Documentos de Académico
Documentos de Profesional
Documentos de Cultura
!n
trying to gct our study publishcd, ]ack and ! cncountcrcd prctty much thc samc
rcsistancc that Alan and ! had lound carlicr. ! was a bit surpriscd and not a littlc
disappointcd by this, bccausc ! had assumcd that now that wc had nailcd thc
cvidcncc that variations wcrc not cxplaincd by illncss, povcrty, or cthnicity, thc
\crmont ndings and thcir implications would rcccivc scrious attcntion lrom
highprolc acadcmic mcdical journals. Howcvcr, wc had no such luck.
Te Health Care World Turned Upside Down
Tc uncovcring ol widcsprcad variations in rcsourcc allocation and utilization
lor clcctivc surgcry, hospitals, nursing homcs, homc hcalth carc, and physi
cian scrviccs, thc strong associations bctwccn supply and utilization, and thc
lack ol association with thc nccds ol paticnts convinccd mc that thc problcms
lacing thc \crmont hcalth carc systcm wcrc morc prolound than thc barricrs
to thc diusion ol ncw tcchnology that thc RMP was dcsigncd to ovcrcomc.
Tc hcalth carc systcm was pcrlorming dicrcntly than prcdictcd by thc
mainstrcam social scicncc ! had studicd at ]ohns Hopkins. Social scicntists
had long rccognizcd that thc cxchangc rclationship bctwccn thc physician
and thc paticnt was radically dicrcnt lrom thc cxchangc rclationship that
dctcrmincs thc dcmand lor othcr goods and scrviccs in most markcts. Tc
doctorpaticnt rclationship is dicrcnt bccausc ol thc asymmctry ol inlorma
tion. Tc paticnt, as a layman, docs not know what hc or shc truly nccds, it
is thc physician who knows thc naturc ol thc paticnts illncss and can sclcct
thc right trcatmcnt. For thcsc rcasons, many social scicntists thought it was
rational lor paticnts to do somcthing thcy would not drcam ol doing in most
markctsthat is, to dclcgatc dccision making to thc scllcr ol scrviccs, thc
physician, who by virtuc ol his spccial knowlcdgc and skill, could act as thcir
rational agcnt in hcalth carc purchasing dccisions.
From thc paticnts point ol vicw, thc agcncy modcl was bclicvcd to bc
rational on thc basis ol scvcral assumptions. First, it was assumcd that clinical
: ~x ix)vobic)iox )o )nv vvoniv: ov ixw~vv~x)vb v~vi~)iox
dccision making is groundcd in mcdical scicncc, physicians havc cvidcncc
bascd knowlcdgc to diagnosc illncss accuratcly and cstimatc thc risks and
bcncts lor thc trcatmcnts thcy prcscribc. Sccond, physicians makc accuratc
judgmcnts conccrning thc trcatmcnts paticnts want: thcy choosc thc trcat
mcnt thc individual paticnt would prclcr, il only thcy wcrc thcmsclvcs physi
cians, and thcrclorc kncw thc lacts and bcttcr undcrstood thcir own truc
wants and nccds. Tis assumption is implicit whcn a paticnt says to his or hcr
physician, Vhat would you do il you wcrc mc: Tird, thc cthics ol prolcs
sionalism protccts thc trust that is thc basis lor thc paticnts willingncss to
dclcgatc dccision making to thc physician. cspitc thc lact that thc physician
bcncts nancially lrom highcr utilization ol his scrviccs, prolcssional cthics
cnsurc that hc or shc will choosc what is bcst lor thc paticnt. Finally, cgrc
gious bchavior by thc lcw uncthical physicians who inducc paticnt dcmand
lor scllscrving motivcs is dctcctcd and controllcd through utilization rcvicw
and othcr mcthods thc prolcssion adopts to disciplinc outlicr bchavior.
Tc dclcgation ol dccision making to physicians was also assumcd to
bc rational lrom socictys point ol vicw. A doctorpaticnt rclationship that
works in thc way ! havc just dcscribcd cnsurcs that thc supply ol mcdical
rcsourccs, including physicians, will not inucncc dcmand in a way that is
wastclul. Prolcssional cthics, bolstcrcd by utilization rcvicw and othcr stratc
gics lor patrolling thc markct lor uncthical bchavior, cnsurcs that thc scrviccs
rccommcndcd by thc physician agcnt arc both ccctivc and valucd. Tus, thc
physician scrvcs as guarantor ol thc c cicnt allocation ol socictys rcsourccs:
il capacity cxcccds that rcquircd to producc ccctivc and valucd scrviccs,
capacity in cxccss will go unuscd. Trough thc physician acting as agcnt lor
both paticnt and socicty, thc markct is thus clcarcd ol cxccss capacity. n
thc othcr hand, whcn thc rcsourccs ol thc hcalth carc systcm arc strcsscd,
whcn providcrs cxprcss conccrn about too littlc capacity, whcn hospital bcds
arc occupicd to thc point ol ovcrow, and whcn physicians waiting rooms arc
lull, thcn, undcr thc agcncy hypothcsis, thc dcmand lor carc cxcccds supply.
To avoid hcalth carc rationing undcr such circumstanccs, thc propcr rolc ol
an cnlightcncd public policy is to providc morc rcsourccs.
nsuring adcquatc rcsourccs was prcciscly what public policy lor hcalth
carc sought to accomplish at thc timc ol our \crmont studicsit was thc
statcd goal ol both thc RMP and ol thc Hill8urton Program, thc lcdcral
subsidics dcsigncd to cnsurc su cicnt hospital bcds. !t also bccamc thc goal
ol physician worklorcc policy. At that timc, thc Unitcd Statcs had alrcady
bcgun a program that would cvcntually rcsult in a doubling ol thc supply ol
physicians.
)nv vvv:ox) vxvvvivxcv :
ur \crmont studics stood as a dircct challcngc to thc lundamcntal
assumptions ol rational agcncy thcory.
6
Vc wcrc suggcsting that supplicr
induccd dcmand lor mcdical carc sccmcd to bc a ccntral tcndcncy ol
\crmonts hcalth carc markct, not an abcrration causcd by a lcw uncthical,
outlicr physicians. Tc incidcncc ol discasc, and thc probability that thc
paticnt would show up at thc physicians o cc sccking carc lor an cpisodc
ol illncss, appcarcd to bc csscntially thc samc lrom onc \crmont community
to anothcr. Vhat varicd was postacccss carcthc amount and typc ol carc
paticnts rcccivcd altcr thcy cntcrcd thc hcalth carc systcm. Vhat also varicd
was thc supply ol mcdical rcsourccs: thc numbcrs ol physicians, hospital bcds,
and nursing homcs, lor cxamplc. Tc thcorics that drovc individual physi
cians dccisions also varicd. As wc would cvcntually discovcr, individual prac
ticc stylcs appcarcd to bc dctcrmincd in part by spccic idcological lactors,
cnthusiasms lor a particular diagnostic tool or trcatmcnt such as tonsillcctomy,
and in part by thc shccr supply or availability ol mcdical rcsourccs. !n othcr
words, physicians who practiccd in a rcgion ol thc statc whcrc hospital bcds
wcrc in abundant supply tcndcd to hospitalizc thcir paticnts morc oltcn than
thcir collcagucs in rcgions whcrc bcds wcrc lcss availablc. And paticnts wcrc
instructcd to rcturn lor a lollowup o cc visit morc lrcqucntly in rcgions
whcrc thcrc wcrc morc physicians, particularly mcdical spccialists.
8ut it was lar lrom clcar that morc was bcttcrthat morc bcds, morc phy
sicians, morc hospitalizations, and morc surgcrics wcrc improving thc wcllarc
ol \crmontcrs who wcrc rccciving morc carc. Tc \crmont studics, by rais
ing qucstions about which ratc was right, thus also challcngcd thc vicw that
thc basic problcm lacing thc hcalth carc systcm was a lack ol rcsourccs that
rcsultcd in undcrscrvicc.
Vhilc thc lilc ol thc RMP turncd out to bc a short onc, thc work wc con
ductcd in \crmont dcncd thc rcscarch problcms and sct thc rcscarch agcnda
that has consumcd my cncrgics ovcr thc subscqucnt ycars. Tat rcscarch, it
turns out, was prcsagcd by carlicr studics, which wc only discovcrcd altcr thc
lact. Had Alan Gittclsohn and ! rcad about thc work ol ]. Alison Glovcr
7
and
Paul Lcmbckc,
8
rcscarchcrs who had documcntcd variation in utilization in
Grcat 8ritain in thc .o.cs and in Ncw York Statc in thc .ocs, wc would havc
bccn bcttcr prcparcd lor thc cxistcncc ol variations in thc ratcs ol surgical
proccdurcs wc discovcrcd in \crmont, il not lor thc shccr magnitudc and thc
cxtcnt ol variations in all typcs ol hcalth carc dclivcry.
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Paticnts traditionally dclcgatc dccision making about trcatmcnts to thcir
physicians, undcr thc assumption that physicians prcscribc trcatmcnts bascd
not only on mcdical scicncc but also on an undcrstanding ol what is bcst
lor thc individual paticnt. mbcddcd in thc idca that thc physician knows
what is bcst lor thc paticnt is thc notion that thc physician also knows what
thc paticnt wants. Yct as carly as thc .o.cs, it was cvidcnt that local mcdical
opinion was bchind thc markcd variation in tonsillcctomy ratcs, rathcr than
clinical scicncc or paticnt (parcntal) prclcrcncc. 8y thc mid.ocs, it bccamc
clcar that thc ratcs ol utilization ol most common surgical proccdurcs varicd
cxtcnsivcly among rcgions, somc morc than othcrs. Physicians cvcrywhcrc
sccmcd to dicr among thcmsclvcs on thc valuc ol many opcrations, on who
would bcnct and who would not, and thcsc dicrcnccs ol opinion dircctly
inucnccd thc incidcncc ol any givcn surgcry. Vhat thc paticnt wantcd oltcn
appcarcd not to mattcr much.
Tc importancc ol scicntic unccrtainty and thc misdiagnosis ol paticnt
prclcrcnccs as a causc ol practicc variation bccamc most clcar ovcr thc coursc
ol a dccadclong rcscarch cort wc undcrtook to undcrstand why surgcry
ratcs lor an cnlargcd prostatc showcd such grcat variation among rcgions
in thc statc ol Mainc. !t turncd out that whilc many urologists undcrtook
surgcry undcr thc assumption that it prolongcd lilc, our rcscarch showcd this
was not thc casc. Howcvcr, surgcry did havc a potcntially positivc ccct on
v~v) ii
Surgical Variation:
Understanding Preference-Sensitive Care
:
thc quality ol lilc by rcducing symptoms. 8ut this bcnct had to bc wcighcd
against thc harmlul ccct ol surgcry on scxual lunction. !t bccamc cvidcnt
through our rcscarch that rational choicc rcquircd thc activc cngagcmcnt ol
thc paticnt in thc choicc ol trcatmcnt. Similar rcscarch sponsorcd by a ncw
lcdcral agcncy, to invcstigatc practicc variations lor back surgcry and cardiac
surgcry, camc to similar conclusions rcgarding thc importancc ol paticnts
undcrstanding thc bcncts and harms ol altcrnativc trcatmcnts and making
inlormcd choiccs.
stablishing a markct whcrc thc utilization ol prclcrcnccscnsitivc trcat
mcnts is dctcrmincd by paticnt dcmand will rcquirc a prolound cultural
changc in thc doctorpaticnt rclationship: rcplacing dclcgatcd dccision mak
ing, and thc doctrinc ol inlormcd conscnt, with sharcd dccision making and
inlormcd paticnt choicc as thc standard lor dctcrmining thc mcdical ncccs
sity ol prclcrcnccscnsitivc trcatmcnts.
Rcmcdying variation in prclcrcnccscnsitivc carc will also rcquirc a changc
in thc rcscarch culturc, a topic that is rclcvant to todays dcbatc ovcr cvidcncc
bascd mcdicinc. Undcr thc Agcncy lor Hcalth Carc Policy and Rcscarch
(lorcrunncr to thc Agcncy lor Hcalthcarc Rcscarch and uality), a collab
orativc rcscarch modcl was cstablishcd that was highly succcsslul in rcducing
scicntic unccrtainty and promoting inlormcd paticnt choicc. Howcvcr, it
also challcngcd thc convcntional wisdom, it was abruptly intcrruptcd by thc
U.S. Congrcss in thc mid.oocs, in largc part bccausc ol strong ncgativc rcac
tion lrom surgcons ovcr thc conclusions ol thc back surgcry rcscarch tcam.
Studics discusscd in this scction suggcst that thc implcmcntation ol sharcd
dccision making will rcducc thc utilization ol surgcry and savc moncy. 8ut
addrcssing unwarrantcd variation in prclcrcnccscnsitivc carc is csscntial not
just lor cconomic rcasons. 8y lailing to takc into account paticnt prclcrcnccs,
and cnabling paticnts to makc inlormcd choiccs, surgcry will bc misuscd. !t
should bc considcrcd a scrious lorm ol mcdical crror whcn surgcons opcratc
on paticnts who would not havc wantcd thc proccdurc had thcy bccn lully
inlormcd and cmpowcrcd to participatc in a mcaninglul way in thc choicc
ol trcatmcnt.
: sivcic~i v~vi~)iox
:o
.
Tonsillectomy and Medical Opinion
A major surgical intcrvcntion is a dramatic cvcnt in thc lilc ol thc paticnt. !t
involvcs a stay in thc hospital or clinic, lor hours or days. Tc paticnt laccs
thc possibility ol pain, inlcction, or an uncxpcctcd rcaction to ancsthcsia or a
drug. Tcn thcrc is thc risk ol crror or an advcrsc cvcnt, thc unlorcsccn pos
sibility that somcthing can go horribly wrong. To subjcct thcir paticnts to
thcsc rigors and risks, surgcons arc by ncccssity truc bclicvcrs in thc c cacy
ol thc opcrations thcy pcrlorm, thcy cannot aord psychologically to doubt
thcir clinical ncccssity. Most surgical paticnts arc also convinccd that thc
bcncts ol surgcry cxcccd thc risks by a widc margin. Yct in thc lacc ol such
ccrtainty and conviction, it is rcmarkablc how much thc ratc ol surgcry can
vary lrom arca to arca.
!
No surgical proccdurc has bccn studicd morc, or illustratcs bcttcr, thc rolc
ol mcdical opinion in dctcrmining thc ratc ol surgcry than tonsillcctomy,
a proccdurc that has lallcn out ol lavor in rcccnt ycars but was practically
a ritc ol passagc lor childrcn only a lcw dccadcs ago. (Tc rate ol surgcry
simply mcans thc numbcr ol surgcrics pcr .,ccc pcoplc. Incidence ol sur
gcry is anothcr way to cxprcss thc samc idca.) Tc rclcvant litcraturc gocs
back . ycars bclorc our \crmont study, to prcVorld Var !! 8ritain, whcn
]. Alison Glovcr, thcn a mcdical o ccr in thc Ministry ol Hcalth, discovcrcd
that a childs chanccs ol undcrgoing tonsillcctomy dcpcndcd on which school
hc attcndcd. Calling thc phcnomcnon hc obscrvcd thc strangc barc lact ol
.c sivcic~i v~vi~)iox
incidcncc,
2
Glovcr built a convincing casc that thc major sourcc ol variation
was dicrcnccs in thc mcdical opinion ol thc school hcalth o ccr rcsponsiblc
lor rclcrral lor surgcry.
Glovcr built his casc on school hcalth rccords, which rcvcalcd a lourlold
variation in thc pcr capita utilization ol tonsillcctomy among 8ritish school
districts. ]ust as Alan Gittclsohn and ! would do in \crmont somc thirty ycars
latcr, Glovcr systcmatically cxamincd and dismisscd altcrnativc cxplanations
lor this variation. Hc took pains to rulc out thc possibility that thc dicr
cnccs in tonsillcctomy ratcs wcrc cxplaincd by lactors on thc dcmand sidc ol
thc cquation. For instancc, bccausc thc child hcalth scrviccs wcrc providcd
lrcc as part ol attcnding school, cconomic lactors and acccss to carc wcrc not
issucs in 8ritain. Hc lookcd lor but could nd no cvidcncc ol an association
bctwccn surgcry ratcs and any impcrsonal lactor prcdictivc ol illncss, such
as ovcrcrowding, povcrty, bad housing, or climatc. Hc wrotc:
!n cach ol thcsc catcgorics thcrc arc cxtrcmc variations in thc opcration
ratc, thc cxtrcmcs oltcn in adjaccnt arcas . Possiblc lactors such as
thc c cicncy ol school dcntal scrvicc, rainlall, climatc, |ovcrcrowding,
uncmploymcnt| and nutrition rcturns havc bccn considcrcd, but with
onc cxtrcmcly doubtlul cxccptionurbanizationnot thc slightcst
suggcstion ol corrclation has bccn obtaincd . 8ut il urbanization bc a
lactor thcrc arc incxplicablc anomalics thc highcst ratcs ol all arc in
ccrtain agricultural countics and thc |urban arcas| with thc highcr ratcs
includc rcsidcntial towns and hcalth rcsorts lamcd lor thcir bcauty,
climatc and spaciousncss.
1
!n thc cnd, Glovcr concludcd that dicrcnccs among childrcn in dicrcnt
school districts could not account lor thc variation in utilization. Tat lclt
only onc possibility: physician judgmcnt. Tc school physicians rcsponsiblc
lor rclcrring thcir studcnts lor tonsillcctomy divcrgcd in thcir opinion as to
which childrcn nccdcd a tonsillcctomy.
Glovcr gavc a plausiblc account lor thc lack ol importancc ol illncss, but
his approach was bascd on an argumcnt ol cxclusion, and hc did not show
dircctly that mcdical opinion was thc sourcc ol thc variation. Unbcknownst
to him, an cxpcrimcnt that dcmonstratcd dircctly that paticnt charactcris
tics and illncss ratcs did not drivc thc tonsillcctomy ratcs had alrcady bccn
rcportcd.
4
!n thc .o.cs, thc Amcrican Child Hcalth Association, likc many
voluntccr hcalth associations ol thc day, vicwcd tonsillcctomy as a public
hcalth good. Tc association wantcd to makc ccrtain that no Ncw York City
school child who nccdcd a tonsillcctomy had bccn ovcrlookcd. To nd out
)oxsiiivc)o:y ~xb :vbic~i ovixiox ..
how much unmct nccd thcrc was, thcy pcrlormcd a sophisticatcd study that,
ironically, not only providcd dircct cvidcncc lor thc cxtraordinary variability
in physicians prolcssional judgmcnt but also lcd to considcrablc doubt about
thc notion ol unmct nccd itscll.
