room—not necessarily a good idea. The concerns of families need to be respected and addressed, but surely it should be professional judgment and not anxious families that dictate the summoning of an emergency response team. The act will require hospitals to implement computerized physician order entry systems by 2012 and electronic medical records by 2005—which is probably a good thing, but not as well-supported by hard evidence as I would like. As Drs. Pamela Hartzband and Jerome Groopman argue in their essay, “Off the Record: Avoiding the Pitfalls of Going Electronic” (New England Journal of Medicine 2008; 358: 1656-8), electronic medical records can “constrain creative clinical thinking” and computers can “become a barrier between patients and physicians.” And the act calls for new initiatives in end of life care and in home care—laudable but at this point vague and without substance.
All these components of the new law focus on improving the efficiency and quality of medical care. The only measure that seeks to control costs by actually changing the way we do things in medicine, not merely by ensuring that we do what we have been doing but with greater efficiency, is the requirement that physicians wishing to build ambulatory surgery centers apply for and receive a “Determination of Need” certificate. The engine that drives costs is technology and right now hospitals and medical groups can build new outpatient centers for doing procedures with essentially no restrictions. And in medicine, if you build a new machine, it will be used, regardless of whether one more scanner or surgical suite actually improves the population’s health. Dr. John Wennberg of Dartmouth, who has devoted his career to the exploration of regional variations in American health care, has found repeatedly that the number of elective procedures in various parts of the country depends not on need but on the capacity to perform those procedures (see for example John Wennberg and Alan Gittlesohn, “Small Area Variation in Health Care Delivery,” Science 1973; 182: 1102-8). Controlling the untrammeled growth of technology by evaluating the need for the centers that house that technology has the potential to have an enormous effect on the future cost of medical care. The caveat is that the legislation needs to have teeth, and it is unclear how the requirement that ambulatory surgical centers demonstrate “need” will play out: how is “need” to be defined and measured? Will the cost of the center be a consideration or if there is “need” (read “demand”), is any cost acceptable? Unfortunately, current Massachusetts Determination of Need regulations for hospitals include no such considerations.
Massachusetts Health Care Reform—Act 2 is an important step in the right direction. But if we want to truly change the way health care is delivered and provide high quality care at an affordable cost, we better start working on Massachusetts Health Care Reform—Act 3.

July 22, 2008

"F" is for Failure

Federal Reserve president Ben Bernanke stood in front of the Senate Finance Committee a month ago and delivered some bad news: the cost of health care is spiraling out of control. And costs will continue to “rise relentlessly,” he said, unless Congress substantially overhauls the health care system (Robert Pear, “Fed Chief Addresses Health Care and Its Cost,” New York Times, June 17, 2008), which it has shown no inclination to do.

At the same time, Bernanke pointed to two other problems with U.S. health care: access and quality. It is these two areas that get most of the attention from lawmakers. Just how poorly the U.S. is doing in these two domains was emphasized yet again in a report released last week by the Commonwealth Fund. The results of the “National Scorecard on U.S. Health System Performance, 2008” are shockingly poor. Lumping all 37 indicators of quality devised by the Fund into one measure, the U.S. scored a 65 out of 100 (down from 67 in 2006). (“Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008,” available at I'd call that a failing grade.

In terms of access, the average score was 58, with 75 million working age adults—42% of the population—either uninsured or underinsured, up from 61 million (35%) in 2003. The direct consequence of lack of coverage is that the U.S. is now in last place among 19 industrialized nations in terms of deaths that could have been prevented with timely and effective care. In terms of quality, only 41% of adults with hypertension were adequately treated—and only 21% of those with hypertension who had no health insurance.

What continues to get relatively little attention is Bernanke’s first point, the high cost of health care. The Commonwealth report notes that the U.S. spends twice as much per capita as other major industrialized countries on health care, though it fares worse on virtually all outcome measures. Even within the U.S., higher levels of spending often translate paradoxically into lower quality care: among Medicare patients treated for heart attacks, hip fractures, or colorectal cancer, the regions of the country with the lowest mortality rates also had lower total costs.