Tc Amcrican Child Hcalth Associations rcscarch dcsign uscd a
random sampling ol .,ccc Ncw York City school childrcn. n cxamina
tion by a school physician, 6c wcrc lound to havc alrcady had a tonsil
lcctomy, and ol thc rcmaining c, ncarly hall wcrc dccmcd in nccd ol thc
opcration. To makc surc that no onc in nccd ol a tonsillcctomy was lclt out,
thc association arrangcd lor thc childrcn not sclcctcd lor tonsillcctomy to
bc rccxamincd by anothcr group ol physicians. Tc sccond wavc ol physi
cians rccommcndcd that c ol these childrcn havc thc opcration. Still
not contcnt that unmct nccd had bccn adcquatcly dctcctcd, thc association
arrangcd lor a third cxamination ol thc twiccrcjcctcd childrcn by anothcr
group ol physicians. n thc third try, thc physicians produccd rccommcn
dations that anothcr should havc thc opcration. 8y thc cnd ol thc
thrcccxamination proccss, only 6 childrcn ol thc original .,ccc cmcrgcd
lrom thc scrccning cxamination without a rccommcndation lor tonsil
lcctomy. !l thc association had put thosc 6 childrcn through additional
rounds ol cxamination, it sccms likcly that virtually cvcry last onc would
havc bccn rccommcndcd lor surgcry, a thought that givcs ncw mcaning to
thc phrasc no child lclt bchind.
Tc most dircct clinical cvidcncc supporting Glovcrs hypothcsis that mcd
ical opinion was driving ratcs ol tonsillcctomy camc somc lorty ycars altcr
his original rcport. Compcllcd by Glovcrs logic, Michacl 8loor, who latcr
bccamc prolcssor ol sociology at Abcrdccn Univcrsity, and his collcagucs,
Gcorgc A. \cntcrs and Michacl L. Samphicr, sct out to documcnt thc rolc
ol mcdical opinion by dircctly obscrving physicians as thcy intcractcd with
thcir paticnts in thc proccss ol rcaching a trcatmcnt dccision.
,6
Tc rcscarch
crs uscd as thcir laboratory two hcalth districts in Scotland with substan
tially dicrcnt tonsillcctomy ratcs. Tc highratc district, thcy showcd, had
highcr ovcrall ratcs ol rclcrral lrom gcncral practitioncrs to surgcons, as wcll
as highcr ratcs lor pcrlorming surgcry on rclcrrcd paticnts, but with con
sidcrablc dicrcnccs among individual physicians within cach arca. Vith
thc pcrmission ol thc surgcons, 8loor and his collcagucs sat in on clinical
cncountcrs to obscrvc and documcnt variation in thc dccision rulcs and prac
ticc pattcrns ol thc physicians, in an cort to corrclatc thcsc dicrcnccs with
thc physicians propcnsity to opcratc. Tcy thcn mct individually with cach
surgcon to makc ccrtain that thcir obscrvations accuratcly rccctcd thc sur
gcons bclicls and practicc.
.: sivcic~i v~vi~)iox
icrcnccs wcrc lound in thc spccic clinical lcaturcs that thc surgcons
thought important in making thcir dccision. !n thcir papcr, 8loor and his
collcagucs
,6
illustratcd thcsc dicrcnccs with dircct quotcs lrom thrcc sur
gcons who had oppositc attitudcs conccrning thc importancc ol clinical nd
ings suggcsting chronic inlcction, as mcasurcd by inammation in thc arca
ncar thc tonsil (thc antcrior pillars) or in thc ccrvical lymph nodcs (glands
in thc ncck):
Surgeon One
thc antcrior pillars bcing injcctcd (inlcctcd) is a lairly constant
|i.c., rcliablc| sign: in thc hcalthy thcy dont sccm to bc, whcrcas in thc
unhcalthy thcrc sccms to bc a sort ol injcctcd |appcarancc|.
Surgeon Two
All thc antcrior pillars will tcll you il thcrcs bccn a rcccnt inlcction
thcyll bc a bit rcddcncd. !ts not ol vcry grcat importancc. Tc glands
arc importantpcrsistcnt glands arc a sign ol pcrsistcnt inlcction.
Surgeon Tree
! dont worry about largc ccrvical glands somc pcoplc say il thcyrc
visiblc its signicant: il a child comcs with visiblc ccrvical glands ! gct
thcir blood cxamincdonc child had lcukcmia il thcyrc not visiblc
but palpablc it docsnt worry mc in thc slightcst.
Tc physicians practicc stylcs also dicrcd rcgarding thc rclativc impor
tancc thcy gavc to thc paticnts mcdical history vcrsus thc physical cxami
nation. Surgcons with a high proclivity to opcratc tcndcd to strcss thc
importancc ol thc physical cxamination. For cxamplc, onc surgcon thought
that thrcc physical signsinlcctcd matcrial in thc tonsil, rcddcncd antcrior
pillars, and palpablc ccrvical lymph nodcswcrc dccisivc and his rulc ol
thumb was to opcratc on any child with two or morc ol thcsc signs. As onc
morc conscrvativc surgcon put it, Somcbody is supposcd to havc said oncc
that thc only point in looking at thc childs throat is to makc surc thc tonsils
arc still thcrc, that no onc clsc was thcrc bclorc you! Tat is an cxaggcration
!m surc but it puts thc point ovcr. Among surgcons who wcrc lcss quick to
opcratc, thc rcvcrsc was thc cascmuch morc strcss was put on thc history. A
child who had sucrcd only thc occasional bout ol tonsillitis probably would
not bc a candidatc lor surgcry, no mattcr how inamcd thc tonsils might bc
on physical cxamination.
)oxsiiivc)o:y ~xb :vbic~i ovixiox ..
icrcnccs among practicc stylcs wcrc also lound in thc dctails clicitcd
lrom thc history and thc intcrprctation ol thc mcaning ol thc rclcrral. nc
surgcon who was quick to opcratc thought that thc mcrc lact ol rclcrral
implicd an cxtcnsivc history ol morbidity, and in most cascs his dccision
making stratcgy combincd an cxamination ol thc child with a simplc chcck
on his assumption ol morbidity by asking thc parcnt il thc child sucrcd a
lot ol troublc.
7
!n dircct contrast, a morc conscrvativc physician actcd as
an indcpcndcnt asscssor, sccking to rcconstruct thc childs clinical history in
dctail.
8
8loor ct al. lound that such dicrcnccs among spccialists in thc dcpth ol
thcir history taking linkcd dircctly to dicrcnccs in thc dccision rulcs thcy
uscd in rccommcnding opcrations. Tc conscrvativc physicians dccision rulcs
could bc charactcrizcd as a list ol chcckcd boxcs: il a child is ol A agc,
and il thc child sucrs sorc throats ol rccurrcncc 8, and il attacks arc ol C
scvcrity, and il thc cxamination ndings arc ol naturc, thcn thc child will
rcccivc disposal.
9
8loor and his collcagucs lound that thc morc spccic
and cxtcnsivc thc dccision rulcs, thc morc symptomatically dicrcntiatcd
wcrc thc paticnts rccciving surgcry and thc morc rcstrictivc wcrc thc critcria
lor surgical admission. Morcovcr, surgcons who lollowcd wclldcncd dcci
sion algorithms wcrc morc conscrvativc in thcir cstimatcs ol thc bcncts ol
thc tonsillcctomy.
Anothcr dicrcncc in practicc stylc that was documcntcd by 8loor and
collcagucs is thc physicians bclicl in watchlul waitingobscrving thc
natural history ol thc discasc proccss bclorc making a nal dccision on thc
surgcry. Conscrvativc surgcons wcrc charactcrizcd as having a highcr than
avcragc tcndcncy to wait and scc altcr dcciding that an opcration was not
an immcdiatc ncccssity and bclicving that an intcrmcdiatc approach (such
as antibiotic trcatmcnt) could bc tricd. As 8loor ct al. quotcd onc surgcon,
Vhat wcrc rcally doing is playing lor timc. ! dont know whcthcr thc
sulphonamidc rcally hclps or notit ccrtainly hclps in thc scnsc that thc
parcnts arc plcascd that shcs gctting somc trcatmcntbut thc important
thing is that wc gain timc to allow thc troublc to rcsolvc itscll.
!0
And il
childrcn thcn wcrc likc childrcn now, oltcn thc symptoms would disappcar
with timc.
8loor ct al.s dctailcd obscrvations ol thc actual bchavior ol clinicians
in rcaching thcir tonsillcctomy dccisions convinccd him that Glovcr was
right. To usc thcir words, thc dicrcnccs in ratcs bctwccn thc rcgions can
bc attributcd to dicrcnccs bctwccn spccialists in thcir asscssmcnt practiccs:
local dicrcnccs in thc naturc ol spccialist practicc crcatc local dicrcnccs
. sivcic~i v~vi~)iox
in surgical incidcncc |Tc ndings| amount to a dctailcd vindication ol
Glovcrs conviction that variations in thc incidcncc ol surgcry arc largcly thc
product ol mcdical opinion rathcr than thc product ol thc dicrcntial distri
bution ol morbidity.
!!
Glovcr
!2
had lollowcd yct anothcr linc ol rcasoning in making his casc lor
thc ccntral rolc ol mcdical opinion in practicc variation. Hc documcntcd thc
prolcssional controvcrsics conccrning thc valuc ol tonsillcctomythc dis
putcs ovcr mcdical thcory and lact that madc it impossiblc lor thc prolcssion
to rcach conscnsus on thc bcst practicc lor dcaling with chronic tonsillitis.
Tonsillcctomy was not a lilcsaving, cmcrgcncy opcration. Somc physicians,
Glovcr among thcm, wcrc skcptical ol its valuc as a prcvcntivc mcasurc,
bclicving thc opcration to bc ccctivc only in propcrly sclcctcd cascs with
dcmonstratcd morbidity, such as thosc with lrcqucntly rcpcatcd attacks
ol acutc tonsillitis which cannot bc cxplaincd by cxtrancous inlcctions.
!1
!n Glovcrs opinion, this rcstrictcd vicw ol thc proccdurcs valuc providcd
no justication lor thc usc ol tonsillcctomy as a public hcalth intcrvcntion
whcrc thc substantial majority ol childrcn wcrc subjcctcd to tonsillcctomy,
as was thc casc in somc school districts (and as was still thc casc in thc
.o6cs in Morrisvillc, \crmont, whcn Alan Gittclsohn and ! camc along).
!n addition to thc dubious notion that school childrcn had a high risk ol
dcvcloping scrious illncss in thc luturc mcrcly bccausc thcy had a pair ol
tonsils, it was Glovcrs judgmcnt that such widcsprcad usc ol tonsillcctomy
as a public hcalth stratcgy dcnicd thc probability that thc tonsil scrvcs somc
usclul purposc, its tcndcncy lor spontancous involution, and thc succcss ol
nonopcrativc mcthods ol trcatmcnt that arc oltcn likcly ovcrlookcd .
Morcovcr, it ignorcd thc lact that tonsillcctomy was a risky proccdurc, hc
rcportcd that : 8ritish school childrcn had dicd lollowing thc surgcry
bctwccn .o.. and .o..
Tc nal plank in Glovcrs argumcnt that mcdical opinion was dctcrmin
ing utilization ratcs camc in thc lorm ol a natural cxpcrimcnt. Hc moni
torcd thc changcs in tonsillcctomy ratcs that lollowcd a changc in thc school
hcalth o ccrthc physician rcsponsiblc lor thc diagnosis and rclcrral ol
childrcn lor tonsillcctomy. His most lamous casc involvcd r. R. P. Garrow,
thc physician who rcplaccd an unnamcd prcdcccssor as school hcalth o ccr
in thc Hornscy 8orough school district, in thc Middlcscx rcgion ol ngland.
Following Garrows rccruitmcnt, thc ratcs ol tonsillcctomy lcll dramatically
and rcmaincd bclow .c ol what it had bccn bclorc Garrow camc on thc
sccnc (Figurc ...).
)oxsiiivc)o:y ~xb :vbic~i ovixiox .
Shifting Practice Patterns
Trcc dccadcs latcr, Alan Gittclsohn and ! witncsscd a similar rapid shilt in
surgcry ratcs in \crmont, but this timc it occurrcd bccausc ol a dclibcratc
changc in trcatmcnt policy among local physicians. Altcr documcnting thc
variations in local tonsillcctomy ratcs across thc statc, ! providcd a rcport to
thc \crmont Statc Mcdical Socicty dctailing thc ratcs lor cach arca. r. Roy
8uttlcs, thc socictys prcsidcnt, circulatcd thc inlormation among \crmont
physicians. Prior to thc rclcasc ol thc rcport, thc chanccs ol undcrgoing ton
sillcctomy during childhood in thc Morrisvillc arca wcrc 6c. n lcarning
ol thc high ratc in thcir arca, two Morrisvillc physicians, r. Lcwis 8lowcrs,
a gcncral surgcon, and r. Robcrt Parkcr, a pcdiatrician, undcrtook a sccond
opinion proccss, which lcd to thc rapid dcclinc ol thcir usc ol thc proccdurc.
Figurc .... Tc tonsillcctomy ratc pcr .c,ccc childrcn in thc Hornscy 8orough
School istrict (.o:: through .o.6) and in thc Morrisvillc, \crmont hospital scrvicc
arca (.o6o through .o). Left, Tonsillcctomy ratcs and incidcncc ol otitis mcdia
or middlc car inlcctions in thc ycars bclorc and altcr r. Garrows appointmcnt as
school physician in .o:o. (Adaptcd lrom Glovcr, ]. Alison. .o.. Tc incidcncc ol
tonsillcctomy in school childrcn. Proceedings of the Royal Society of Medicine ..: .:.o.:.6.
Rcprintcd in thc International Journal of Epidemiology, :cc,.:o.o. Rcproduccd by
pcrmission ol thc Royal Socicty ol Mcdicinc Prcss, London, and xlord Univcrsity
Prcss, xlord, UK.) Right, Changc lollowing thc lccdback ol inlormation on thc ratcs
ol tonsillcctomy in Morrisvillc, \crmont. (Adaptcd with pcrmission lrom Pediatrics,
\ol. o, Pagcs :.:6, Copyright .o by thc Amcrican Acadcmy ol Pcdiatrics.)
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6
Tonsillcctomy ratc
Cascs ol otitis mcdia
Hornsey Borough, UK
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Tonsillcctomy ratc
Morrisville, VT, USA
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Ycar Ycar
.6 sivcic~i v~vi~)iox
!n a rcport publishcd in Pediatrics
!4
thcy dcscribcd what madc thcm changc
thcir practicc:
Awarcncss ol thc dicrcnccs among thc arcas lcd us to rcvicw thc litcr
aturc on indications lor tonsillcctomy and to rcvicw cach candidatc
lor tonsillcctomy, whcthcr sccn on rclcrral or in our own practiccs. 8y
thc cnd ol .o:, wc rcvicwcd most ol thc tonsillcctomics pcrlormcd at
our local hospital. Vc bclicvc this proccss ol obtaining a sccond opin
ion hclpcd us standardizc thc dccision proccss.
Vithin two ycars, thc pcr capita ratc ol tonsillcctomy in Morrisvillc had
droppcd to lcss than .c, bccausc ol changcs in local practicc stylcs (scc
Figurc ...).
Glovcrs studics also lorcshadowcd thc usc ol quasicxpcrimcntal dcsigns
to cvaluatc thc outcomcs ol carc, dcsigns that wc would bcgin using in Mainc
in thc .ocs. Hc lollowcd thc outcomcs ol paticnts lor up to cight ycars altcr
thc rapid dcclinc in tonsillcctomics lollowing thc changc in thc school physi
cian in thc Hornscy 8orough. Tc abrupt changc in practicc pattcrn was not
associatcd with an incrcasc in car inlcctions, thc assumcd outcomc il childrcn
wcrc not givcn thc bcnct ol widcsprcad usc ol tonsillcctomy: ]udging by
thc |incidcncc ol | otitis mcdia nothing harmlul but rathcr thc rcvcrsc has
happcncd lrom thc substitution, in all but thc most carclully sclcctcd lraction
ol cascs, ol conscrvativc mcthods lor opcration.
!
!n thc casc ol tonsillcc
tomy, morc was not bcttcr lor hcalth.
Although Glovcrs studics prcccdcd thc work wc would conduct thirtyvc
ycars latcr, and mcdical scicncc and tcchnology had gallopcd lorward ovcr
that pcriod ol timc, somc things rcmaincd thc samc. Glovcr bcgan his rcport
on thc incidcncc ol tonsillcctomy with a bricl history ol mcdical opinion that
bcgan with his own boyhood, in thc .ocs. Hc wrotc that hc could not rccall
a singlc classmatc who had undcrgonc tonsillcctomy. 8y thc mid.o.cs, morc
than c ol studcnts attcnding his childhood school had rcccivcd tonsil
lcctomics. Tc tonsillcctomy cpidcmic also lcll on my own lamily according
to gcncration. My lathcr, born in Norway just altcr thc turn ol thc ccntury,
cscapcd thc proccdurc cntircly, as did most ol his gcncration. ! was not so
lucky. !n thc latc .o.cs my lamily livcd in 8cllows Falls, \crmont, and at thc
agc ol , ! undcrwcnt my rst tonsillcctomy in thc local hospital. ! was onc
ol thc lucky oncs to havc my opcration in thc hospital. Many ol my lricnds
in thosc cprcssioncra ycars wcrc not so lortunatc. Tcir parcnts could not
aord thc hospital, so thcy had thcir opcrations in thc school gymnasium
)oxsiiivc)o:y ~xb :vbic~i ovixiox .
during tonsillcctcctomy daya mass surgcry cvcnt hcld pcriodically to
cnsurc that cvcryonc in 8cllows Falls who nccdcd an opcration rcccivcd an
opcration. Although prccisc statistics arc not availablc, this apparcntly mcant
practically cvcry child in town.
My tonsillcctomy carccr wasnt nishcd with thc 8cllows Falls opcration.
At agc .:, altcr my lamily had movcd to thc statc ol Vashington, ! was scnt
oncc again to thc opcrating room lor a rcdo tonsillcctomy. Apparcntly, thc
rst surgcon had lclt a bit ol my original tonsils lor thc ncxt physician to
rcmovc.
8y thc mid.o6cs, thc cpidcmic was rcccding, and as thc \crmont data
camc onlinc, wc could monitor thc incidcncc in various communitics. Ccrtain
hot spots such as Morrisvillc rcmaincd, but opinion thcrc changcd rapidly
oncc thc physicians bccamc awarc ol thc ratc at which childrcn wcrc undcr
going tonsillcctomy. !n 8cllows Falls, thc incidcncc ol tonsillcctomy was also
quitc high until, suddcnly, it lcll to practically zcro. As ! lookcd closcr at what
was happcning in my old homctown, ! discovcrcd that thc last tonsillcctomy
pcrlormcd at thc local hospital was rccordcd as dcad on dischargcTc
child had dicd during or shortly altcr thc opcration. !t sccmcd likc a painlul
way to concludc an cpidcmic ol surgcry.
Tc risc and lall ol mcdical opinion on thc valuc ol tonsillcctomy scrvc as a
rcmindcr ol thc importancc ol paying critical attcntion to thc assumptions
bchind cvcryday surgical practicc. Tc trcatmcnt thcorics bchind tonsillcc
tomy justicd a dccadcslong pattcrn ol practicc that at its hcight imposcd
on a largc majority ol childrcn an opcration that provcd to bc, lor thc most
part, unncccssary. My own childrcns, and now my grandchildrcns, gcncra
tions havc prctty much cscapcd thc proccdurc, but cvcry agc has its tonsillcc
tomy cquivalcnt. !ndccd, many routincly pcrlormcd proccdurcs and surgcrics
vary as cxtcnsivcly among rcgions and arc backcd up with littlc scicntic
cvidcncc conccrning thc outcomcs ol carc and thc prclcrcnccs ol paticnts.
Chaptcr looks closcly at scvcral ol thcsc situations.
.
Troughout thc .ocs, ! sought opportunitics to cxtcnd our \crmont stud
ics into ncw tcrritorics, in Mainc and Rhodc !sland, and as rcsults bccamc
availablc, wc notcd an intriguing consistcncy in thc pattcrn ol variation ol
utilization. A givcn surgical proccdurc sccmcd to obcy its own rulc in tcrms
ol how much its usc varicd lrom placc to placc. For cxamplc, thc incidcncc ol
surgical rcpair ol a hcrnia, which had shown littlc variation among \crmont
rcgions, also cxhibitcd littlc variation in Mainc and Rhodc !sland. Surgcry to
rcmovc gallstoncs or thc appcndix was morc variablc than hcrnia rcpair but,
comparcd with othcr proccdurcs, cxhibitcd only modcratc variation within
all thrcc statcs. 8y contrast, prostatcctomy lor noncanccrous cnlargcmcnt ol
thc prostatc and hystcrcctomy wcrc quitc variablc lrom arca to arca and also
showcd similar pattcrns bctwccn thc statcs. Tc ratc lor tonsillcctomy was
all ovcr thc map, thc most wildly varying ol all (Figurc ..). As wc lookcd at
thcsc pattcrns, it bccamc apparcnt that an individual proccdurc seemed to have
its own characteristic tendency to vary.
8uilding on thc insights ol Glovcr, ! suspcctcd that thc morc surgcons
disagrccd among thcmsclvcs about thc c cacy ol a proccdurc, and thc
indications lor which it should bc uscd, thc morc variation wc would scc
in thc surgical ratc. ! workcd with r. 8cnjamin 8arncs, a Tults Univcrsity
transplant surgcon, and r. ]ohn 8unkcr, an ancsthcsiologist who at that
timc scrvcd as dircctor ol Harvard Univcrsitys Ccntcr lor thc valuation ol
)
c sivcic~i v~vi~)iox
diagnosis is oltcn madc by thc paticnt or a lamily mcmbcr. At that timc in
thc Unitcd Statcs, thc prcscription lor a hcrnia opcration, likc hospitalization
lor hip lracturc, was not a discrctionary dccision that could bc lclt to thc
judgmcnt ol thc individual physician. Surgcry was always dccmcd ncccssary,
oncc thc diagnosis had bccn madc, to prcvcnt thc incarccration or strangu
lation ol thc bowcl, which rcquircd cmcrgcncy surgcry. (As ! will discuss in
a momcnt, outcomcs rcscarch in thc past lcw ycars shows that this conscnsus
was bascd on an crroncous assumption about how lrcqucntly strangulation
happcns.) Howcvcr, this unilormity in clinical opinion on thc right trcat
mcnt did not cxtcnd to thc Unitcd Kingdom. Tcrc, physicians oltcn prc
scribcd a truss as an altcrnativc to surgcry, and thc availability ol this option
was consistcnt with thc highcr dcgrcc ol variation sccn in ratcs lor inguinal
hcrnia rcpair in thc Unitcd Kingdom.
2
(Scc pagc o.)
ur rcvicw ol thc scicntic cvidcncc supporting an appcndcctomy lor
appcndicitis rcvcalcd a lack ol controvcrsics conccrning thc thcorctical
rcasons lor that surgcry. All physicians vicwcd this opcration lor paticnts
as nondiscrctionary. Yct thc proccdurc ratcs varicd, and thcy varicd su
cicntly to suggcst that physician opinion might bc working to contributc to
thc variation. As it turncd out, thc controvcrsy wc cncountcrcd conccrncd
not thc trcatmcnt ol thc condition but rathcr its diagnosis. thcr causcs ol
abdominal pain, nausca, and vomiting arc commonly conluscd with appcndi
citis, so somc paticnts who do not havc appcndicitis havc an appcndcctomy.
Clinicians whosc conccrns ccntcrcd on avoiding dclay in opcrating arc morc
pronc to makc a lalscpositivc crror, that is, to opcratc on somconc who docs
not havc appcndicitis. n thc othcr hand, thosc who dclay opcrating until
thc causc is clcar may miss thc opportunity lor carly intcrvcntion and thus
havc a highcr complication ratc. !n our study ol thc litcraturc, wc could nd
no cmpirical cvidcncc conccrning thc conscqucnccs lor paticnt outcomcs ol
thcsc dicrcnccs in practicc stylcs.
Tc disagrccmcnt ovcr thc valuc ol gallbladdcr surgcry ccntcrcd on its
usc to rcmovc asymptomatic, or silcnt, gallstoncs.
1
Many Amcricanssomc
cstimatcs arc as high as :c lor middlcagcd adults harbor thcsc silcnt gall
stoncs, which arc usually discovcrcd by accidcnt through an xray or othcr
imaging cxamination undcrtakcn lor somc othcr purposc. At thc timc ol
our study, somc physicians advocatcd (as somc still do today) thc prcvcntivc
rcmoval ol such stoncs, whilc othcrs bclicvcd thc risks ol surgcry wcrc not
worth thc potcntial bcncts. Tc situation lor gallstoncs is thus quitc similar
to that lor tonsillcctomy, cxccpt that in this casc thc argumcnt in lavor ol sur
gcry was bascd on a hypothcsizcd gain in thc lcngth ol lilc that would lollow
carly rcmoval. Tis prcvcntivc surgcry was justicd on thc bclicl that lilc
ix)vvvvv)ixc )nv v~))vvx ov sivcic~i v~vi~)iox .
cxpcctancy is improvcd bccausc thc surgcry rcmovcs thc possibility ol scri
ous gallbladdcr discasc somctimc in thc luturc, whcn thc paticnt is oldcr and
sickcr and thcrclorc morc at risk ol dying lrom surgcry lollowing a symp
tomatic attack. thcrs bclicvcd that thc risks ol dcvcloping a complication
altcr surgcry and thc associatcd probability ol dcath wcrc su cicntly high,
cvcn lor a youngcr paticnt, that it was not worth doing thc surgcry bclorc
it was rcally ncccssary. Somc silcnt gallstoncs rcmain silcnt lor thc rcst ol
thc paticnts lilc, so why pcrlorm an opcration that might ncvcr bc nccdcd:
Physicians in this camp ol opinion advocatcd what wc cvcntually dubbcd
watchlul waiting: to obscrvc and opcratc only il and whcn thc condition
and its symptoms bccomcs scvcrc cnough that intcrvcntion is warrantcd.
Prostatcctomy and hystcrcctomy showcd considcrablc variation in dicrcnt
gcographic locations, and thc controvcrsics surrounding prostatcctomy, as !
discuss at lcngth in Chaptcr 6, involvcd yct anothcr cxamplc ol surgcry as prc
vcntion. Tc thcory that lay bchind hystcrcctomy, on thc othcr hand, ccntcrcd
primarily on its valuc in improving thc quality ol lilc. Tc most common rca
son lor rccommcnding hystcrcctomy was and still is thc trcatmcnt ol pain and
blccding associatcd with mcnopausc. Hormonal trcatmcnt was an altcrnativc
to hystcrcctomy, as was watchlul waiting, bccausc mcnopausc is complctcd
cvcntually and thc blccding and othcr symptoms rcsolvc. Tc rccommcnda
tion lor surgcry thus involvcd judgmcnts about thc impact ol surgcry on thc
quality ol lilc and whcthcr, givcn its costs and risks, surgcry could bc justicd
whcn thc problcm usually gocs away on its own in a lcw months or ycars. (Vc
lound a clcar conscnsus in thc litcraturc that surgcry was thc only appropriatc
trcatmcnt lor canccr ol thc utcrus, assuming thc canccr had not sprcad to thc
point at which an opcration was lutilc. 8ut lcss than .c ol hystcrcctomics
in thc Unitcd Statcs wcrc pcrlormcd lor trcating canccr.) Tc controvcrsics in
thc litcraturc ccntcrcd in part on qucstions conccrning thc possiblc ncgativc
impact ol hystcrcctomy on cmotional hcalth and othcr aspccts ol thc quality
ol lilc. As was thc casc lor thc othcr opcrations that 8cnjamin, ]ohn, and !
rcvicwcd, wc could nd no clinical trials that ocrcd objcctivc cvidcncc to
rcsolvc thc dicrcnccs in prolcssional opinion. !n othcr words, physicians wcrc
routincly pcrlorming many dicrcnt kinds ol surgcrics bascd largcly on thco
rics, bclicls, and traditionbut rcmarkably littlc valid cvidcncc.
Prognosis, Patient Preference, and Medical Opinion
Tc lack ol cvidcncc lor thc c cacy ol various surgical trcatmcnts was
rcmarkablc in itscll, but thcrc was anothcr aspcct ol thc mcdical litcraturc
: sivcic~i v~vi~)iox
that sccmcd cvcn morc astonishing. Although thcrc was considcrablc dcbatc
conccrning thc prognosis, or outcomcs, ol surgical trcatmcnts, vcry littlc ol
thc discussion locuscd on what paticnts wantcd. Vhat was thc paticnts prcl
crcncc whcn laccd with surgcry: Tc topic rarcly camc up and, whcn it did,
thc intcnt was oltcn to dismiss thc importancc ol thc paticnts rolc in dcci
sion making and to acccpt unqucstioningly thc notion that physicians arc
compctcnt to diagnosc what paticnts dcsirc.
Yct, whcn physicians thcmsclvcs arc paticnts, thc qucstion ol what paticnts
want suddcnly bccomcs a topic ol intcrcst. Vc had bccn alcrtcd to this idca
altcr wc participatcd in a scminar at Harvard Univcrsity in thc mid.ocs on
surgical practicc. ur collcaguc uncan Ncuhauscr prcscntcd a papcr at thc
scminar arguing lor thc importancc ol paticnt prclcrcncc, cvcn in thc casc ol
an inguinal hcrnia rcpair, which in this country was virtually always trcatcd
with surgcry.
4
!n making his casc, hc citcd thc cxpcricncc ol two physicians
as cvidcncc lor intcrpcrsonal dicrcnccs. nc notcd 8oston surgcon who
oncc uscd a truss said thcy wcrc dirty, tight, uncomlortablc, hot, and smclly,
and hc would not wish thc cldcrly, who sucr as it is, to bc compcllcd to usc
thcm. Anothcr physician Ncuhauscr quotcd said hc had a painlcss hcrnia
and prclcrrcd to avoid an opcration.
!n our rcvicw ol thc litcraturc, wc lound only onc cxamplc ol conccrn
about paticnt prclcrcnccs with rcgard to surgcry. !t, too, camc lrom a physi
cian, who, in a lcttcr to thc cditor ol thc New England Journal of Medicine,
dcscribcd his stratcgy lor avoiding surgcry lor bcnign prostatic hypcrplasia, a
diagnosis that oltcn lcd to a prostatcctomy:
8cnign prostatic hypcrplasia has awakcncd mc scvcral timcs a night lor
ycars. Tis past wintcr ! bcgan to wakc up cvcry hour or two with
visions ol an impcnding (opcration). Tcrc was always morc urinc that
could bc voidcd . ! bcgan to spcnd a minutc or morc voiding, but
carclully not straining, until no morc could bc obtaincd. Tc rcsults
wcrc immcdiatc and dramatic. ! now slccp thrcc or lour hours at a
timc and occasionally gct up only oncc in cight hours . !l ! am lazy
and lail to takc plcnty ol timc to void, thcrc is a prompt rcturn ol thc
lrcqucncy. !t may bc that this tcchnic will prccludc unncccssary surgcry,
cvcn without a sccond opinion.
)
Figurc ... Tc surgical signaturcs ol thc vc most populous hospital scrvicc arcas
in Mainc (.o). For cach arca, thc ratc rclativc to thc statc avcragc lor vc surgical
proccdurcs is displaycd. (Adaptcd lrom Vcnnbcrg, ]. and A. Gittclsohn. .o. Hcalth
Carc clivcry in Mainc !: Pattcrns ol Usc ol Common Surgical Proccdurcs. Journal of
the Maine Medical Association 66:.:...c, .o. Uscd with thc pcrmission ol thc Mainc
Mcdical Association.)
6 sivcic~i v~vi~)iox
morc than :. timcs that ol Portland. Surgcons practicing in thc Vatcrvillc
arca wcrc particularly pronc to opcratc on hcmorrhoids, achicving a ratc :.
timcs grcatcr than thc statc avcragc and .6 timcs grcatcr than thc surgcons
scrving Portland. !n 8angor, surgcry ratcs ovcrall wcrc lowcr than in thc
othcr rcgions.
Vhcn conlrontcd with thc surgical signaturcs in thcir own community,
physicians want to bclicvc thcir practicc prolcs arc thc rcsult ol paticnt nccd.
Timc and timc again, whcn my collcagucs and ! havc prcscntcd our data to
physicians, many in thc audicncc arguc vigorously against thc notion that
it is thcir opinions that play a major rolc in dctcrmining what kind ol carc
thcir paticnts rcccivc. Yct simply changing thc opinions ol local practitioncrs
can havc a rcmarkablc ccct on thc ratc ol surgcry in a rcgion. !n thc casc ol
tonsillcctomy, as discusscd in Chaptcr ., Glovcr documcntcd what happcncd
whcn r. R. P. Garrow rcplaccd a rctiring school hcalth o ccr who had grcat
cnthusiasm lor thc surgcry, and in Morrisvillc, \crmont, local physicians dra
matically and swiltly rcduccd thc ratc ol tonsillcctomy altcr dcciding to scck
a sccond opinion bclorc rccommcnding it.
ur monitoring ol thc ratcs ol surgcry in Maincand thc publication
ol thc rcsults in thc Journal of the Maine Medical Associationprovidcs yct a
third cxamplc ol abrupt changc, this onc cxplaincd whcn thc managcmcnt
ol a hospital in Lcwiston, Mainc, cmbarrasscd by knowlcdgc ol its high
surgcry ratc lor hystcrcctomy, imposcd a quota on thc numbcr ol proccdurcs
that should bc pcrlormcd. vcr onc lourycar pcriod in thc .ocs, hystcrcc
tomy ratcs in Lcwiston wcrc such that ovcr cc morc womcn wcrc opcratcd
on than would havc cxpcricnccd surgcry had thc avcragc ratc lor thc statc
applicd.
2
Most ol thc surgcrics wcrc undcrtakcn by two vcry cnthusiastic sur
gcons in Lcwiston, who kcpt thcmsclvcs so busy that about 6c ol womcn
in thc rcgion wcrc cstimatcd to bc utcruslrcc by agc c.
Tc intcrvcntion in Lcwiston was organizcd by r. anicl Hanlcy, thc
cditor ol thc Journal of the Maine Medical Association and sccrctary ol thc
Mainc Mcdical Association. Likc r. 8uttlcs in \crmont, who uscd our data
to inlorm physicians in Morrisvillc about thcir high ratc ol tonsillcctomy,
an wcnt lrom town to town in Mainc, showing physicians our data on
thc pattcrns ol variation in surgcry in thc statc. Hanlcy mct with r. 8ucll
Millcr and scvcral ol his collcagucs lrom thc statc chaptcr ol thc Amcrican
Collcgc ol Gynccology to dcvisc a plan to challcngc thc practicc pattcrns ol
thc gynccologists in Lcwiston. Altcr scvcral mcctings, thc mcdical lcadcrship
in thc hospital scrving thc Lcwiston arca dccidcd to govcrn thc quantity ol
surgcry by imposing a quota on thc numbcr ol hystcrcctomics thc surgcons
could pcrlorm ovcr thc coursc ol a ycar. Tc quota was sct to bring thc ratc
:~vxv) vov vvvvvvvxcvsvxsi)ivv sivcvvy
ol hystcrcctomics pcrlormcd down to thc statc avcragc. Tc c cacy ol this
policy ol limits and its stability ovcr timc wcrc quitc rcmarkablc. 8y .o., thc
ratc ol hystcrcctomy had dcclincd , whcrc it rcmaincd until at lcast .oo
(Figurc .:).
Tc data in Figurc .: attcst to thc prccision with which providcrs can
control thc ratc ol clcctivc surgcry. Tcy mct thcir production goal, ycar in
and ycar out. Yct dcspitc thc succcss ol thc quota in bringing down thc ratc
ol hystcrcctomy, thc physicians wcrc not ncccssarily opcrating on thc right
womcn. Tcrc was no way to cnsurc that physicians wcrc not doing unncc
cssary surgcrics in somc cascs and lailing to pcrlorm nccdcd (or wantcd)
opcrations in othcrs, bccausc thc quota did not guarantcc that thc surgcons
wcrc taking into account thcir paticnts own prclcrcnccs. Pcrhaps thcrc wcrc
womcn in Lcwiston whosc symptoms wcrc so bothcrsomc that thcy wantcd
hystcrcctomics but wcrc not ocrcd surgcry. !t was also possiblc that womcn
whosc utcrus was rcmovcd would havc choscn watchlul waiting or hormonc
thcrapy, had thcy bccn givcn an opportunity to truly undcrstand thc tradcos
ol thc surgcry, its vcry rcal risks as wcll as its potcntial bcncts.
Figurc .:. Hystcrcctomy ratcs lor Mainc and lor rcsidcnts ol hospital scrvicc arca
!!! lrom .o. through .oo. Tc gurc givcs thc agcadjustcd hystcrcctomy ratc ovcr a
twcntylourycar pcriod lor rcsidcnts ol Lcwiston, Mainc (Urban .). ata lccdback (F)
rst took placc in .oo. (Sourcc: Kcllcr, R.8., . . Vcnnbcrg, and . N. Soulc. .oo.
Changing physician bchavior: Tc Mainc Mcdical Asscssmcnt Foundation. Quality
Management in Health Care Summcr,():.... Rcproduccd with pcrmission lrom
Quality Management in Health Care, Lippincott Villiams & Vilkins, publishcrs.)
Ycar
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F
sivcic~i v~vi~)iox
Tis is the essential fallacy of quotas, or indeed any other attempt to con-
trol demand for discretionary surgery on the basis of rules of thumb, or prac-
tice guidelines that fail to take the individual patients own preference into
account. Tc statcs avcragc lor hystcrcctomy was, altcr all, mcrcly thc
wcightcd avcragc ol thc variation in mcdical opinion among thc physicians
and surgcons practicing in thc Maincs hospital scrvicc arcas. To put this
anothcr way, thc Mainc avcragc would havc bccn dicrcnt had a dicrcnt
group ol surgcons dccidcd to practicc thcrc. Making mcdical dccisions lor
prclcrcnccscnsitivc carc on thc basis ol statistical avcragcs providcs no
assurancc that proccdurcs arc bcing pcrlormcd on paticnts who nccd or
want thc opcrations thcy gct.
Ubiquitous and Persistent
Tc surgical signaturc phcnomcnon has turncd out to bc commonplacc, a
charactcristic ol hcalth carc in cvcry rcgion ol thc country, including carc
dclivcrcd by thc most prcstigious ol providcrs. nc ol my lavoritc small arca
comparisons locuscd on 8oston and Ncw Havcn, two communitics whosc
rcsidcnts rcccivc most ol thcir carc lrom laculty mcmbcrs ol somc ol thc
nations most rcnowncd mcdical schools. nc would assumc that bccausc
ol thc crcdcntials ol thcsc hospitals and physicians, thc carc rcccivcd by thc
populations in thcsc two citics would bc ol thc highcst quality, bascd on
thc most crcdiblc mcdical cvidcncc. Yct how that high quality carc dil
lcrcd! For somc opcrations, thc chanccs ol surgcry wcrc much highcr in
Ncw Havcn than in 8oston, whilc lor othcrs, 8ostonians wcrc much morc
likcly to undcrgo surgcry. uring thc .ocs, lor cxamplc, a rcsidcnt ol Ncw
Havcn was twicc as likcly to undcrgo a hystcrcctomy or coronary artcry
bypass gralt (CA8G) as a 8ostonian. For carotid cndartcrcctomy (sur
gcry to unblock thc major artcrics lccding thc brain) and hip rcplaccmcnt
surgcry, thc risk was, rcspcctivcly, :. and ..6 timcs grcatcr lor rcsidcnts ol
8oston.