The presidential candidates say laughably little about health care costs. A side-by-side comparison of their statements on health care reveals only a few points about cost. The democratic and republican proposals are limited, unimaginative—and remarkably similar (see the analysis by the Henry J. Kaiser Family Foundation, “2008 Presidential Candidate Health Care Proposals: Side-by-Side Summary,” at

Both Obama and McCain advocate malpractice reform and greater competition among insurance plans. Both candidates allude to the high cost of prescription drugs and favor encouraging the use of generics, and both talk in general terms about the need for increased attention to preventive care and the treatment of chronic conditions. These are all important issues but they will not solve the problem of the high cost of care. Obama specifically advocates investing in electronic medical records and health information technology (to improve efficiency) and McCain wants to give consumers more information about treatment options (in the na├»ve hope that they will choose less expensive care). But neither talks about the real culprit—the excessive use of high cost technology, even when it is of little or no benefit (see for example Kenneth Thorpe et al, “Which Medical Conditions Account for the Rise in Health Care Spending? Health Affairs, August 25, 2004).

The New York Times, by contrast, is finally beginning to understand the role of technology in driving up the cost of medical care. Over the last month, the Times has featured an article about the use of Avastin (Bevacizumab), a form of chemotherapy costing as much as $100,000/patient/year (Gina Kolata and Andrew Pollack, “Costly Cancer Drug Offers Hope, But Also a Dilemma,” New York Times, July 6, 2008) and another article about the use of an implantable defibrillator in a 99 year old woman (Anemona Hartcollis, “Rise Seen in Medical Effort to Treat the Very Old,” New York Times, July 18, 2008). But both articles wistfully conclude that we are facing a heart-rending dilemma, what the journalists view as an insoluble conflict between the legitimate wish of sick patients to get better and the societal need to constrain costs.

In fact, there is a perfectly reasonable solution: physicians should be restricted in their use of expensive technology to situations in which it has been demonstrated to be beneficial; and Medicare should set reimbursement for high tech interventions at a level reflecting their cost-effectiveness. In the case of Avastin, for example, it may be rational to prescribe the drug for those forms of cancer for which it has been shown to be beneficial, even when the benefit is the prolongation of life by only several months, but not for other forms of cancer for which efficacy is entirely speculative. Moreover, Medicare should set reimbursement at a rate commensurate with benefit, as is done in Australia. When this has been done in the U.S., as when the Centers for Medicare and Medicaid set the reimbursement rate for the left ventricular assist device (an invasive, expensive, but occasionally modestly effective means of treating advanced heart failure) well below the manufacturer’s charges, the rate of use stayed very low. In the case of the defibrillator/pacemaker, which in the Times example was inserted to prevent symptoms of dizziness and weakness, it would have sufficed to implant a pacemaker (cost $11,712 in FY 2005). There is no need to deprive a patient of an effective treatment that will ameliorate symptoms simply to control costs. The problem is that the patient was given a combination defibrillator/pacemaker, a sophisticated device intended to prevent sudden death as well as to counteract a low heart rate—more than doubling the cost ($28,442 in FY 2005) without conferring any advantage in terms of quality of life. The total annual spending on implantable defibrillators in the U.S. is over $1 billion/year, some of which is clearly beneficial, but some of which is not.

Improving access and quality, while tremendously important, will just exacerbate the cost issue if we tackle them without simultaneously addressing cost. It is time for Congress, the Administration, the presidential candidates, and the American people to stop burying their heads in the sand. U.S. health care just got a failing grade: if you sent your child to an expensive private school and he came home with F’s and D’s on his report card, would you blithely and unquestioningly continue to fork out exorbitant tuition payments because the headmaster assured you the school was the best in the world?

May 09, 2008

The Boomers are Coming, the Boomers are Coming

I often wonder just how many billions of dollars Americans spend every year on producing reports. Think tanks, government agencies, and academic departments, not to mention corporations, are forever releasing reports. Most of them are filed away, largely unread, certainly unheeded. Every so often a report actually has a major impact—on policy, on behavior, or on public understanding. The Surgeon General’s Report, The Health Consequences of Smoking, first released in 1971, led to a campaign to promote health by quitting smoking. As a result, per capita cigarette consumption is down in the U.S., as are the incidence of lung cancer and the death rate from heart disease, the primary diseases attributable to smoking.

Several weeks ago, the Institute of Medicine released a new report, Retooling for an Aging America: Building the Health Care Workforce. With luck, this will be one of those reports that triggers a response, but given its low key presentation, unsexy topic, and unpopular message, I fear it will be ignored.