1
Tc common causc lor thcsc dicrcnccs bctwccn thcsc two arcas scrvcd
by acadcmic mcdical ccntcrs could bc traccd, oncc again, to Glovcrs thcory
ol mcdical opinions strongly hcld by small groups ol physicians conccrn
ing mcdical c cacy or valuc to paticnts. Trough intcrvicws with physi
cians in both 8oston and Ncw Havcn, ! lcarncd that thc low ratc ol carotid
cndartcrcctomy ratcs in Ncw Havcn comparcd to 8oston could bc attrib
utcd to a group ol skcptical ncurologists who simply did not bclicvc in thc
proccdurc, prclcrring aspirin to surgcry lor any paticnt who camc to thcm
:~vxv) vov vvvvvvvxcvsvxsi)ivv sivcvvy o
lor advicc. 8y contrast, thc physicians in 8oston had, on avcragc, grcatcr
laith in carotid artcry surgcry (although rclativc to many othcr parts ol
thc country, thc 8oston ratcs wcrc rathcr low). Tc conscrvativc mcdical
managcmcnt ol coronary artcry discasc and symptoms ol mcnopausc was
morc popular in 8oston, whcrcas clinicians in Ncw Havcn morc oltcn
prclcrrcd surgical managcmcnt, which mcant that morc CA8G and hys
tcrcctomics wcrc pcrlormcd. n thc othcr hand, Ncw Havcn physicians
wcrc morc cnthusiastic about thc conscrvativc managcmcnt ol arthritis ol
thc hip.
8cginning in thc .oocs, our work on thc artmouth Atlas Projcct has
madc it possiblc to monitor thc surgical signaturc phcnomcnon throughout
thc Unitcd Statcs, and thc pattcrn is thc samc writ largc. Takc thc ratcs lor
surgcry lor dcgcncrativc discascs ol thc hip and kncc, conditions that arc
oltcn trcatcd by orthopcdic surgcons. !n Chaptcr , ! illustratcd thc striking
variation among thc .c6 artmouth Atlas Projcct rcgions in thc usc ol kncc
or hip rcplaccmcnt lor thcsc conditions. Tc chancc ol having a kncc or hip
rcplaccmcnt varied about ve times lrom thc lowcst to thc highcst rcgion in
thc country.
Yct within a givcn rcgion, thcrc is a rcmarkablc constancy in thc pattcrn
ol practicc ovcr timc: rcgions that rank high in a proccdurc ratc at onc
pcriod in timc tcnd to do so in subscqucnt pcriods. Tis is cvidcnt through
thc corrclations in Figurc .., which shows thc rclationship bctwccn ratcs
lor hip rcplaccmcnt and kncc rcplaccmcnt in .oo6 and :cc. Tc coc cicnt
+
:
:
6
R
:
- o.: R
:
- o.o
+ : : 6
8
+:
+6
8 +: +6
Hip rcplaccmcnt pcr +,ooo
Mcdicarc cnrollccs (+oo6)
Kncc rcplaccmcnt pcr +,ooo
Mcdicarc cnrollccs (+oo6)
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Figurc ... Tc association bctwccn surgcry ratcs in .oo6 and :cc lor hip (left) and
kncc rcplaccmcnt (right) among hospital rclcrral rcgions. (Sourcc: artmouth Atlas
Projcct databasc.)
6c sivcic~i v~vi~)iox
ol dctcrmination (thc R
2
statistic) indicatcs a strong association: a largc
majorityabout col thc variation in surgcry ratcs lor kncc and hip
rcplaccmcnt in :cc was cxplaincd by thc variation in surgcry ratcs in .oo6,
a dccadc carlicr. (Scc pagc : in thc Appcndix lor an cxplanation ol thc R
2
statistic and rcgrcssion lincs.) Tis constancy was maintaincd, cvcn though
thcrc was a substantial trcnd upward in ovcrall ratc, thc U.S. avcragc ratc ol
surgcry incrcascd 6. lor kncc rcplaccmcnt and . lor total hip rcplacc
mcnt. Most rcgions cxpcricnccd substantial incrcascs and thcrc was littlc
cvidcncc ol rcgrcssion to thc mcan.
Consistcncy in thc ratcs ol spccic proccdurcs ovcr timc is sccn lor othcr
proccdurcs, although to a lcsscr dcgrcc. Tc corrclation bctwccn inpaticnt
surgcry in .oo6 and :cc lor back surgcry was R
2
- c., lor carotid artcry
surgcry, R
2
- c.., lor radical prostatcctomy, R
2
- c.., lor mastcctomy,
R
2
- c..., lor coronary artcry surgcry, R
2
- c..:, and lor PC!, R
2
- c..:.
Te Paradoxical Role of Surgeon Supply in Rates of Surgery
Vhat about thc rclationship bctwccn thc supply ol rcsourccs and thc usc ol
prclcrcnccscnsitivc surgcry: For ycars, hcalth scrvicc rcscarchcrs havc docu
mcntcd that morc surgcons pcr capita mcans morc surgcry pcr capita, but
thcsc studics havc bccn primarily conccrncd with thc association bctwccn
thc ovcrall supply ol surgcons and thc ovcrall ratc ol surgcry.
4
Morc rcccntly,
wc havc bccn looking at thc association bctwccn thc ratc lor an individual
proccdurc and thc supply ol thc surgical spccialists who pcrlorm thc surgcry.
Givcn thc cvidcncc that morc surgcons mcans morc surgcry, it camc as a sur
prisc to nd out that among thc .c6 hospital rclcrral rcgions, there is little or
no relationship between the rate of a given procedure and the supply of the surgeons
trained in the specialty that performs that procedure.
Takc thc casc ol thc pcr capita numbcr ol orthopcdic surgcons and thc
ratcs ol hip rcplaccmcnt and kncc rcplaccmcnt (Figurc .). Vhat can
account lor this puzzling lack ol corrclation: !n a rational hcalth carc mar
kct, an incrcmcntal incrcasc in prolcssional capacity would prcsumably bc
sprcad on thc basis ol clinical nccd. !n thc casc ol capacity to trcat paticnts
with orthopcdic conditions, it would bc sprcad among surgical managcmcnt
ol all thc conditions that can bc trcatcd by orthopcdists: arthritis ol thc hip,
kncc, and back, carpal tunncl discasc, shouldcr conditions, impairmcnts ol
thc loot and anklc, sports mcdicinc and trauma, ctc. nc would thus cxpcct
to scc a positivc association bctwccn individual proccdurcs and ovcrall surgi
cal capacity. !n othcr words, il thc hcalth carc markct lunctioncd in thc way
:~vxv) vov vvvvvvvxcvsvxsi)ivv sivcvvy 6.
prcdictcd by rational agcncy thcory, surgical utilization in rcgions that gain
orthopcdists would bc allocatcd in a way that cnsurcd that all bascs wcrc
covcrcd, and paticnts with dicrcnt conditions would gct thc surgcrics thcy
nccd. Morcovcr, rcgions with low ratcs lor a givcn proccdurc, and thus prc
sumably grcatcr unmct nccd, would bc cxpcctcd to incrcasc thc numbcr ol
orthopcdists capablc ol providing thosc proccdurcs. Capacity in highratc
rcgions lor that proccdurc ought to dcclinc. !n othcr words, you would cxpcct
to scc rcgrcssion toward thc mcan. 8ut this is not what wc scc.
! think an important cxplanation lor this phcnomcnon is subspccializa
tion. !n thcir initial training programs, orthopcdic surgcons arc cxposcd
to a crossscction ol conditions that mcmbcrs ol thcir spccialty trcat, such
as arthritis ol thc kncc and hip, which can bc trcatcd surgically with joint
rcplaccmcnts. thcr conditions orthopcdists cncountcr includc carpcl tun
ncl syndromc (surgical rcpair), trauma (various proccdurcs), and a numbcr ol
conditions accting thc shouldcr, anklc, and loot (surgical rcpairs). Howcvcr,
latcr in thcir training or carly in thcir practicc ycars, thcy tcnd to spccializc
in onc or two ol thcsc conditions, achicving grcatcr compctcncc in a narrow
rangc ol surgical proccdurcs, with somc spccializing in backs, othcrs in hip
and kncc rcplaccmcnt, and still othcrs in shouldcr surgcry. Vhcn it all gcts
addcd up at thc local markct lcvcl, or thc rcgional lcvcl, thcrc is littlc cor
rclation bctwccn overall supply ol orthopcdic surgcons and thc numbcr who
dcvotc thcir workload to a particular subsct ol proccdurcs. Somc rcgions may
havc a lot ol orthopcdists who primarily pcrlorm back surgcry, whilc othcrs
Figurc .. Tc association bctwccn supply ol orthopcdic surgcons (:cc6) and ratcs
lor hip (left) and kncc rcplaccmcnt (right) (:cc) among hospital rclcrral rcgions.
(Sourcc: artmouth Atlas Projcct databasc.)
R
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- o.+ R
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+
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rthopcdic surgcons pcr
100,000 rcsidcnts (:oo6)
rthopcdic surgcons pcr
+oo,ooo rcsidcnts (:oo6)
6: sivcic~i v~vi~)iox
may havc a handlul who pcrlorm back surgcry, somc who pcrlorm hip
surgcry, and othcrs who pcrlorm shouldcrs and hand surgcry.
Vc havc sccn a similar lack ol corrclation bctwccn thc supply ol vascular
surgcons and carotid artcry surgcry and lowcr cxtrcmity artcrial bypass
proccdurcs, bctwccn gcncral surgcons and mastcctomy and gallbladdcr
surgcry, and bctwccn urologists and prostatcctomy.
+
:
:
6
+ : : 6 8 o. +.o +. :.o :. :.o
+
:
:
6
:~vxv) vov vvvvvvvxcvsvxsi)ivv sivcvvy 6.
ocs this mcan that thc PC! proccdurc should bc classicd as a supply
scnsitivc scrvicc (a conccpt that ! will discuss at grcatcr lcngth latcr in this
book): Not at all. Vhcn donc as a mcans lor trcating a hcart attack, clin
ical trials show that thc proccdurc is highly ccctivc in rcducing mortality
and cardiac damagc. Vhcn undcrtakcn lor this purposc, thc proccdurc is an
cxamplc ol ccctivc carc. Howcvcr, in most cxamplcs ol its usc, thc primary
purposc is to trcat chcst pain or stablc angina, and lor this indication, as
discusscd in Chaptcr , thc proccdurc is clcctivc and thus prclcrcncc
scnsitivcthcrc is morc than onc ccctivc trcatmcnt and thc choicc should
dcpcnd on paticnt prclcrcncc, not on local mcdical opinion.
High Rates Do Not Necessarily Mean Unnecessary Care
from the Physicians Point of View
A study donc in :ccc by Gillian Hawkcr and hcr collcagucs in ntario,
Canada,
6
providcs thc missing link to gaining an undcrstanding ol thc mar
kct lor prclcrcnccscnsitivc carc: it hclps us undcrstand why thc variations
in kncc and hip rcplaccmcnt arc so stablc ovcr timc, why surgcry ratcs show
littlc rcgrcssion to thc mcan, why thcrc arc no apparcnt barricrs to thc markct
cntry ol orthopcdic surgcons who spccializc in kncc and hip rcplaccmcnts into
rcgions whcrc thc ratcs ol surgcry arc alrcady high, and why all ol this can occur
without transgrcssing prolcssional standards and normsat lcast undcr thc
prcvalcnt rational agcncy modcl that dclcgatcs clinical dccisions to physicians.
Hawkcr and hcr collcagucs sought to undcrstand thc nccd lor joint rcplacc
mcnt in two Canadian rcgions, onc with a highsurgcry ratc and thc othcr with
a low ratc. !nitially thcy locuscd on dcning mcdical nccd in thc traditional
way. Using thc latcst cvidcnccbascd guidclincs lor idcntilying candidatcs who
wcrc clinically appropriatc lor surgcry, thcy intcrvicwcd a rcprcscntativc samplc
ol thc gcncral population ovcr c ycars ol agc. A standardizcd qucstionnairc
was uscd to idcntily thosc with limitation ol motion and symptoms ol arthritis
ol thc hip and kncc su cicntly poor to warrant lurthcr asscssmcnt ol nccd lor
surgcry. Tc paticnts who passcd this initial scrccn wcrc thcn givcn an imag
ing cxamination to dcnc thc paticnt population who, according to practicc
guidclincs, nccdcd surgcry.
Tc rst surprisc camc whcn thc rcscarchcrs lound that thc population
bascd need dcncd in this way was much highcr than thc obscrvcd ratcs ol
joint rcplaccmcnt surgcry, cvcn in thc rcgion whcrc ratcs ol surgcry wcrc
highcr. Tis suggcstcd substantial underuse ol surgcry, not cxactly good ncws
lor thc Canadian hcalth carc systcm, which alrcady opcratcs undcr thc cloud
6 sivcic~i v~vi~)iox
ol suspicion that it withholds valuablc carc lor cconomic rcasons. !ndccd,
it was not good ncws lor thc Amcrican hcalth carc systcm, cithcr. Tc pcr
capita numbcr ol paticnts whom thc study idcnticd as clinically appropri
atc lor joint rcplaccmcnt cxcccdcd thc surgcry ratcs lound in thc artmouth
Atlas Projcct rcgion in thc Unitcd Statcs whcrc joint rcplaccmcnt ratcs arc
thc highcst, suggcsting undcrusc in this country as wcll.
8ut thc nal stcp in thc Hawkcr groups asscssmcnt proccss produccd
an cvcn grcatcr surprisc. Tc paticnts who mct thc cvidcnccbascd clini
cal guidclincs lor undcrgoing joint rcplaccmcnt wcrc thcn askcd a scrics
ol qucstions dcsigncd to asccrtain thcir dcsirc and willingncss to undcrgo
surgcry. Much ol thc intcrvicw locuscd on thc paticnts prclcrcnccsgivcn
thcir clinical situation, would thcy prclcr surgcry, or would thcy prclcr morc
conscrvativc mcans ol managing thcir disability: nly 14.9 of the patients
in the high-rate region and only 8.5 in the low-rate region who were eligible for
surgery, according to evidence-based clinical guidelines, actually wanted surgery.
Tat mcans that givcn thc currcnt stagc in thc cvolution ol thcir clinical
problcm, bctwccn 6 and o. prclcrrcd mcdical managcmcnt. A rcviscd
cstimatc ol nccd that includcd paticnt prclcrcnccs thus suggcstcd that thc
surgcry ratcs in Canada wcrc closc to mccting nccd, if only those who wanted
surgery were the ones who actually got it.
Tc Hawkcr study providcs an important insight into thc limitations ol
thc prcvalcnt mcthod lor dctcrmining surgical nccd bascd on objcctivc clin
ical inlormation, as obtaincd lrom clinical history (progrcssion ol morbid
ity), thc clinical intcrvicw (currcnt symptom lcvcl), thc physical cxamination
(limitation ol mobility), and biomcdical tcsts (prcscncc ol joint discasc docu
mcntcd by imaging cxaminations). vcn whcn cvidcnccbascd, thc mcthod
can lcad to unncccssary surgcrythat is, surgcry on paticnts who do not
want thc opcration.
Tc Hawkcr study also points to thc wcakncss ol dclcgatcd dccision mak
ing in constraining dcmand. At lcast in thc casc ol kncc and hip rcplaccmcnt,
thc numbcr ol paticnts who mcct bcst practiccs appropriatcncss critcria
lor mcdical nccd cstablishcd in this lashion cxcccds thc amount ol surgcry
now providcd, cvcn in rcgions whcrc thc ratc ol thc surgcry is thc highcst.
Howcvcr, thc Hawkcr bcnchmark indicatcs a much lowcr lcvcl ol dcmand
whcn clinical dccision making is bascd on choiccs madc by lully inlormcd
paticnts, rathcr than a dccision that has bccn dclcgatcd to thc physician (or
madc by a lcss than lully inlormcd paticnt). !n othcr words, whcn thc markct
lor surgcry opcratcs undcr thc assumption that it is rational to dclcgatc dcci
sion making to thc physicians, orthopcdic surgcons havc a ncarly bottomlcss
wcll ol potcntial paticnts to work on, at lcast according to thcir clinical critcria
:~vxv) vov vvvvvvvxcvsvxsi)ivv sivcvvy 6
lor appropriatcncsscvcn whcn thcir critcria arc cvidcnccbascd. Tis mcans
that il a ncw surgcon comcs to town spccializing in kncc rcplaccmcnt, morc
paticnts will gct ncw knccs. And il that town happcns to bccomc thc homc
lor yct anothcr orthopcdist who pcrlorms kncc rcplaccmcnts, cvcn morc
paticnts will undcrgo kncc rcplaccmcnt. 8ut having morc surgcons docs not
mcan thc right paticnts (i.c., thosc who not only nccd ncw knccs according
to prolcssional judgmcnt but also want thcm) arc undcrgoing surgcry.
For a lcw surgical proccdurcs, notably hip lracturcs rcpair and colcctomy lor
colon canccr, thc incidcncc ol illncss imposcs a natural limit on thc dcmand
lor surgcry. !n othcr words, thc ratc ol surgcry tracks thc incidcncc ol thc con
dition. For most proccdurcs, howcvcr, thc ratc ol surgcry varics substantially
lrom onc markct arca to anothcr, unrclatcd to variation in illncssor paticnt
prclcrcnccs. 8ccausc paticnt prclcrcnccs arc not now routincly and systcmati
cally clicitcd, and thc clinical dccision proccss docs not rccognizc thc ccntral
importancc ol an accuratc diagnosis ol what paticnts want (as opposcd to
what physicians think thcy nccd), many paticnts arc likcly undcrgoing surgcry
that thcy would not want il thcy wcrc lully inlormcd and cmpowcrcd to
participatc in a mcaninglul way in thc choicc ol trcatmcnt.
stablishing a markct whcrc thc utilization ol prclcrcnccscnsitivc trcat
mcnt is dctcrmincd by paticnt dcmand will rcquirc a cultural changc in
thc doctorpaticnt rclationship. !t will rcquirc rcplacing dclcgatcd dccision
making with sharcd dccision making, and cstablishing inlormcd paticnt
choicc as thc standard ol carc lor dctcrmining mcdical ncccssity.
Chaptcr 6 dcscribcs a dccadclong rcscarch projcct targctcd at undcr
standing thc clinical rcasons lor practicc variation in thc surgical trcatmcnt
ol bcnign prostatc hypcrplasia, or 8PH, a condition that accts many mcn
as thcy agc. Tis rcscarch lcd to an cxpcrimcnt to rcplacc dclcgatcd dccision
making with sharcd dccision making, to cmpowcr mcaninglul paticnt par
ticipation in trcatmcnt choicc.