Written in the non-inflammatory, academic style of the IOM, Retooling quietly argues that if we are to provide high quality care for the baby boomers in their old age, we need to geriatricize both health care professionals and personal caregivers. In an equally subdued voice, the report’s writers also conclude that we need to overhaul our entire approach to medical care. They’re right. I hope someone is listening.

The first of the 78 million baby boomers will turn age 65 in 2011. When the last baby boomer turns 65 in 2030, “older adults” will make up 20% of the population, up from the current 12%. Unless we find a cure for Alzheimer’s disease in the immediate future, which is extremely unlikely, and unless we can prevent or cure osteoarthritis, diabetes, and vascular disease, the boomers will develop all these problems in phenomenal numbers. Although they will be healthier than their counterparts a decade ago, many will eventually develop multiple medical problems and will need both health care and personal care if they are to hope to have a reasonable quality of life.

What the new IOM report tells us is that we do not have enough physicians, nurses, social workers, and physical therapists with special expertise in taking care of older adults to handle this enormous wave. We do not have enough home health aides and other personal care attendants to assist older people with basic “activities of daily living” such as dressing, bathing, and eating, given that we can expect that in 2030, over 9 million people will need this kind of help (that’s based on another important report, this one by Robert Friedland, writing for the Georgetown University Long-Term Care Financing Project in 2004: Caregivers and Long-term Care Needs in the 21st Century: Will Public Policy Meet the Challenge?) And informal caregivers—the family members and friends who provide the bulk of the care to frail older Americans—are already overwhelmed physically, emotionally, and financially by their responsibilities.

Retooling for an Aging America tells us very clearly what steps we need to take to begin to fix this problem. It uses the bland language of “increasing recruitment and retention” of personnel, but quickly gets to the central issue: few people are going to jump at the chance to take care of the elderly, whether they be physicians, nurses, or home health aides, unless they receive appropriate recognition, social and financial, for their work. That means compensation needs to go up—a lot. Currently, geriatricians earn on average less than the primary care physicians who see a more diverse population of adults, who in turn earn far less than gastroenterologists or cardiologists. Taking care of frail older people takes extra time, it requires coordination of multiple services, and it necessitates discussions with family members, all of which are reimbursed poorly or not at all. The suggestion that public and private payers provide financial incentives to increase the number of geriatric specialists in all health professions is key. So too is the recommendation that professionals with special expertise in geriatrics receive enhanced reimbursement, though given budgetary constraints, it seems more plausible that physician incomes will need to be redistributed than that payment to those on the bottom end of the totem pole will rise. Similarly, aides who provide hands on care for older people are among the most poorly paid workers in our society, they have the highest rates of on the job injury, and they have few opportunities for advancement. Without better wages, adequate fringe benefits, and an attractive career ladder, it’s hard to imagine the situation will change. The recommendation that state Medicaid programs increase pay and fringe benefits for direct care workers and establish wage floors is an important first step. It does not, however, go nearly far enough, and is not as sweeping as another report that is probably already collecting dust—the study prepared by the much maligned President’s Council on Bioethics in 2005, Taking Care: Ethical Caregiving in Our Aging Society.

It is in the arena of “redesigning models of care” that the report is at its most radical. It begins with the tepid comment that “care that is currently provided to older adults often falls short of acceptable levels of quality.” Then it heats up a bit, acknowledging that the vision of health care services it proposes represents “a major departure from the current system” that will require changes in the ways services are “organized, financed, and delivered.” The report recommends three fundamental changes: care must be comprehensive, it must be efficient, and it must rely on the active participation of older adults.

By comprehensive care, the report means that our current fragmented system has to go. Right now, Medicare doesn’t have an incentive to provide home care because it would be cheaper for patients to go into a nursing home (paid by Medicaid or private funds) than it is for patients to stay at home and have a visiting nurse and physical therapist (paid by Medicare). Today, physician practices shy away from using multidisciplinary teams, the backbone of good geriatric care, because this kind of care is inadequately compensated. Comprehensive care means including both acute care and long term care (at home, in assisted living, and in nursing homes--currently the stepchild of the American health care system) under one umbrella.

By efficient care, the report means that we need to create seamless transitions between the sites where older people receive health care such as the office, the hospital, the skilled nursing facility, and the home setting. This will require better systems of communication and widespread adoption of a single electronic medical record.

By active participation, the report implies that effective management of chronic diseases—and almost a quarter of Medicare beneficiaries have at least 4 chronic diseases—requires self-management. Given that many older patients cannot, by themselves, engage in self-management, a more realistic recommendation would be the involvement of families in all aspects of health care.

So far, Retooling has been written up in the Wall Street Journal and the LA Times but not, as best I can determine, in the New York Times or the Washington Post. This mild-mannered report, which makes reasonable suggestions but says little about how its recommendations might be implemented (or paid for) could well be destined for the dustbin. Let’s hope not. We really need to do something to prepare for the baby boomers, and we need to start now. Write your congressman. Whisper in the ear of the presidential candidates, who have said little or nothing about long term care. Act now.

April 16, 2008

Don't Look Back

For 35 years, the Dartmouth Atlas of Health Care has been publishing startling data on regional variation in the amount of money spent on medical care in the U.S. It has consistently shown—and the newest version of the Atlas, released this month, is no exception—that Medicare spending on chronically ill patients during the last 2 years of life varies enormously across states (Dartmouth Atlas of Health Care 2008, . In recent years, for example, California spent $57,914/patient compared to Iowa, which spent $33,864/patient in the 2 years before death. When the brains behind the Atlas looked at what all the extra money is spent on in “high expenditure” states like California, they found that it’s not spent on effective care (interventions that have been shown unambiguously to be beneficial) and it’s not spent on preference-sensitive care (treatments that some patients select while other patients choose other equally effective treatments with a different side effect profile). Rather, it is lavished on supply-sensitive care: services whose supply determines utilization, without any clear-cut benefit. In states like Massachusetts, for example, with a disproportionately high number of specialists and lots of technology, patients have correspondingly more doctor visits with specialists and receive more high tech diagnostic tests.

It’s not that some areas have more specialists and fancy equipment per capita because they have a higher percentage of sick people in the population. When age and gender are taken into consideration, the rates of illness in California and Iowa are remarkably similar. California just has more medical resources per person, so it devotes more resources to the care of Californians. As a result, patients with chronic illness in some parts of the country spent 6 days in the hospital during their last 6 months of life, while patients in other regions spent 22 days.

The critical question is whether there is any added value to the extra expenditures, and if so, is it worth the additional cost? The creators of the Dartmouth Atlas say there is no additional value, since all the patients they studied died, regardless of what was spent on them.

But this analysis looks only at chronically ill patients who died and then asks what kind of care they received in the 2 years before their deaths. There’s a problem with looking back in this way. The problem is that 2 years before they died, their physicians did not know they were going to die. The real question is, did those chronically ill patients who lived benefit from all the extra medical care they got? What we need to do to answer this question is to study a group of chronically ill patients in a high roller state like New York and the same number of comparable patients in a low spending state like North Dakota. Some of these people, if followed for the next two years, will live and some will die, no matter how much is expended on them. After two years have passed, we can determine not only what fraction lived in each of the two states, but also what happened to the ones who lived. Did they live longer in New York than their counterparts in North Dakota? Was their quality of life any better? If neither those who lived nor those who died benefited from all the additional resources devoted to their care, then clearly New York was spending too much. But if some people benefited, even if others did not, then the issue is more complex. It’s complicated further if those who lived benefited but those who died were made worse off because of the resources spent on them—if they underwent painful procedures and spent a great deal of time in the Intensive Care Unit. In either case, we need to come up with a way—cost-effectiveness analysis is an example—to decide whether we derive sufficient value from the added money spent to make it worthwhile.

To be fair, the creators of the Dartmouth Atlas perfectly well recognize the desirability of looking forward instead of backwards. An important study carried out by this group based on data from 1993-1995 and published in 2003 did exactly that. Elliott Fisher, David Wennberg, and their colleagues studied a group of patient hospitalized for either a hip fracture, colon cancer, or a heart attack, as well as a large representative sample of other Medicare patients. They then asked what happened over the next 5 years: within each group, was there any difference in mortality, in functional status (the ability to care for oneself), or in patient satisfaction, depending on how much money was spent on medical care? What they found was that those people who lived in regions with the highest spending received 60% more medical care than those with the lowest level of spending, with no differences in outcomes (Elliott Fisher, David Wennberg, Therese Stukel et al, “The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 2003; 138: 288-298). But this study relies on data that’s 15 years old, and it’s just one study. I think it’s very likely that the regional differences in expenditures uncovered in the 2008 Dartmouth Atlas similarly do not translate into benefit for patients—neither for those who lived nor for those who died. But we could be far more confident in this result if we conducted more studies that looked forward instead of back.