66
!n thc latc .ocs, our rcscarch tcam was ablc to movc bcyond thc statistical
dcscription ol surgical variation to undcrtakc a scrics ol dctailcd studics in
thc statc ol Mainc that lcd to a diagnosis ol thc clinical causcs ol varia
tion and a stratcgy lor rcducing unwarrantcd variation in prclcrcnccscnsi
tivc trcatmcnts. Tc opportunity cvolvcd lrom thc publication in .o in thc
Journal of the Maine Medical Association ol our data on gcographic variation
(including thc surgical signaturc lor thc vc largcst Mainc communitics dis
cusscd in Chaptcr ).
!
!n our papcr, wc madc thc thcn rathcr novcl argumcnt
that variations that cannot bc attributcd to illncss or acccss to carc should
bc intcrprctcd as an indication ol variation in prolcssional opinion, and thc
rcmcdy lor that variation ought to bc outcomcs rcscarch.
!n an accompanying cditorial, r. anicl Hanlcy, thc cditor ol thc jour
nal, challcngcd his lcllow physicians to rcspond. All this will rcquirc a scrics
ol dctailcd looks by thosc who know thc situation bcstthc Physicians
thcmsclvcs, hc wrotc. Tis mcans timc and cort, but thc rcwards arc
grcat: a bcttcr undcrstanding ol thc dccisionmaking proccss in Mcdicinc
(Surgcry) and a chancc to build a mcdical cducation program that is
tailorcd to dcmonstratcd nccds.
2
an titlcd his cditorial, in his typical tongucinchcck lashion, A Tool lor
All Committccs, and hc acknowlcdgcd that our work and rccommcndations
would undoubtcdly raisc somc hacklcs. 8ut as sccrctary ol thc Mainc Mcdical
6
Learning What Works and
What Patients Want
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x) 6
Association and a wcllknown and highly rcspcctcd physician in his statc,
an had a way ol smoothing thc way lor us. Hc was lor many ycars an activc
mcmbcr ol thc U.S. lympic Committcc, scrving as its principal advisor in
dcaling with thc cpidcmic ol drug usc among lympic athlctcs that brokc
out in thc mid.ocs, hc was also thc bclovcd campus physician lor 8owdoin
Collcgc. Morcovcr, hc was cxtrcmcly proud ol his prolcssion but insistcnt on
its nccd to takc rcsponsibility lor thc quality ol hcalth carc. Primarily bccausc
ol ans advocacy, thc Commonwcalth Fund agrccd to invcst somc capital
into what bccamc thc Mainc Mcdical Asscssmcnt Foundation, a nonprot
group that scrvcd as a local point lor promoting prolcssional accountability
lor practicc variations and trcatmcnt outcomcs (8ox 6..).
8ox 6... A Short History of the Maine Medical Assessment
Foundation
Tc Foundation had its bcginning in .oc as thc Mainc Mcdical
Asscssmcnt Program, organizcd by r. anicl Hanlcy undcr thc
Commonwcalth Funds grant to lacilitatc thc lccdback ol inlorma
tion on practicc variation to Mainc physicians. vcr its rst tcn ycars,
thc projcct organizcd study groups in intcrnal mcdicinc, pcdiatrics,
urology, gynccology, and orthopcdics to cxaminc practicc variations
rclatcd to thcir spccialtics. ach ol thcsc groups undcrtook thc thrcc
stcp proccss. Stcp nc was to idcntily blatant cxamplcs ol ovcrusc or
undcrusc ol carc and urgc local physicians to changc thcir practiccs.
Tis approach workcd rcasonably wcll in thc casc ol hystcrcctomics
in Lcwiston, Mainc, as ! dcscribcd in Chaptcr . !l thc variation was
not obviously duc to thc dclivcry ol unncccssary carc, Stcp Two was to
undcrtakc a rcvicw ol thc scicntic litcraturc to idcntily what would
nowadays bc callcd bcst practiccs. !l disagrccmcnt rcmaincd altcr
rcvicw ol thc scicntic litcraturc, our third stcp was to undcrtakc out
comcs rcscarch to rcducc scicntic unccrtainty.
1
Tc pcdiatrics, gynccology, and orthopcdic study groups carricd out
Stcp nc intcrvcntions that lcd to a rapid rcduction ol thc utiliza
tion ratcs in highratc rcgions. Trcc ol thc study groups joincd with
acadcmic rcscarchcrs to undcrtakc Stcp Trcc outcomcs rcscarch lor
low back pain (spinc surgcry), abnormal utcrinc blccding (hystcrcc
tomy), and an cnlargcd prostatc (prostatc surgcry).
(continued)
6 sivcic~i v~vi~)iox
Vc workcd as a tcam to gct Mainc physicians on board lor a program
aimcd at undcrstanding practicc variation and improving clinical dccision
making. ur rcscarch tcam prcparcd rcports lor lccdback to Mainc phy
sicians, much along thc lincs ol thosc wc uscd in \crmont. Tc lccdback
scssions took placc ovcr a twoday rctrcat at artmouths Minary Ccntcr,
an idyllic lodgc on thc shorcs ol Squam Lakc, thc sctting ol thc .o. movic
n Goldcn Pond. Tc scssions wcrc organizcd around spccialty groups
and thc targcts lor lccdback wcrc thc proccdurcs thcy pcrlormcd. Typically,
thc rst hour or so was spcnt cstablishing crcdibility ol thc data, a task
that, by thcn, ! thought ! had morc or lcss mastcrcdat lcast ! thought so
until ! mct r. Robcrt Kcllcr, who lcd thc orthopcdic study group. Altcr
! wcnt through a scrics ol rcports showing variation in kncc, hip, and
back surgcryand thinking ! saw an cmcrging conscnsus that thc varia
tion was rclatcd to surgical opinion! showcd thc pattcrn ol variation in
!n .oo, thc program was rcorganizcd as Tc Mainc Mcdical
Asscssmcnt Foundation, and r. Robcrt Kcllcr, an orthopcdic surgcon
lrom 8cllast, Mainc, succccdcd an Hanlcy as cxccutivc dircctor ol
thc loundation. vcr thc ncxt scvcral ycars, 8ob workcd to cnlargc
thc lccdback nctwork to includc lourtccn activc study groups, and my
son avid Vcnnbcrg, along with avid Soulc, a scnior data analyst
who had bccn a coauthor on our surgical papcr in thc Journal of Maine
Medical Association, crcatcd most ol thc lccdback rcports to thc study
groups. Tc succcss ol thc loundation in changing practicc pattcrns
and in organizing physicians in cvcryday practicc to study thc out
comcs ol thcir carc, attractcd a good dcal ol attcntion in Vashington,
thanks in largc part to thc lricndship bctwccn an Hanlcy and Scnatc
majority lcadcr Gcorgc Mitchcll. Trough this avcnuc ol inucncc,
thc Mainc Mcdical Asscssmcnt Foundation camc to scrvc as thc
modcl lor Scction cc ol thc Clintons Hcalth Sccurity Act calling
lor thc cstablishmcnt ol Rcgional Prolcssional Foundations to providc
inlrastructurc lor physicians to invcstigatc practicc variations and par
ticipatc in studics to rcducc unwarrantcd variation.
4
8ut this was not
to bc. Vithout lcdcral support or consistcnt support lrom paycrs, thc
nancial condition ol thc loundation grcw morc and morc prccarious
and ultimatcly, in :ccc, it had to closc its doors.
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x) 6o
hospitalizations lor a lracturcd hip. 8ob Kcllcr immcdiatcly challcngcd thc
validity ol thc data. ur rcports showcd that hip lracturcs varicd ncarly
as cxtcnsivcly as back surgcry. 8ut Kcllcr kncw that hip lracturcs lclt no
room lor discrction: cvcryonc had to bc admittcd to hospital, illncss is a
primary drivcr ol utilization, and thc artmouth data just did not makc
scnsc. avid Soulc and ! quickly rcgroupcd and took anothcr look at thc
data. Vc had madc a mistakcmiscoding hip lracturc to includc scvcral
othcr lracturcs that did not bclong in thc groupthus crcating variation
that was not rcal. Vithin a lcw hours wc wcrc ablc to rcrun thc data and
cstablish that hip lracturc hospitalizations showcd littlc variation among
Mainc communitics.
vcntually, 8ob bccamc a strong advocatc lor thc Mainc projcct and
ultimatcly succccdcd an as thc cxccutivc dircctor ol thc Mainc Mcdical
Asscssmcnt Foundation. !ndccd, onc ol thc most important outcomcs ol
thcsc carly lorays into improving clinical dccision making was thc rccogni
tion ol thc importancc ol involving practicing physicians in thc proccss ol
asscssing cvidcncc. Vc also lormulatcd a systcmatic mcthod, involving thrcc
scparatc but intcrlocking stcps, lor asscssing cxisting mcdical cvidcncc and
conducting outcomcs rcscarch (scc 8ox 6..).
A kcyand rcvolutionarycomponcnt ol our conccption ol outcomcs
rcscarch was including thc paticnts vicw ol thc conscqucnccs ol dicrcnt
trcatmcnt options.
Tis rcscarch would lcad to thc dcvclopmcnt ol systcm
atic mcthods lor gathcring outcomcs data and probing thc prclcrcnccs ol
paticntsmcthods that would havc a bricl momcnt on thc national stagc
until thcy wcrc sidclincd in thc mid.oocs, whcn thc U.S. Congrcss pullcd
thc rug out lrom undcr comparativc ccctivcncss rcscarch.
Doing the Tree-Step for Prostate Disease
Tc most succcsslul and longcst lasting rcscarch program to grow out ol thc
Mainc cxpcricncc provcd to bc thc study ol thc outcomcs ol trcatmcnt lor
an cnlargcd prostatc, or 8PH (8ox 6.:). Tc ]ohn A. Hartlord Foundation,
through thc advocacy ol, rst, ]ohn 8illings and thcn his succcssor, Richard
Sharpc, providcd thc gcncrous and longtcrm lunding rcquircd to sustain thc
program. Starting in thc carly .ocs, it continucd lor morc than a dccadc: it
lcd to thc dcvclopmcnt ol a scrics ol mcthods and stratcgics lor outcomcs
rcscarch and, as ! discuss in Chaptcr , providcd thc prototypc lor thc Paticnt
utcomcs Rcscarch Tcams (PRTs) organizcd by thc lcdcral govcrnmcnt
in .o.
c sivcic~i v~vi~)iox
!n Mainc in thc latc .ocs, thc probability ol undcrgoing a prostatc opcr
ation lor 8PH by agc rangcd lrom lcss than :c ol mcn in somc parts ol
thc statc to morc than 6c in othcr parts. A study group consisting ol urolo
gists lrom around thc statc was lormcd to addrcss thc rcasons lor thcsc strik
ing variations in surgcry ratcs, undcr thc lcadcrship ol r. Robcrt Timothy, a
urologist practicing at thc Mainc Mcdical Ccntcr in Portland. Rcports wcrc
madc availablc to cach urologist comparing thc ratcs ol prostatcctomy lor
8PH in his own and in all othcr hospital scrvicc arcas in Mainc. 8ccausc
most hospitals in Mainc had only onc or two urologists, and most hospital
arcas had only onc hospital, thc conncction bctwccn thc surgical dccisions
madc by thc physicians rccciving thc rcports and thc ratcs ol surgcry in thcir
hospital scrvicc arca was incscapablc.
Tc projcct bcgan with a twoday Minary Ccntcr rctrcat with our rcscarch
tcam and thc urologists lrom Mainc that illuminatcd why ratcs ol trcat
mcnt varicd. Mainc urologists hcld two distinctly dicrcnt surgical thcorics,
which thcy uscd to justily thcir dccisions to opcratc. Most urologists prac
ticcd undcr thc prcvcntivc thcory ol surgcry, which was rootcd in thc idca
that thc opcration should bc donc carly to prcvcnt discasc progrcssion and
bad outcomcs lrom occurring at a latcr datc. Tc assumption was similar to
thc silcnt gallstonc assumption discusscd in Chaptcr that carly rcmoval
8ox 6.:. What Is BPH?
Tc rcadcr who is not lamiliar with 8PH will nccd a littlc background
on thc clinical issucs involvcd. First, 8PH is thc abbrcviation lor bcnign
prostatic hypcrplasia, a noncanccrous growth ol thc prostatc gland
that is part ol thc normal aging proccss in mcn. Somctimc bcyond thcir
cth birthday, most mcn bccomc awarc ol changcs in thcir pattcrns ol
urination and many cxpcricncc annoying urinary tract symptoms. Tc
symptoms includc di culty in urination, thc nccd to gct up lrcqucntly
at night to urinatc, and an uncomlortablc urgcncy to urinatc. Somc
mcn cxpcricncc an cmbarrassing dribbling altcr urination and a lcw
will havc acutc urinary rctcntion, a vcry painlul cpisodc during which
thcy cannot urinatc at all and must scck immcdiatc mcdical attcntion
to havc a cathctcr put into thc bladdcr to drain thc urinc. At thc timc ol
our initial rcscarch, prostatcctomythc surgical rcmoval ol thc pros
tatc gland, which sits at thc basc ol thc pcnis ncar thc outlct ol thc
bladdcrwas thc only activc trcatmcnt availablc lor 8PH.
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x) .
solvcd a problcm that would only gct worsc il nothing was donc. 8y opcrating
carly on thc prostatc, thc backup ol urinc bchind thc cnlargcd prostatc could
bc avoidcda backup that could damagc thc bladdcr and kidncys and cvcn
provc latal upon occasion. Morcovcr, by opcrating carlywhcn thc paticnt
was youngcr and hcalthicrthc surgcry carricd lcss risk than it might il pcr
lormcd latcr. Tus, lilc cxpcctancy lor thc population ol paticnts with carly
8PH would bc incrcascd and morbidity would bc rcduccd by carly surgcry.
r so thc adhcrcnts to thc prcvcntivc thcory ol 8PH bclicvcd.
A minority ol Mainc urologists did not hold such a pcssimistic vicw ol thc
natural history ol untrcatcd 8PH. !n thcir opinion, lor most mcn thc discasc
would not progrcss to thc point whcrc surgcry was nccdcd to prcvcnt damagc
to thc bladdcr or thc kidncys or to savc thc paticnts lilc. Undcr thcir thcory,
surgcry was justicd by its supcrior ability to improvc thc quality ol lilc by
rcducing troublcsomc urinary tract symptoms, such as di culty in voiding,
lrcqucncy ol urination, and urgcncy, as wcll as its powcr to rcducc thc risk ol
acutc urinary rctcntion and urinary tract inlcctions.
!n addition to thcsc disagrccmcnts conccrning thc thcorctical basis lor
undcrtaking surgcry (dicrcnccs somctimcs lound cvcn among urologists
working togcthcr in thc samc hospital), physicians also varicd according to thc
clinical rulcs ol thumb thcy uscd to dctcrminc mcdical nccd. Somc physicians
rclicd primarily on a simplc biomcdical tcst to dctcrminc nccd, namcly urinc
ow ratcthc volumc ol urinc a paticnt could void into a collcction dcvicc pcr
minutc. !l urinc ow lcll bclow a critical minimum, in thcir opinion, surgcry
was nccdcd. thcrs mcasurcd postvoid rcsidual (thc amount ol urinc that was
lclt in thc bladdcr altcr urination). thcrs, likc somc physicians 8loor cncoun
tcrcd in his tonsillcctomy study, rclicd mostly on clinical history, rccommcnd
ing surgcry lor paticnts who wcrc gctting up two or morc timcs a night.
!n thc livcly convcrsations and somctimcs hcatcd dcbatcs ovcr thc rcasons
to opcratc, it bccamc apparcnt that opinions dicrcd as much ovcr actual lact as
ovcr thcory. Vc askcd thc physicians to cstimatc thc probability that a paticnt
would havc a bad outcomc lrom surgcry, such as an opcrativc dcath, impo
tcncc, postopcrativc lcakagc ol urinc (incontincncc), and stricturcs causcd by
urcthral scarring (urcthral stricturc). pinions divcrgcd markcdly. stimatcs
ol thc chanccs lor acutc urinary rctcntion wcrc similarly varicd. Rccurrcnt
growth ol prostatc tissuc and thc occasional nccd lor anothcr opcration wcrc
rccognizcd as problcms, but opinions dicrcd substantially on how much ol
a problcm thcsc issucs rcprcscntcd. Tcrc was unilorm agrccmcnt among all
physiciansthc prcvcntivc as wcll as thc qualityollilc campsthat sur
gcry improvcd symptoms and lunctional status but littlc agrccmcnt as to how
much improvcmcnt it could providc, and lor which paticnts. !ndccd, morc
: sivcic~i v~vi~)iox
lundamcntally, thcrc was no agrccdon mcthod lor objcctivcly mcasuring thc
burdcn ol urinary symptoms.
As a rcsult ol thcsc convcrsations, our rcscarch tcam quickly procccdcd
to thc sccond stcp in thc thrccstcp proccss. Vc rcvicwcd thc tcxtbooks and
journal articlcs on 8PH to scc il thc mcdical litcraturc could bc uscd to comc
up with rccommcndations lor bcst practiccs that would rcducc thc unccr
tainty and disagrccmcnts ovcr lact and thcory. Tc rcsults ol thc litcraturc
rcvicw wcrc disappointing. Vc lound no rcports ol randomizcd controllcd
clinical trials (RCTs) comparing prostatcctomy to watchlul waiting. !ndccd,
wc could not cvcn nd any populationbascd cohort studicsthc sccond
bcst mcthodology lor cvaluating outcomcs. Pcrhaps most astonishing ol
all, cvcn studics that wcrc dcsigncd to look at qualityollilc improvcmcnt
askcd physicians rathcr than paticnts to cvaluatc symptom rclicl.
!t simply was not possiblc to gct a handlc on thc risks and bcncts. Tc
cstimatcs on which thc urologists dcpcndcd camc lrom hospitalbascd casc
scrics ol paticnts. Casc history studics can sucr lrom what is callcd publica-
tion bias. 8ccausc thc dccision to publish is voluntary, only institutions with
good rcsults arc motivatcd to publish. Tc litcraturc thus tcnds to givc a morc
optimistic cstimatc lor bcncts and an undcrcstimation ol harms than would
bc thc casc il all hospitals wcrc routincly rcporting thcir ndings.
Tc inadcquacics in thc litcraturc lclt us with puzzling unccrtaintics about
what thc rcsults ol prostatc surgcry actually wcrc. Vcrc paticnts symptoms
cascd: Vas thc risk ol acutc urinary rctcntion rcduccd, or thc risk ol scrious
injury to thc kidncys and bladdcr: Tcrc was no way to know lrom thc avail
ablc litcraturc. Vc nccdcd to procccd to thc third stcpconducting outcomc
rcscarch. Tis was to givc our group thc opportunity to tcst a numbcr ol idcas
and conccpts lor applying intcrdisciplinary rcscarch tcams to cvaluatc thc
ccctivcncss ol mcdical carc, many ol which ! had rst cncountcrcd during
thc vc ycars that ! was a mcmbcr ol thc Ccntcr lor thc Analysis ol Hcalth
Practiccs at thc Harvard School ol Public Hcalth (8ox 6..).