If the conclusions of the Dartmouth Atlas are correct, we need to put a stop to the endless proliferation of sub-specialists, of expensive diagnostic equipment such as PET scanners, and of facilities such as outpatient surgical centers. We should instead identify what medical interventions truly make a difference and limit the supply of those that do not.

March 27, 2008

Do No Harm: New Data on Dementia

At 43 pages, the newly released report from the Alzheimer’s Association, “Alzheimer’s Disease Facts and Figures.” is 50% longer than last year’s report and every bit as alarming ( Today, 5.2 million Americans have Alzheimer’s disease. By 2050, between 11 million and 16 million people will be afflicted unless medical science finds a way to prevent or treat this progressive, ultimately fatal brain disease.

To its credit, the report shies away from hyperbole. Under the heading of treatment and prevention, the authors state unequivocally: “No treatment is available to delay or stop the deterioration of brain cells in Alzheimer’s disease.” They add that while the FDA has approved five drugs for the treatment of Alzheimer’s, these drugs “temporarily slow worsening symptoms for about six to 12 months, on average, for about half of the individuals who take them,” hardly a ringing endorsement for pharmacologic treatment.

Recognizing that one of the major challenges in providing for individuals with dementia is who will take care of them, the report features a major section on family caregiving. Close to 10 million family members, friends, and neighbors provide unpaid care for a person with dementia in the U.S. today. All told, they contribute an estimated 8.4 billion hours of care per year. The impact on the caregivers’ emotional well-being, health, employment, and financial security is considerable. The need for caregivers—paid and unpaid, family and professional—is reaching crisis proportions. The report only hints at the magnitude of the problem (see the President’s Council on Bioethics, Taking Care: Ethical Caregiving in Our Aging Society, 2005,

But the most striking statistics in this number-laden report are those relating to hospitalization rates—and costs—for individuals with dementia. Medicare beneficiaries over age 65 with dementia are 3.4 times more likely to be hospitalized each year than are their non-demented counterparts. Looked at differently, this means that 25% of older patients in American hospitals at any point in time have dementia. Not surprisingly, annual Medicare costs for those with dementia are high: $13,207 per person compared to $4,454 per non-demented person. This discrepancy is directly attributable to the disproportionately high rate of hospitalization. But not only are people with dementia at high risk of hospitalization, once they’re in the hospital, they cost Medicare 3.2 times more than other patients: they have more complex diseases, undergo more procedures, and stay in the hospital longer.

The data on hospitalization rates are extraordinary because it is far from clear that it makes sense to subject individuals with dementia to frequent and lengthy hospitalizations. The more advanced their dementia, the more frightening the experience of being in a strange place, cared for by a new and unfamiliar nurse every eight hours—and the less they have to gain. In one study of survival after hospitalization, for example, 55% of patients with dementia and a hip fracture were dead in six months, compared to 12% without dementia treated for a hip fracture, and 53% of patients with dementia and pneumonia were dead in six months, compared to 13% of those without dementia treated for pneumonia (RS Morrison, A Siu, “Survival in End-Stage Dementia Following Acute Illness,” Journal of the American Medical Association 2000; 284: 47-52). These uncomprehending patients who are near the end of their lives endure intravenous injections, nasogastric tubes and other uncomfortable and scary procedures in exchange for a small chance of living ever so slightly longer in their demented state (S Mitchell, D Kiely, and MB Hamel, “Dying with Advanced Dementia in the Nursing Home,” Archives of Internal Medicine 2004; 164:321-6). Surely the burdens of invasive treatment outweigh the benefits. A palliative approach to care, focusing on comfort rather than a misguided attempt to increase longevity, makes sense.

The report concludes by noting that the lifetime risk of developing dementia is 21% for women and 14% for men, assuming they live to be at least 55. A low fat diet, rich in fruits and vegetables, may attenuate these stark numbers slightly, as may a vigorous social network. Research into drugs and vaccines to delay the onset of dementia or treat the disease once it develops is thriving and may yet produce a magic bullet that dramatically alters the odds of dying of dementia. But in the mean time, we need to overhaul the prevailing approach to the care of individuals who have this devastating disease. It’s one of the few areas of medicine in which doing the right thing actually has the potential to save money.