Large Databases Provide Some Answers
At thc timc our group was sccking to hclp thc urologists ol Mainc comc to
grips with practicc variations, wc wcrc also conducting rcscarch into ncw
ways to study outcomcs using data lrom Mcdicarc claims. 8ccausc most 8PH
opcrations arc donc on mcn ovcr 6 ycars ol agc, thc Mcdicarc claims data
wcrc wcll suitcd lor studying this condition. Mcdicarc claims data makc a
ccrtain typc ol outcomcs studypopulationbascd cohort studicspossiblc
8ox 6... Te Center for the Analysis of Health Practices at the
Harvard School of Public Health
Tc Ccntcr lor thc Analysis ol Hcalth Practiccs was thc inspiration
ol Howard Hiatt, thcn dcan ol Harvards School ol Public Hcalth.
Howard, an accomplishcd prolcssor ol mcdicinc and wcllknown
biomcdical rcscarchcr, was onc ol thc rst to rccognizc thc impor
tant rolc that physicians play in thc growth ol hcalth carc costs, and
givcn his background in clinical mcdicinc, hc was acutcly awarc ol
its scicntic wcakncsscs. n bccoming dcan ol thc School ol Public
Hcalth, hc dccidcd to somcthing about it. Hc undcrstood, as had
Kcrr Vhitc at ]ohns Hopkins, that thc scicnccs that prospcrcd in
schools ol public hcalth, such as cpidcmiology, biostatistics, dcci
sion analysis, and thc social scicnccs, wcrc ol vital importancc to thc
ordcrly dcvclopmcnt ol thc scicntic basis ol clinical mcdicinc. !n
.o, hc crcatcd thc Ccntcr lor thc Analysis ol Hcalth Practiccs as
thc local point lor intcgrating thcsc disciplincs into a scicncc ol
hcalth carc dclivcry and brought on board ]ohn 8unkcr, thc chair
ol thc cpartmcnt ol Ancsthcsiology at Stanlord Univcrsity. Vhilc
at Stanlord, ]ohn, togcthcr with Frcd Mostcllcr, hcad ol Harvards
statistics dcpartmcnt, was instrumcntal in a groundbrcaking invcs
tigation into uncxplaincd variations in surgical dcath ratcs among
hospitalsa study cuphcmistically known as thc institutional dicr
cnccs study.
6
Tc study raiscd many issucs conccrning thc quality ol
surgical practiccs in thc Unitcd Statcs and sct thc agcnda lor much ol
our discussion at thc ccntcr at Harvard.
Undcr 8unkcrs and Mostcllcrs lcadcrship, thc locus ol intcllcc
tual dcvclopmcnt bccamc a biwcckly scminar ovcr dinncr hcld at thc
Harvard Faculty Club. Tc pricc ol mcmbcrship was agrccmcnt by
cach participant to prcscnt a papcr on somc aspcct ol thc cvaluation
ol surgcry and to agrcc that thc papcr bc includcd in thc procccdings
ol thc scminar, which ultimatcly wcrc publishcd by xlord Univcrsity
Prcss.
7
Tc scminar mcmbcrs includcd cconomists, dccision analysts,
sociologists, biostatisticians, cpidcmiologists, and clinicians, cach with
dicrcnt pcrspcctivcs and dicrcnt contributions to makc to thc group
goal ol undcrstanding surgical practicc. !t was during this timc that
]ohn 8unkcr, ]ack Fowlcr, and ! rst conductcd opcncndcd intcrvicws
(continued)
.
sivcic~i v~vi~)iox
on a grand scalc. Tus, thc largc majority ol Amcrican mcn who arc ovcr 6
ycars ol agc and havc had a prostatcctomy can bc includcd in a cohort study
ol thc outcomcs ol this opcration. For this scgmcnt ol thc population, thcrc
is no sclcction bias, bccausc wc could look at virtually cvcry man ovcr agc 6
who undcrwcnt surgcry.
Tc valuc ol thc Mcdicarc databasc rcsts in part in thc complctcncss ol thc
transaction inlormation it contains. ach timc a hospital or a physician providcs
a mcdical scrvicc (such as a prostatcctomy), a bill is submittcd to Mcdicarc that
idcntics thc scrviccs pcrlormcd. Vhcn anothcr scrvicc is pcrlormcd, anothcr
bill is submittcd, and thcsc cvcnts can bc linkcd lor cach paticnt. !l a sccond
prostatc surgcry is pcrlormcd, this bccomcs known, il lurthcr diagnos
tic studics arc donc, this is rccordcd. !l thc paticnt dics, this too is notcd. 8y
linking thcsc data togcthcr lor all paticnts in Mainc, a complctc cnumcration
ol important outcomcs and thc timc bctwccn cvcnts could bc obtaincd lor
paticnts 6 ycars ol agc and oldcr,
8
making it possiblc to calculatc thc risk lor
rcopcration, lor subscqucnt diagnostic intcrvcntions, and lor mortality.
ur initial (unpublishcd) study idcnticd all Mcdicarc paticnts in Mainc
who had a prostatcctomy ovcr a thrccycar pcriod. Tc importancc ol publica
tion bias in thc prcviously publishcd litcraturc quickly bccamc apparcnt. Tc
actual outcomcs lor Mainc paticnts who undcrwcnt surgcry wcrc substan
tially worsc than prcdictcd by thc publishcd mcdical litcraturc. An cxtcnsivc
rcvicw ol thc litcraturc lor a .o National !nstitutcs ol Hcalth conlcrcncc
with paticnts who had undcrgonc hystcrcctomics, lcarning rsthand
about thcir surgical cxpcricnccs. !t bccamc clcar lrom thcir storics that
thc outcomcs that mattcrcd to paticnts wcrc not ncccssarily high on
thc list ol thosc valucd by physicians. For paticnts, dcprcssion and
dccrcascd intcrcst in scx lollowing hystcrcctomy wcrc important out
comcs, oncs that lcw physicians sccmcd to rccognizc as notcworthy.
Although this rcscarch rcmaincd prcliminary and did not lcad to a
publication, thc cxpcricncc anchorcd in my mind thc importancc ol
dircct dialog with thc paticnt to cstablish thc list ol outcomcs that
should bc thc targct ol outcomcs rcscarch.
Tc cxpcricncc provcd to bc a lormativc onc, sctting thc stagc
lor thc intcrdisciplinary approach that would comc to charactcr
izc our rcscarch corts in Mainc and, ultimatcly, thc organization ol
artmouths Ccntcr lor thc valuativc Clinical Scicnccs in .o.
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x)
on 8PH cstimatcd postopcrativc mortality ol prostatcctomy to bc lcss than
onc pcrccnt cvcn though poor risk paticnts arc rarcly dcnicd thc opcration.
9
!n rcality, at lcast in Mainc, . ol Mcdicarc paticnts 6 ycars ol agc and
oldcr wcrc dcad within thrcc months ol thcir prostatcctomy. For somc mcn,
thc risk was much highcr. Mortality rcachcd . by six months lor mcn who
rcsidcd in nursing homcs bclorc thcir opcration. How much ol this mortality
was attributablc to thc opcration and how much was duc to othcr illncsscs
could not bc asccrtaincd without a clinical trial. Howcvcr, as our rcscarch was
to show, thc principal rcason lor undcrtaking thc opcration lor most paticnts
was to improvc thc quality ol lilc. !n thc months lollowing thc opcration,
quality ol lilc is low bccausc ol thc shorttcrm cccts ol thc surgcry, so mcn
who dic so soon altcr surgcry gain vcry littlc, il anything.
Tc litcraturcbascd cstimatcs lor longtcrm morbidity wcrc also quitc
optimistic: According to thc .o litcraturc rcvicw,
!0
Longtcrm morbidity is
limitcd. Tc proccdurc providcs corrcction ol urinary stasis in approximatcly
oco pcrccnt ol paticnts opcratcd upon. Tc nccd lor lurthcr opcrativc trcat
mcnt is uncommon. Again, thc Mcdicarc data showcd a vcry dicrcnt pic
turc lor Mainc. Vc uscd thc claims to idcntily complications lrom surgcry.
vcr a lourycar pcriod altcr surgcry, .. ol surgcry paticnts cxpcricnccd a
scarring (stricturc) ol thc urcthra that rcquircd trcatmcntsomctimcs addi
tional surgcry, :c ol mcn undcrwcnt lurthcr diagnostic workups, usually
involving having a cystoscopc inscrtcd into thc urcthra, and .c had a scc
ond prostatcctomy. At thc cnd ol lour ycars, only : ol paticnts having a
prostatcctomy wcrc still alivc and lrcc lrom onc or morc ol thc postopcrativc
complications just listcd. Tis pcssimistic cstimatc lor thc longtcrm curc ratc
(i.c., thosc who wcrc alivc and lrcc lrom subscqucnt urological intcrvcntion)
was in stark contrast to thc conclusion rcachcd in thc litcraturc.
Tc claims data studics had an immcdiatc impact on Maincs Urology
Study Group. Tc inlormation changcd thc way thcy trcatcd urinary symp
toms in mcn who wcrc also chronically ill, as most physicians bccamc much
morc rcluctant to rccommcnd a prostatcctomy to thcir cldcrly, highrisk
paticnts, particularly thosc rcsiding in nursing homcs.
Fccdback ol inlormation on thc outcomcs ol thc paticnts whom thc urol
ogists ol Mainc wcrc rcsponsiblc lor trcating provcd dccisivc in opcning thc
door to thc ncxt stcp in thc asscssmcnt proccss: cvaluation ol thc spccic thc
orics bchind thc variation in practicc wc wcrc documcnting. 8ut to do this,
! nccdcd to cxpand thc rcscarch tcam bcyond mcdical carc cpidcmiologists.
Fortunatcly, scvcral collcagucs with thc ncccssary skills had alrcady bccomc
dccply intcrcstcd in studying practicc variation and thcir rccruitmcnt to thc
Mainc projcct would provc dccisivc to its ultimatc succcss. ]ack Fowlcr, whosc
6 sivcic~i v~vi~)iox
skills as a social psychologist wcrc critical in mcasuring paticnt outcomcs,
continucd to stay in touch and wc had alrcady conductcd somc prcliminary
studics. !n .o., r. Albcrt Mullcy, who at a young agc had bccomc hcad
ol primary carc mcdicinc at thc Massachusctts Gcncral Hospital (MGH),
attcndcd a scminar ! gavc that includcd carly data lrom Mainc and immc
diatcly saw thc broad importancc ol practicc variation lor clinical mcdicinc.
His intcrcst in hcalth policy and dccision analysis had bccn piqucd by a ycar
at Harvard Univcrsitys Kcnncdy School ol Govcrnmcnt, and hc had built his
MGH rcscarch tcam around thc applications ol dccision scicnccs to clinical
dccision making and had rccruitcd r. Michacl Mikc 8arry, a promising
young dccision analyst who was also traincd as a primary carc clinician. Vith
thc rccruitmcnt ol ]ack, Al, and Mikc to thc Mainc projcct, wc wcrc rcady to
tacklc Stcp Trcc in rationalizing practicc variations lor 8PH.
Evaluating the Teories
8y thc mid.ocs, a scnsc ol trust and coopcration bctwccn thc Mainc Urology
Study Group and thc outcomcs rcscarchcrs was rmly cstablishcd. Tc trou
bling conicts in thcir surgical thcorics had bccn cxposcd and thc studics wc
could do with claims data had bccn donc. vcryonc agrccd that thc ncxt stcp
should bc to tcst thc prcvcntivc thcory ol prostatcctomy. Vhcn comparcd to
watchlul waiting, docs carly prostatcctomy prcvcnt 8PH lrom progrcssing
to a point whcrc blockagc ol urinc ow obstructs thc bladdcr and kidncys,
lcading to highcr mortality and morbidity: Nobody kncw thc answcr, in largc
mcasurc bccausc nobody kncw thc natural history ol untrcatcd 8PHits
ratc ol progrcssion to chronic obstruction il lclt untrcatcd. To tcst thc prc
vcntivc thcory, two mcmbcrs ol thc asscssmcnt tcam, Mikc and Al, both
physicians and cxpcrts in dccision analysis, constructcd a modcl to comparc
lilc cxpcctancy among paticnts who undcrwcnt surgcry to thosc who chosc
watchlul waiting. Tc modcl madc it clcar that thc probabilitics govcrning
lour critical cvcnts nccdcd to bc undcrstood:
Tc chancc ol dcath immcdiatcly lollowing surgcry (givcn thc agc ..
and illncss lcvcl ol thc paticnt)
Lilc cxpcctancy (givcn thc agc and illncss lcvcl ol thc paticnt) :.
Tc risk ol a sccond prostatcctomy ovcr timc ..
Tc chancc that untrcatcd 8PH will progrcss to thc point whcrc a paticnt .
who clcctcd watchlul waiting nccds an opcration to prcvcnt dcath or
scrious bladdcr dccompcnsation lrom uppcr urinary tract obstruction
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x)
Tc way in which our rcscarch tcam idcnticd and put togcthcr thc
various strands ol cvidcncc to cstimatc thcsc probabilitics illustratcs thc
cclcctic, opportunistic approach somctimcs rcquircd lor succcsslul outcomcs
rcscarch. Trcc sourccs ol data wcrc uscd. Tc inlormation on thc chanccs
lor rcopcration and lor opcrativc mortality camc lrom thc Mcdicarc claims
data. Tc inlormation on lilc cxpcctancy camc lrom thc vital rccords. Tc
inlormation on thc natural history ol untrcatcd 8PH camc lrom thc mcdical
litcraturc. Using inlormation lrom thcsc various sourccs, Mikc and Al wcrc
ablc to show that thc prcvcntivc thcory was vcry likcly incorrcct: no matter
what the age or illness level of the patient at the time of surgery, the chances of death
from the surgery was not made up for by gains in life expectancy among those who
survived the operation.
!!
Tc oldcr or sickcr thc paticnt, thc grcatcr thc loss
ol lilc cxpcctancy was lrom prostatcctomy lor paticnts with 8PH who did
not havc ovcrt bladdcr or kidncy lailurc. For cxamplc, an cycarold man in
avcragc hcalth appcarcd to losc about :. months ol lilc, whilc a 6cycarold,
also in avcragc hcalth, lost about two wccks.
isproving thc prcvcntivc thcory mcant that thc usc ol thc opcration lor
most paticnts had to bc justicd on thc basis ol its valuc lor rcducing symp
toms and improving thc quality ol lilc. 8ut how good was thc cvidcncc that
thc opcration actually workcd: Tc data availablc lrom thc mcdical litcraturc
and thc Mcdicarc claims had not hclpcd. To ll in thc gaps in knowlcdgc, wc
wantcd to conduct an RCT to dcnc thc symptomatic outcomcs ol mcn who
had a prostatcctomy. 8y now, our urology collcagucs in Mainc vicwcd this
inlormation as critical to thcir ability to advisc thcir paticnts on trcatmcnt
options and thcy voluntccrcd thcir practiccs as thc sourcc ol paticnts lor a
lollowup study ol thc ccct ol prostatc surgcry on symptoms, complica
tions, and lunctional status. Tcy insistcd, howcvcr, that wc usc a cascscrics
approach, not thc RCT wc rcscarchcrs rccommcndcd. Vhilc thcy wcrc not
surc cxactly what wcrc thc probabilitics lor outcomcs, thcy wcrc unitcd in
thcir bclicl that prostatc surgcry ocrcd much bcttcr rclicl lrom symptoms
than watchlul waiting. Tcy thought it would not bc cthical lor thcm to claim
that thcy wcrc unccrtain about this lact, thcy wcrc not at thc cquipoisc in
prolcssional opinion that is traditionally rcquircd to justily an cxpcrimcnt.
Tcrc was, howcvcr, considcrablc disagrccmcnt about what outcomcs wcrc
actually important to paticnts and how thcy should bc cvaluatcd. ur urol
ogy collcagucs, likc most physicians traincd in thc traditions ol biomcdical
scicncc, had spcnt littlc timc worrying about thc subjcctivc sidc ol mcdi
cal practicc, thc mcasurcmcnt ol solt outcomcs such as symptoms, incon
tincncc, impotcncc, and lunctional status. Nor did thcy givc much thought
to thcir ability to diagnosc paticnt prclcrcnccs. Most hcld that thc propcr
sivcic~i v~vi~)iox
mctric lor cvaluating prostatc paticnts and thcir trcatmcnts was urinc ow, it
scrvcd as an indicator both ol thc nccd lor trcatmcnt (whcn it indicatcs out
lct obstruction) and ol thc succcss ol trcatmcnt (whcn urinc ow improvcs
bccausc thc obstruction has bccn rclicvcd). Urinc ow, as a biomarkcr lor
both diagnosis ol nccd and outcomc ol carc, sccmcd to t ncatly into thcir
conccptualization ol mcdicinc as a scicncc.
What Matters to Patients
Vc lookcd at thc rcscarch problcm a littlc dicrcntly. A distinguishing
lcaturc ol our approach to outcomcs was thc insistcncc wc placcd on obtain
ing inlormation about all of the outcomes that matter to patients. Vhilc wc
rcspcctcd thc urologists opinions that urinc ow might bc corrclatcd both
with thc paticnts pcrccption ol nccd and with thc improvcmcnts hc might
cxpcricncc as a rcsult ol trcatmcnt, wc insistcd that thc propcr locus lor out
comcs rcscarch is on thc list ol problcms that actually bothcr paticntsnot
biomcdical surrogatcs lor thcsc problcms as vicwcd through prolcssional
cycs. Tc rclationship bctwccn improvcmcnt in urinc ow and thc outcomcs
that mattcrcd to paticnts had ncvcr bccn cstablishcd.
Vc alrcady had a good idca that what mattcrs to paticntswhat thcy
bclicvc is rclcvant to thcir choicc ol trcatmcntscannot bc intuitcd by
rcscarchcrs any morc than it can by physicians. Vc had gaincd this insight
in part through a scrics ol intcrvicws conductcd in 8oston with womcn lol
lowing hystcrcctomy, many ol whom wcrc troublcd by dcprcssion and loss
ol intcrcst in scxsidc cccts ol thc surgcry that gcncrally did not conccrn
thcir surgcons. Vc kncw that paticnts nccdcd to bc askcd about thcsc mattcrs
in a systcmatic way.
]ack Fowlcr conductcd intcrvicws with paticnts with 8PH to dcvclop an
cxtcnsivc list ol conccrns and cxpcctations lor thc dicrcnt trcatmcnts. Tc
paticnts intcrvicwcd includcd thosc with symptoms, somc ol whom wcrc
contcmplating surgcry and somc who had alrcady had surgcry. vcnts that
paticnts considcrcd to bc complications or unplcasant outcomcs lor sur
gcry and watchlul waiting wcrc carclully solicitcd. uring thc scssions with
paticnts considcring surgcry, ]ack and his tcam askcd a scrics ol opcncndcd
qucstions dcsigncd to clicit how paticnts lclt about thcir symptoms and thcir
rcasons lor considcring thc opcration.
Tc qucstions thcy askcd illustratcd anothcr important, distinguishing
lcaturc ol our approach to outcomcs rcscarch. Not only wcrc wc intcrcstcd in
obtaining knowlcdgc about thc rangc ol problcms and conccrns that mattcr
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x) o
to paticnts, but wc also locuscd on thc valuc paticnts placc on thcir lcars,
conccrns, and cxpcctations about thcir condition and thc possiblc trcatmcnts.
8ccausc paticnts arc not all thc samc in how thcy rcact to thcir symptoms,
wc wcrc cagcr to lcarn lrom individuals how bothcrsomc thcir symptoms
sccmcd. For paticnts who had had surgcry, wc conccntratcd on thcir rcaction
to thc surgical cxpcricncc. Not surprisingly, ]ack lound important dicrcnccs
among paticnts. Hc also lound that somc paticnts who had alrcady had sur
gcry did not havc a propcr undcrstanding ol thc actual purposc ol thc trcat
mcnt. For cxamplc, somc paticnts (it turncd out to bc about .) undcrwcnt
surgcry undcr thc lalsc cxpcctation that surgcry would prcvcnt canccr ol thc
prostatc.
Tc litcraturc rcvicw and thc rcsults ol thc intcrvicws wcrc thcn uscd to
dcvclop a qucstionnairc lor mcasuring symptoms, complications ol trcat
mcnt, and subjcctivc attitudcs toward symptoms and risk. Tis mcthod, ol
rst intcrvicwing paticnts with opcncndcd qucstions, thcn using thcir con
ccrns to dcvclop a qucstionnairc, would cvcntually bccomc a standard procc
durc lor dcvcloping objcctivc mcasurcs ol important subjcctivc outcomcs.
Tc alliancc bctwccn practicing physicians and outcomcs rcscarchcrs was
critically important in lcarning what works. Using thc qucstionnairc, wc
studicd thc impact ol prostatcctomy on symptoms, lunctional status, and
paticntrcportcd complications among paticnts all ovcr thc statc ol Mainc
who had undcrgonc 8PH surgcry. !ntcrvicws wcrc conductcd prior to sur
gcry and at intcrvals ol thrcc, six, and twclvc months altcr surgcry. Vc lound
that lor most mcn with symptoms duc to 8PH, thc improvcmcnts lollowing
surgcry wcrc quitc spcctacular.
!2
Tc urologists wcrc right. An RCT was not
nccdcd to tcst thc hypothcsis that prostatcctomy rclicvcd symptoms bcttcr
than watchlul waiting, lor this outcomc, thc surgcry was a slamdunk.
8ut it turncd out that oncc mcn lully undcrstood thc potcntial downsidc
to surgcry, thc dccision to go undcr thc knilc was no longcr so casy. Tc gains
in symptom rclicl wcrc purchascd at a pricc. First, thcy wcrc availablc only to
paticnts who wcrc willing to takc thc risks ol thc opcration, including dcath,
urcthral stricturc, and rctrogradc cjaculation, a postopcration complication
in which cjaculation occurs into thc bladdcr rathcr than out ol thc pcnisa
problcm that thc grcat majority ol mcn arc lclt with altcr surgcry. Although
urologists tcnd to think ol rctrogradc cjaculation as a normal outcomc ol
surgcry, wc lcarncd lrom our intcrvicws that somc mcn wcrc quitc upsct by
it. As a rcsult, rctrogradc cjaculation lcd to a nct dcclinc in quality ol lilc
lor somc mcn, rcgardlcss ol thcir ncwlound casc in urination. Morcovcr,
it bccamc clcar that not all paticnts wcrc cqually bothcrcd by thcir urinary
tract symptoms, including thosc who wcrc scvcrcly symptomatic. Tcrc was
c sivcic~i v~vi~)iox
virtually no corrclation bctwccn objcctivc clinical mcasurcs likc urinc ow and
how grcatly mcn wcrc bothcrcd by thcir symptoms. !n vicw ol thc tradcos
and thc dicring subjcctivc rcsponscs to a givcn lcvcl ol symptoms, it sccmcd
likcly that not all mcn, il ocrcd a choicc, would want surgcry. Somc might
wcll choosc watchlul waiting. Mikc and Al complctcd our asscssmcnt by
conrming, with a lormal dccision analysis, that rational choicc ol trcatmcnt
was indccd highly dcpcndcnt on paticnts prclcrcnccs lor outcomcs and thcir
attitudcs toward thc risks.
!1
Vc wcrc now in a position to diagnosc thc clinical causcs ol thc small arca
variations in prostatcctomy ratc. Tcy wcrc duc to incorrcct mcdical opin
ion lavoring thc prcvcntivc thcory ol carly prostatcctomy and to thc lailurc
ol physicians to takc paticnt prclcrcnccs adcquatcly into account in rccom
mcnding prostatcctomy.
!4
Addressing the Predicament of Choice
Vith a diagnosis ol thc causc ol gcographic variation in prostatcctomy ratcs
in hand, wc could now think about a rcmcdy. Vc bcgan to conccivc ol a vcry
dicrcnt modcl lor how physicians and paticnts should comc to dccisions
about a coursc ol trcatmcnt, a modcl that dcpcnds on paticnt prclcrcnccs.
Vc camc to scc that dclcgatcd dccision making and its cthical loundation in
inlormcd conscnt should bc rcplaccd by a proccss ol sharcd dccision making,
groundcd in a dicrcnt cthicthc cthic ol inlormcd paticnt choicc. Undcr
thc modcl wc cnvisioncd, thc paticnt must bc invitcd to participatc activcly in
thc dccision, lcarn to look ahcad at thc possiblc outcomcs hc might lacc lol
lowing altcrnativc trcatmcnts, and to think about how cach ol thosc sccnarios
might acct him. !n thc casc ol 8PH, this mcans bcing awarc ol thc advan
tagcs ol surgcry, but also its harmsthc risks lor incontincncc, acutc rctcn
tion, rctrogradc cjaculation, and othcr scxual dyslunctions. !t mcans bcing
awarc ol thc hazards ol watchlul waiting, including acutc urinary rctcntion.
!t also mcans undcrstanding thc currcnt limits ol mcdical scicncc and what
is known and not known about thc prognoscs lor thc outcomcs that mattcr
to paticnts.
Vc lound a way to providc dccision support lor sharcd dccision making
to mcn contcmplating surgcry lor 8PH by using a ncw tcchnology that rst
bccamc availablc in thc latc .ocs, thc intcractivc vidcodisc playcr. Tc vid
codisc playcr, a prccursor ol thc !ntcrnct and todays \ tcchnology, mar
ricd thc computcr to vidco. Tc computcr solvcd thc problcm ol convcying
probability inlormation about outcomcs, tailorcd to thc individual (or, rcally,
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x) .
his paticnt subgroup).
!
Tc vidco hclpcd us nd a solution to thc problcm
ol rcprcscnting possiblc outcomcs in a way that madc thcm sccm rcal to
paticnts. ur dccision aid vidco includcd lms ol paticnts who had cxpcri
cnccd good outcomcs as wcll as thosc who had complications lollowing both
watchlul waiting and surgcry. Vc callcd thcsc vidcos sharcd dccisionmaking
programs (SPs). (An cxccrpt ol thc original SP is availablc lor download
lrom YouTubc at: www.youtubc.com/original SP)
Tc paticnt dccision aid was dcsigncd to support sharcd dccision
making in cvcryday practicc. !n our original 8PH vidco,
!6
thc narrator sct
thc stagc:
Tcrc is a dccision to bc madc by you and your doctor. How you dccidc
dcpcnds on how you lccl about your symptoms and how you lccl about
thc possiblc harms and bcncts ol surgcry comparcd to thc possiblc
harms and bcncts ol watchlul waiting. Vcll tcll you how likcly it is
that thcsc harms and bcncts might occur, but thcn you must dccidc,
bascd on how you would lccl about thcsc harms and bcncts il thcy
happcncd to you. Kccp in mind that cithcr choicc has possiblc harms
and bcncts. How you dccidc should involvc your own cvaluation
ol thcm.
Following this narration wcrc intcrvicws with two physicianpaticnts,
both ol whom cxpcricnccd scvcrc symptoms lrom thcir prostatc condi
tion but chosc dicrcnt trcatmcnts. ur logic lor sclccting physicians
was that il paticnts scc that physicians can choosc dicrcntly, thcy will
undcrstand that thcy, too, havc a choicc. r. X, who chosc watchlul wait
ing, cxplaincd to thc paticnt his approach to risk asscssmcnt: ! consid
crcd thc advantagc ol thc opcration against thc amount ol troublc ! am
having with thc symptoms and thc cxtcnt to which (thc opcration) might
rclicvc thcm. And ! lclt that ! am not bothcrcd cnough cvcn by thcsc
lairly scvcrc symptoms to undcrtakc thc risk ol incontincncc which thc
opcration involvcs. r. Y, on thc othcr hand, cmphasizcd thc amount ol
troublc hc was having with thc symptoms and how thcy intcrlcrcd with
thc quality ol his lilc: (!t was) thc lccling that ! had a lull bladdcr, to
know that it took a long timc to cmpty it and thc lact that ! would havc
to wakc up morc oltcn at night. And again, thc rcstrictivc lcaturcs, to bc
ablc to do lcss and lcss things or to worry about morc and morc things as
! bcgan to plan my daily routinc.
Tc two physician paticnts had typical outcomcs lollowing surgcry
and watchlul waiting. r. Y was among thc c ol mcn who havc a vcry
: sivcic~i v~vi~)iox
satislactory rcsult lrom surgcry. Tc narrator asks him how hc larcd: h,
innitcly bcttcr. ]ust a totally dicrcnt situation. Such a lccling ol rclicl. !
rcmcmbcr thc day whcn ! walkcd into my urologists o cc, and |bcgan sing
ing): Summcrtimc, and thc pccing is casy. Tats thc way ! lclt. ! rcmcmbcr
anothcr occasion whcn hc askcd mc about strcngth ol strcam and lcngth ol
strcam and all that. ! dcscribcd my abilitymy rcgaincd ability to put my
initials in thc snow. Tat was grcat to bc ablc to do!!
r. X, who was scvcrcly symptomatic, had symptoms that wcrc worsc than
most 8PH paticnts who watchcd thc vidco. For such paticnts, his dcscription
ol his status as a watchlul waitcr ocrcd vicwcrs insight into thc luturc thcy
might lacc il thcy chosc watchlul waiting:
. Tc symptoms you havc mcntioncd to what cxtcnt do thcy
intcrlcrc with your activitics ol daily living:
r. X: ! supposc wcvc madc a lot ol adjustmcnts and it has takcn a
lot ol planning and anticipation. For cxamplc, all tickcts on thc
airlincr or conccrts or thcatcrs had bcttcr bc on thc aislc sidc so
! can gct out in a hurry il ! nccd to.
r. X: ! dont go through a thrcchour movic without having to lcavc.
. Youvc said that thc symptoms arc gctting gradually worsc. How
closc arc you to changing your mind:
r. X: !ts hard to quantitatc, but ! think ! still scc a margin principally
bccausc thcrc is such irrcgularity in this.
Vc dcsigncd our program to inlorm paticnts that cithcr choicc can havc
its problcms as wcll as its advantagcs. \icwcrs saw intcrvicws with paticnts
who cxpcricnccd complications, onc on thc watchlul waiting sidc and onc on
thc surgcry sidc. Tc two complications wc chosc to illustratc had about thc
samc chancc ol occurring. A paticnt with surgically induccd incontincncc
rcportcd:
! havc lcakagc. ! think thc word is incontinence or somcthing likc that.
And ! was gctting wct all thc timc and ol coursc ! didnt know what
to do about all that so my wilc and ! gurcd it out. ! wcnt out and
bought somc jockcy shorts and sort ol Kotcx typc stu and put it
insidc and ! would havc to changc that thrcc or lour timcs a day,
which ! am still doing. !t didnt pour out, but it would on occasion
lcak out and was much worsc whcn ! walkcd around a lot or stood a
lot this camc out ol thc bluc (lollowing surgcry). Tis was a minus,
a big minus.
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x) .
A watchlul waitcr who had an cpisodc ol acutc rctcntion answcrcd qucs
tions about his cxpcricncc:
. Vcrc you in a lot ol pain:
A. Ycs, a lot ol pain, pain that ! couldnt control or hclp. So nally, in
gctting up to thc doctor, ! got on thc tablc to bc intcrvicwcd thcrc
and ! said, Hold on doctor, bclorc you go any lurthcr, thc rst thing
you do is drain that bladdcr.
. How did it lccl whcn thcy nally did usc thc cathctcr:
A. Hcavcnly! !t was likc bcing undcr watcr longcr than you wantcd
to bc and you had to hold your brcath longcr than you wantcd to
and thc momcnt that cathctcr clcarcd thc passagc thcrc, it was a
rclicl likc that pain was lcaving all thc timcright up until it got
comlortablcthc doctor madc two or thrcc trips with thc urinal
bowl until thcrc was no morc.
!n kccping with our paticntoricntcd pcrspcctivc, thc paticnt dccision aid
was dcsigncd to includc thc lull gamut ol inlormation rcquircd by thc paticnt,
as asccrtaincd by cxtcnsivc locus groups. Paticnts wcrc askcd to cxplain thcir
pcrccptions about thcir condition, thc symptoms that bothcrcd thcm, and
what thcy wantcd to know in choosing a trcatmcnt. Tosc with complications
wcrc askcd what thcy would havc wantcd to know about possiblc complica
tions bclorc thcy madc thcir dccision. Tc lcars paticnts havc, and thcir cxpcc
tations and misundcrstandings, wcrc idcnticd and this inlormation was uscd
to plan thc prcscntation to corrcct signicant mispcrccptions. For cxamplc,
somc mcn thought having a prostatcctomy would climinatc thcir chanccs ol
gctting prostatc canccr, a complctcly wrong pcrccption that lcd to wrong dcci
sions. To dcal with this mispcrccption, wc addcd a scction to thc program:
You should know that an opcration cant bc considcrcd a curc lor can
ccr bccausc it docsnt rcmovc all prostatc tissuc, lor thc samc rcason, an
opcration docsnt prcvcnt luturc prostatc canccr. Vorrics about canccr
shouldnt inucncc your dccision to choosc surgcry or watchlul waiting.
Vc also thought it was important to inlorm paticnts about currcnt lim
its to mcdical knowlcdgc. Tc risk ol scrious urinary tract rctcntion among
watchlul waiting paticnts was a good cxamplc:
Tc risk ol scrious urinary tract inlcctions hasnt bccn vcry wcll studicd
in mcn with 8PH, but its salc to assumc that it happcns cvcn lcss oltcn
than acutc rctcntion, that is, lcss than : ol mcn ovcr ycars.
sivcic~i v~vi~)iox
!n dcsigning thc 8PH paticnt dccision aid, wc laccd thrcc tasks. Tc rst
was to gct thc scicncc right. Vc bclicvcd that this was rcasonably assurcd
by our adhcrcncc to scicntic mcthods and pccr rcvicw, and our insistcncc
on inlorming paticnts ol our unccrtainty, as in thc cxamplc ol probabilitics
lor urinary tract inlcction. Tc sccond was to makc clcar and comprchcn
siblc thc csscntial lcaturcs ol thc dccision. ur succcss in communicating
inlormation was cvaluatcd by tcsting vicwcr rcactions and in tcsting whcthcr
vicwcrs undcrstood thc objcctivc contcnt ol thc prcscntation.
!7
Tc third task
was to achicvc balancc and lairncss in thc prcscntation ol trcatmcnt options.
Tis was in many ways thc most di cult task. Vc lound no gold standard
mcthods lor cvaluation and dcpcndcd primarily on thc judgmcnts ol locus
groups with paticnts as wcll as clinicians (ol varying spccialtics). Altcr scvcral
rcvisions, conscnsus was rcachcd that thc program was considcrcd lair. (Tc
cmcrgcncc ol paticnt prclcrcnccs as a kcy to rational dccision making opcns
up a wholc ncw cld ol mcdical rcscarch dcaling with thc communication ol
risk and thc balanccd dcscription ol trcatmcnt choiccs, issucs ! will discuss
bricy in Chaptcr .)
What Do Patients Want?
Altcr thc 8PH paticnt dccision aid was nalizcd, it was installcd in a numbcr
ol urological practiccs in thc Unitcd Statcs and Canada. Tc impact on paticnts
dccisions has bccn tcstcd with hundrcds ol paticnts with 8PH who wcrc pos
siblc candidatcs lor surgcry, but whosc clinicians bclicvcd thcy could also salcly
choosc watchlul waiting without immcdiatc risk ol acutc urinary rctcntion.
Prior to vicwing thc program, paticnts wcrc askcd to ll out qucstionnaircs
rcgarding thcir symptoms and inlormation rclcvant to thcir trcatmcnt prcl
crcnccs. Altcr vicwing thc program, paticnts ratcd thc cxpcricncc. Tcy also
agrccd to ll out qucstionnaircs pcriodically about thcir trcatmcnt choiccs,
thcir symptoms, thcir prclcrcnccs, and how thcy lclt things wcrc working out.
Tc cvaluation proccss allowcd us to answcr two important qucstions
conccrning thc lcasibility and impact ol sharcd dccision making.
.. o Paticnts Rcally Vant to Participatc in thc Choicc ol Trcatmcnt:
Following thcir scssion with thc SP, most paticnts wcrc rcady to makc up
thcir minds about thcir trcatmcnt. Conccrns that paticnts would not want
as much inlormation as wc prcscntcd or that thcy would not want to play
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x)
an important rolc in dccision making wcrc not substantiatcd. !mprcssivc
cvidcncc lor thc cmpowcrmcnt ol paticnts with SPs occurrcd carly in thc
coursc ol our cvaluation whcn ltccn paticnts alrcady schcdulcd lor surgcry
at a \ctcrans Administration (\A) Hospital wcrc inadvcrtcntly shown thc
SP. Hall ol thc paticnts dccidcd against surgcry, cvcn though thcy had
alrcady acccptcd thcir physicians rccommcndation to havc it.
:. Vhcn Paticnts Arc !nlormcd about ptions, o Tcy Choosc
Morc Rationally lrom Tcir wn Point ol \icw:
Tis is thc bottomlinc qucstion: ocs thc usc ol dccision aids and thc implc
mcntation ol a sharcd dccisionmaking proccss promotc inlormcd paticnt
choicc: An answcr was providcd by an important study spcarhcadcd by Mikc
8arry and ]ack Fowlcr.
!8
First, thcy lound that symptoms mattcrcd in prc
dicting choicc. Comparcd to thosc with modcratc symptoms, paticnts who
wcrc scvcrcly symptomatic wcrc about twicc as likcly to choosc surgcry, thc
trcatmcnt with thc bcst chancc ol improving symptoms. 8ut cvcn among thc
most scvcrcly symptomatic, only a minority ol paticnts wantcd surgcry: .. ol
thosc with modcratc symptoms, and :: ol thosc with scvcrc symptoms chosc
surgcry.
Vhat mattcrcd most in dctcrmining choicc was not symptoms, but
two othcr lactors govcrning thc paticnts dccision: thc paticnts own atti
tudcs toward his symptomshow much hc was bothcrcd by thcmand thc
patients degree of concern about risks to his sexuality (impotence and problems
with ejaculation).
!t is worth lollowing thc logic ol Mikcs and ]acks study to cxaminc thc
mcans by which thcy invcstigatcd how thcsc two sphcrcsthc objcctivc
statc ol symptom lcvcl and thc attitudc ol thc paticnt toward thcmintcract
to prcdict thc choicc that paticnts will makc in thc sharcd dccisionmaking
cnvironmcnt. Tc rcscarchcrs uscd a standardizcd qucstionnairc to cvaluatc
thc paticnts symptoms and askcd thc lollowing qucstion to rank thcir atti
tudcs toward thcir symptoms: Supposc your urinary symptoms staycd just
about thc samc as thcy arc now lor thc rcst ol your lilc. How would you lccl
about that: Surprisingly, only a minority ol paticnts was bothcrcd vcry much
by thc prospcct that thcir symptoms would rcmain thc samc, cvcn among
thosc who wcrc scvcrcly symptomatic
!9
(Tablc 6..).