January 24, 2008

MiniClinics on the March: Politics, Policy, and the Public's Health

In the ten months that I have served on the Massachusetts Public Health Council, no issue has been more contentious than “limited service clinics,” quickie drop-in offices offering treatment of minor illnesses that will be located primarily in pharmacies and staffed by nurse practitioners. The 15-member council, which is empowered to help shape health care policy in Massachusetts, has approved expensive new scanners, multi-million dollar outpatient buildings, and the creation of additional hospital beds with scarcely a whimper of protest. Many of these capital expenditures will predictably drive up health care costs in the state of Massachusetts, potentially threatening outlays for services essential to the health and well-being of the citizens of the Commonwealth. The benefit accruing from these capital investments is not subject to scrutiny.

The regulations that will permit the introduction of limited service clinics in Massachusetts, by contrast, provoked a storm of protest. Council members were deluged with petitions from interested parties—primarily physician groups arguing against this form of medical practice. The Council spent the better part of two of its monthly meetings debating the issue. But was the issue really the regulations—the Department of Public Health did an admirable job of developing detailed regulations that conformed to the proposed regulations developed by the American Academy of Family Physicians—or rather the belief of a variety of interest groups that mini-clinics are dangerous because they offer episodic care rather than coordinated care, they will be staffed by nurse practitioners rather than physicians, they will tend to be for-profit, and many will be located in drug stores, which sell cigarettes. Do any of these concerns hold up?

Nothing but the best…
Ideally, if you live in Massachusetts, you have your own primary care physician. Not only that, but you have ready access to that physician—no week-long waits for an appointment, no 2-hour waits to be seen even if you have an appointment. In the best all of all worlds, if you are elderly and have multiple chronic illnesses, you have coordinated care, facilitated by a case manager (see R. Bernabei et al, “Randomised Trial of Impact of Model of Integrated Care and Case Management for Older People Living in Community,” British Medical Journal 1998; 316: 1348-1352). You also have health insurance coverage to pay for your visit to the physician. And if you happen not to be a resident, but merely visiting the state, you are able to find a primary care practice ready and willing to accommodate you if you happen to get sick while you’re here.

The reality is very different. Massachusetts has a shortage of primary care doctors. Generalists don’t want to move to the state, where salaries are below the national average and the cost of living is well above the national average. Despite the recent initiative to require health insurance for all residents, not everyone has coverage. “Coverage” may include substantial co-payments and deductibles. Thousands of patients throng to emergency rooms for care every day—where the wait to be seen is usually measured in hours, not minutes.

The fix for these problems is complex. And it’s not a problem that Massachusetts can solve alone—nation-wide, primary care is in a slump. The number of young physicians going into primary care is declining every year, and the reasons range from high student loans to fear of litigation, with a dozen other factors in between that adversely affect physicians’ willingness to practice general medicine.

Over the short term, limited service clinics can help. They provide an alternative way for patients to get treatment for straightforward problems such as sore throats and sprained ankles. They can administer flu shots and help tourists with a rash or a stomach bug. With suitable regulatory oversight, mini-clinics can improve the public’s health.

The NP/Physician Wars
Physicians have been suspicious of the care provided by nurse practitioners for years. But the evidence is that in the arenas where NPs work, they often do at least as good a job as physicians. A study by Mary Mundinger et al (“Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial,” Journal of the American Medical Association 2000; 283: 59-68), found no differences in outcomes or satisfaction among over 3000 adults, some of whom received care from NPs and some from MDs—except in the case of management of high blood pressure, where NPs performed better. In data specifically on limited service clinics released as part of the Minnesota Health Care Quality Report, the NP-run clinics received a 100% rating for the treatment of sore throat in the pediatric population in 2006. When I randomly chose a not-for-profit clinic operating in the same Minnesota county to compare to Minute Clinic, I found it had a 72% rating on the sore throat treatment indicator (see

NPs always have MD back-up and supervision. It’s a condition of their licensure. But that doesn’t mean a doctor must be on the premises. NPs have been providing high quality care in nursing homes (where doctors often fear to tread) for years, as well as in hospices and in patients’ homes. There is no reason to worry they will misdiagnose or mistreat the routine ailments that will come to their attention in mini-clinics.

Big bad for-profit health care…
Many health care institutions throughout the United States are for-profit. There are for-profit HMOs, for-profit hospitals, and for-profit physician group practices, among others. The data on the effect of for-profit status on the quality of care is mixed. A National Bureau of Economic Research Conference Report comparing for-profit hospitals to not-for-profit hospitals found evidence that in some situations, for-profit hospitals are higher quality than not for profit hospitals (David Cutler, ed, The Changing Hospital Industry: Comparing Not-for-Profit and For-Profit Institutions, Chicago: University of Chicago Press, 2000). On the other hand, a study comparing health plans found for-profit plans performed less well than not-for-profit plans on 3 out of 4 quality indicators (EL Schneider et al, “Quality of Care in For-Profit and Not-for-Profit Health Plans Enrolling Medicare Beneficiaries,” American Journal of Medicine 2005; 118: 1392-1400).

For-profit health care is no stranger to Massachusetts. We have for-profit nursing homes. We have for-profit hospices. There is no justification for dismissing limited service clinics simply because many of them will be owned and operated by CVS.

It’s an outrage to have a health care clinic within a facility that sells cigarettes…
Cigarettes are one of the leading causes of some of the major killers: coronary heart disease, emphysema, and lung cancer. Clearly, the Massachusetts Department of Public Health needs to be concerned with strategies to decrease cigarette smoking and to prevent young people from starting to smoke in the first place. But we do not ban the sale of cigarettes outright. We do not tax cigarettes enough to make them unaffordable to all but the very rich. And we do not prevent drug stores that sell prescription drugs for the treatment of coronary heart disease, emphysema, and lung cancer from also selling cigarettes. I fail to see why we should prevent those same drug stores from housing a health clinic.

The bottom line
I hope that some day all patients in Massachusetts have access to top notch primary care. In particular, I hope that frail geriatric patients will have the kind of integrated care that I believe is best achieved through a case-managed, capitated health plan. In fact, I hope that there will be so little demand for mini-clinics that they disappear. But for the moment, I suspect they will provide a valuable service for many sick people in Massachusetts.

It is time for policy makers to pay at least as much attention to the rising cost of health care and its potentially dire consequences as to mini-clinics. Just this morning the Boston Globe reported that Governor Patrick has proposed a $28.2 billion budget that includes a 1.3 billion dollar budget gap, “created mainly by rising health care costs and decreased revenues.” The Congressional Budget Office recently released statistics indicating that barring any changes in policy, total spending on health care, which currently accounts for 16% of the Gross Domestic Project, will rise to 25% in 2025 and 37% in 2050. Federal spending on Medicare and Medicaid alone (net of beneficiaries’ premiums) is now 4% of GDP and will rise to 7% in 2025 and 12% in 2050 (see Medicaid is a joint federal/state program: for every dollar spent by the federal government on Medicaid in Massachusetts, the state spends another dollar. And over the long run, as Medicare costs soar, the federal government will have less and less to spend on other programs that affect everyone, including Massachusetts residents.

The leading engine behind this unsustainable growth in spending is technology (See James Lubitz, “Health, Technology, and Medical Care Spending,” Health Affairs 2005; W5: R81-R85). While some forms of technology contribute much to health, others simply contribute to costs. Hospital beds, once built, will be used. But more is not always better. In a major study, Medicare enrollees living in high spending regions of the country received more care but did not have better health outcomes or greater satisfaction with their care (Elliott Fisher et al, “The Implications of Regional Variations in Medicare Spending: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 2003; 138: 288-298).

The Public Health Council can do little more than rubber-stamp most of the requests it receives for substantial capital expansion. Massachusetts Determination of Need law does not permit the Public Health Council to do much other than review whether health care facilities submitting requests for substantial capital expenditures have engaged in the recommended planning process, whether they have developed the requisite community health services initiatives, and whether the proposed construction complies with existing standards. Ostensibly, the law is intended to “promote availability and accessibility of cost effective quality health care.” But the current statute promotes the evaluation of cost effectiveness without the ability to consider effectiveness. If Massachusetts is to have sound health policies, and if the PHC is to devote its time to the critical issues facing the state, the legislature will have to revamp the Determination of Need law of the Commonwealth.