Paticnts wcrc also askcd qucstions about thcir dcgrcc ol conccrn about
complications: Supposc a trcatmcnt curcd your urinary symptoms, but
you wcrc unablc to havc scxual crcctions. How would you lccl about your
6 sivcic~i v~vi~)iox
situation: Tc individual paticnts attitudcs about thc possibility lor impo
tcncc and thc dcgrcc to which hc was bothcrcd by his symptoms provcd to
bc vcry strong prcdictors ol choicc ol trcatmcnt. Paticnts who wcrc ncga
tivc about thcir symptoms wcrc scvcn timcs morc likcly to choosc surgcry
than thosc who had a positivc or a mixcd attitudc, thosc who wcrc ncgativc
about thc prospcct ol impotcncc wcrc vc timcs morc likcly to choosc watch
lul waiting than thosc who had mixcd lcclings or didnt sccm to carc. Tus,
whilc thc objcctivc rcason lor doing surgcry was to rcducc symptoms, thc
asscssmcnt ol thc nccd lor surgcry rcquircs thc cvaluation ol how much thc
paticnt is bothcrcd by his symptoms and his conccrns about thc impact ol
surgcry on scxuality.
Which Rate Is Right?
ur 8PH studics also hcld intriguing hints that thc right ratc lor prostatc
ctomythat happcns whcn dcmand lor discrctionary surgcry is bascd on
inlormcd paticnt choiccmight bc lowcr than thc ratc at which mcn wcrc
actually undcrgoing thc proccdurc. Tc cvidcncc camc lrom a study our group
conductcd among 8PH paticnts cnrollcd in two prcpaid group practiccs: thc
Kaiscr Pcrmancntc Mcdical Group in cnvcr, Colorado, and Group Hcalth
Coopcrativc in Scattlc, Vashington. Altcr sharcd dccision making lor 8PH
was implcmcntcd in thcsc plans, thc ratcs lor surgcry droppcd an astonishing
c bclow basclinc and in comparison to a control population.
20
Tc ratcs lor
surgcry in thcsc organizations wcrc alrcady bclow thc national avcragc prior to
our study. Altcr sharcd dccision making was widcly implcmcntcd lor 8PH, thcir
Tablc 6... How Paticnts with an nlargcd Prostatc Fclt about Tcir Symptoms
According to Symptom Scvcrity
Symptom Level
Attitude Toward Teir Symptoms
Mostly Satised Mixed Reaction Mostly Dissatised
Mild
Modcratc :. :.
Scvcrc .o . :
Source: Floyd ]ackson Fowlcr, ]r., Tc Rolc ol Paticnt Prclcrcnccs in Mcdical Carc (Papcr prc
scntcd at thc istinguishcd Lccturc Scrics, cc ol Graduatc Studics and Rcscarch, Univcrsity ol
Massachusctts, Novcmbcr .oo). |Uscd by pcrmission ol Floyd ]ackson Fowlcr, ]r.|
iv~vxixc wn~) wovxs ~xb wn~) v~)ivx)s w~x)
ratcs wcrc at thc bottom ol thc national distribution (Figurc 6..). !l thc prclcr
cncc pattcrns ol mcn in thcsc two HMs rccctcd thc avcragc lor Amcricans,
thcn thc amount ol surgcry prcscribcd and pcrlormcd in thc Unitcd Statcs lor
8PH during thc study ycars would havc cxcccdcd thc amount that inlormcd
paticnts wantcd in virtually cvcry rcgion ol thc country.
Te Value of Outcomes Research
Lct mc summarizc thc progrcss that was madc ovcr thc lourtccnycar pcriod
(.o through .oo) ol thc Mainc phasc ol our outcomcs rcscarch projcct.
!n rcsponsc to lccdback on variation, an Hanlcy was ablc to organizc thc
urologists in Mainc to comc togcthcr to dcbatc thc rcasons lor variation. Tc
convcrsations soon locuscd on thc dicrcnccs in thcory among thc urologists
thcmsclvcs and this, in turn, lcd to a scrics ol studics that rcsultcd in show
ing that thc prcvcntivc thcory ol surgical intcrvcntion was countcrlactual
that surgcry on largc numbcrs ol cldcrly mcn could not bc justicd on thc
Figurc 6... Ratcs ol transurcthral prostatcctomy lor bcnign prostatic hypcrplasia
(TURP) among hospital rclcrral rcgions (.oo: through .oo.) comparcd to ratcs lor
two sta modcl HMs bclorc and altcr introduction ol sharcd dccision making. Tc
data lrom thc two HMs havc bccn poolcd. Tc ratc bclorc sharcd dccision making
is lor .o through .oo, thc bcnchmark undcr sharcd dccision making is lor .ooc and
.oo.. (Sourcc: artmouth Atlas Projcct databasc.)
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HM ratc bclorc sharcd
dccision making
8cnchmark undcr sharcd
dccision making
sivcic~i v~vi~)iox
basis ol thc proccdurcs ability to prcvcnt dcath and disability duc to obstruc
tion ol thc urinary tract. 8y contrast, thc quality ol lilc thcory was sustaincd:
thc proccdurc was quitc ccctivc in rcducing symptoms, but rational choicc
dcpcndcd on thc paticnt dcciding bctwccn thc proccdurcs supcrior ability to
rcducc urinary tract symptoms and its ncgativc impact on scxuality and othcr
complications. Studics ol thc prclcrcnccs ol mcn, cvcn thosc with scvcrc
symptoms, dcmonstratcd that only a minority would want surgcry, givcn thc
tradcos that surgcry imposcs.
Rational choicc thus dcpcndcd on sorting out thc individual paticnts prcl
crcnccs. Paticnt prclcrcnccs could not bc prcdictcd by any ol thc traditional
tools availablc to physicians, including paticnt history, physical cxamination,
or biological tcsts such as urinc ow. Urinc ow was lound to bc uncorrc
latcd with symptom lcvcl and thcrclorc unhclplul in cvaluating nccd.
2!
!n
turn, whilc symptom lcvcl was an important prcdictor ol nccdand could
bc mcasurcd objcctivcly with a standardizcd qucstionnairc, it providcd no
rcliablc rulc ol thumb on which to basc dccisions: only a minority ol cvcn
thc most scvcrcly symptomatic mcn wantcd surgcry oncc thcy wcrc inlormcd
ol thc lull scopc ol tradcos. Rathcr, it was two subjcctivc aspccts ol paticnt
choicchow much thcy wcrc bothcrcd by thcir symptoms and thcir conccrn
about thc impact ol surgcry on scxualitythat provcd to bc morc important
in prcdicting paticnt choicc than symptom lcvcl. Tc critical naturc ol thcsc
lactors only bccamc clcar through implcmcnting a sharcd dccisionmaking
proccss.
utcomcs rcscarch docs not takc placc within thc controllcd cnvironmcnt ol
a rcscarch laboratory, it rcquircs thc activc cngagcmcnt ol physicians thcm
sclvcsthosc whosc vcry thcorics and pattcrns ol practicc arc to bccomc thc
subjcct ol cvaluation. !t rcquircs trust and, bccausc thc rcscarch is long tcrm
and oltcn itcrativc in naturc, a stablc inlrastructurc to support thc rcscarch.
ur studics in Mainc hclpcd to clarily thc rationalc lor using surgcry to trcat
bcnign prostatic hypcrplasia and providcd a stratcgy lor cstimating thc truc
dcmand ol discrctionary surgcry through sharcd dccision making. 8y thc
cnd ol thc .ocs, thc valuc ol outcomcs rcscarch had widcr rccognition, and
thc Mainc Mcdical Asscssmcnt Program bccamc thc prototypc lor a national
rcscarch program to addrcss unwarrantcd practicc variation. For a lcw ycars,
it sccmcd as il thc nation might actually bc prcparcd to invcst in thc rcscarch
that is ncccssary to providc mcdicinc with a rm scicntic looting and basc
thc utilization ol discrctionary surgcry both on what works and what paticnts
want. Chaptcr dcscribcs somc ol thc lcssons lcarncd.
o
uring thc .ocs, practicc variations and outcomcs rcscarch attractcd a good
dcal ol attcntion among mcmbcrs ol thc U.S. Congrcss, stimulatcd by a
growing world litcraturc documcnting thc ubiquity ol practicc variation and
its conncction to mcdical spcnding. !n .o, Scnator avid urcnbcrgcr, a
Rcpublican lrom Minncsota and chair ol thc Scnatc Financc Subcommittcc
on Hcalth, uscd his inucncc to cstablish an outcomcs rcscarch program,
which bccamc known as thc Paticnt utcomcs Rcscarch Tcam, or PRT
program. Modclcd altcr our Mainc projcct on bcnign prostatic hypcrpla
sia (8PH) (discusscd in Chaptcr 6), lour tcams wcrc lundcd undcr thc
National Ccntcr lor Hcalth Scrviccs Rcscarch: cach locuscd on conditions
lor which surgical trcatmcnt ratcs varicd cxtcnsivcly among rcgions. Tc con
ditions includcd angina or chcst pain duc to coronary artcry discasc, low
back pain duc to hcrniatcd intcrvcrtcbral disc or spinal stcnosis, cataracts,
and prostatc discasc. ur rcscarch group bccamc thc prostatc discasc PRT,
cxpanding its 8PH locus to includc carlystagc prostatc canccr. Two ycars
latcr, Congrcss brought into bcing thc Agcncy lor Hcalth Carc Policy and
Rcscarch (AHCPR |namc changcd in .ooo to thc Agcncy lor Hcalthcarc
Rcscarch and uality (AHR)|, with thc much morc ambitious agcnda ol
organizing a comprchcnsivc national approach to improving thc scicntic
basis lor both clinical practicc and policy dccision making in hcalth carc. Tc
PRT projcct bccamc part ol AHCPRs mcdical ccctivcncss program.
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..c :vbic~i v~vi~)iox
a paticnt is not so clcarcut and thc supply ol cascs that currcnt mcdical
practicc labcls as appropriatc lor admission ncarly always cxcccds capacity.
!n othcr words, thcrc arc ncarly always morc sick pcoplc than thcrc arc bcds.
For most acutc and chronic illncsscs, thc diagnosis is not in itscll su cicnt
grounds lor hospitalization. Tc clinician is lorccd to makc dccisions on thc
hospitalization ol individual cascs that havc a placc on a spcctrum ol scvcr
ityto distinguish bctwccn shadcs ol grcy, not thc binary blackandwhitc
hip lracturc dccision. Physicians makc thcsc dccisions within thc contcxt ol
availablc bcds. Tc kcy idca hcrc is that whcn a physician laccs unccrtainty
conccrning mcdical prognosis, thc dominant cultural bias is to crr on what is
pcrccivcd to bc thc sidc ol salctyto prcscribc hospitalization whcn a bcd is
availablc. Morcovcr, undcr lcclorscrvicc Mcdicarc, cconomic inccntivcs arc
squarcly in sync with thc morc is bcttcr assumption, cvcn whcn thc physi
cian docs not dircctly bcnct nancially lrom thc dccision to hospitalizc.
!n thc abscncc ol cxplicit thcory and usclul rulcs ol thumb, dccision mak
ing is oltcn guidcd by a gcncral assumption that whcn in doubt, morc hcalth
carc is bcttcr. 8oth doctors and paticnts assumc that thc acutc hospital sct
ting, with all ol its rcsourccs and conccntratcd mcdical skills, is a bcttcr placc
to dcal with sick paticnts with guardcd or unccrtain prognoscs than arc othcr
scttings, likc thc paticnts homc or cvcn thc nursing homc, whcrc carc is
sccmingly lcss organizcd and thcrc arc lcwcr physicians and nurscs availablc.
Undcr such an assumption, thc availability ol bcds bccomcs critical. Among
tcaching hospitals in 8oston and Ncw Havcn, thc occupancy ratcs wcrc all
quitc high, but bcds wcrc always availablc lor thc low variation conditions
likc hip lracturc, or canccr paticnts nccding surgcry, cascs that cvcryonc
agrccs rcquirc hospitalization. 8ut thcsc conditions comprisc only a small
proportion ol paticnts using bcdscvcn in rcgions with constraincd bcds pcr
.,ccc pcoplc. Tus, at any givcn point in timc, thc paticnt population ol thc
hospital with mcdical diagnoscs is composcd mostly ol paticnts with acutc
and chronic illncsscs that arc susccptiblc to thc thrcshold ccct ol capacity.
And whcn thcrc arc morc bcds pcr capita, thcrc arc morc opportunitics to
placc thc paticnt in thc salcr inpaticnt cnvironmcnt.
Tc rcadcr will rccall that our studics in Mainc lound that cach hospital
scrvicc arca had a surgical signaturc, its own pcculiar pattcrn ol surgical ratcs
lor dicrcnt conditionshigh ratcs lor somc, low ratcs lor othcrs. Morcovcr,
thc ovcrall ratc ol surgcry (thc total dischargc ratc) is not closcly corrclatcd
with thc ratc lor any givcn surgical proccdurc. 8y contrast, thc ratc ol hospi
talization lor a spccic high variation mcdical condition tcnds to bc closcly
associatcd with total dischargc ratcs, and within a givcn rcgion, hospitaliza
tion ratcs tcnd to bc morc or lcss unilorm across all high variation mcdical
ixbvvs)~xbixc sivviysvxsi)ivv c~vv ...
conditions. Tc mcdical signaturcs lor 8oston and Ncw Havcn, as rcportcd
in thc .oo Atlas, arc illustratcd in Figurc .:.
Vc lound a similar pattcrn whcn wc lookcd at thc lrcqucncy ol physician
visits. Paticnts had morc physician visits pcr capita in rcgions whcrc thc pcr
capita supply ol physicians was highcr, particularly lor physicians that spcnd
most ol thcir practicc timc on oldcr, chronically ill paticnts, such as gcncral
intcrnists and cardiologists (Figurc ..). Tis association bctwccn supply and
utilization makcs scnsc in thc outpaticnt sctting, givcn what is known about
thc way paticnts arc schcdulcd lor lollowup visits. Most physician visits
arc rcvisits, schcdulcd by thc physician (or, morc likcly, thcir o cc pcrson
ncl), who typically ll most availablc hours with cstablishcd paticnts. Most
paticnts with chronic illncsscs arc assumcd to nccd monitoring, and thc only
rcal qucstion thc physician laccs in rcschcduling is thc rclativc nccd among
thc individual paticnts lor whom hc routincly providcs carc. (Tc sickcr oncs,
ol coursc arc sccn morc oltcn.) 8ut il physicians havc lcwcr paticnts in thcir
paticnt population, thc lrcqucncy ol rcvisits will bc highcr lor all paticnts
with chronic illncssthc sickcst and lcss sick as wcll.
Figurc .:. Tc mcdical signaturcs ol thc 8oston and Ncw Havcn hospital scrvicc
arcas (.oo through .oo). (Sourcc: Vcnnbcrg, ]. ., and M. M. Coopcr, cds. .oo. Te
Dartmouth Atlas of Health Care 1998, Chicago, !L: Amcrican Hospital Publishing.)
+.+
o.o8
+.+o
+.oo
:.o:
+.+8
o.o+
+.o
+.+
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o.6+
o.:8
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+.+8
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Ncw Havcn
Ratio ol 8oston dischargc ratc to Ncw Havcn dischargc ratc:
+.6+ +.+ +.66 +.8 +.: :.+ +.: +.8o :.o6 +.o
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Figurc ... Tc association bctwccn cardiologists and visits to cardiologists among
hospital rclcrral rcgions (.oo6). (Sourcc: Vcnnbcrg, ]. ., and . S. Fishcr, cds. :cc6.
Te Care of Patients with Severe Chronic Illness: A Report on the Medicare Program by the
Dartmouth Atlas Project. Te Dartmouth Atlas of Health Care 2006. Hanovcr, NH: Tc
Ccntcr lor thc valuativc Clinical Scicnccs |onlinc|.)
R
:
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Cardiologists pcr +oo,ooo rcsidcnts (+oo6)
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!ts tcmpting lor somc to bclicvc that physicians arc acting as scllscrving,
cvcn cynical induccrs ol dcmand, hospitalizing paticnts and schcduling rcvis
its so that thcy can makc morc moncy. 8ut this cannot bc thc cxplanation, as
thcrc arc no normativc scicntic standards lor rcschcduling or hospitalization
to bc transgrcsscd. Astonishing as it may sccm to many paticnts and cvcn
somc hcalth carc policy analysts, mcdical scicncc providcs no guidancc on
what thc bcst practicc intcrval bctwccn visits should bc or whcn to hospital
izc. Tcrc is rcmarkably littlc mcdical thcory and almost no mcdical cvidcncc
conccrning thc optimum lrcqucncy ol intcrvcntions lor supplyscnsitivc scr
viccs. Tis was cvidcnt both through my pcrsonal intcrvicws with acadcmic
clinicians in 8oston and Ncw Havcn, and also in thc lack ol lormal discoursc
in mcdical tcxts conccrning bcst practiccs rcgarding thc appropriatc lrc
qucncy ol thc usc ol supplyscnsitivc scrviccs. !n thc standard mcdical tcxts
that inlorm thc practicc ol both primary and mcdical spccialty carc, and in
thc practicc guidclincs that constrain clinical dccision making, onc scarchcs
in vain lor cvcn thc briclcst discussion conccrning thc critcria lor admitting
chronically ill paticnts to thc hospital and to intcnsivc carc, or thc optimal
intcrval bctwccn rcvisits lor paticnts with cstablishcd discasc.
Tc lack ol guidclincs, or cvidcncc, or any lorm ol normativc scicntic
constraint on physician dccision making lor supplyscnsitivc carc has a pro
lound impact on thc hcalth carc cconomy. Tc numbcr ol physician o cc
hours availablc lor monitoring and managing thc carc ol thc population living
ixbvvs)~xbixc sivviysvxsi)ivv c~vv ...
in a rcgion is closcly dcpcndcnt on thc supply ol clinically activc physicians
pcr .cc,ccc rcsidcnts. Takc a hypothctical casc. !n rcgion A, which has twicc
as many cardiologists as rcgion 8, twicc as many hours will bc availablc lor
a cardiologist to schcdulc. n avcragc, rcgion As population will cxpcricncc
twicc as many visits pcr pcrson comparcd with rcgion 8, and thc mcan intcrval
bctwccn visits will bc about hall that ol Rcgion 8. Ncithcr thc paticnts nor thc
clinicians in rcgions A and 8 will bc awarc ol thc dicrcnccs in practicc stylc.
Tc paticnts will assumc that thcir mcdical nccd dctcrmincs thc schcdulc lor
rcvisits. Physicians will allocatc thcir timc to paticnts on thc basis ol rclativc
illncss, with thc sickcr paticnts cxpcricncing morc lrcqucnt visits. Most physi
cians in both communitics will bc working long hours, bclicving that thc carc
thcy providc is ncccssary carc, and totally unawarc that capacity dicrsor
that capacity inucnccs thcir clinical dccision making. nly thc cpidcmiolo
gist, pccring at hcalth carc lrom .c,ccc lcct, can scc thc pattcrns ol practicc
and makc thc conncction bctwccn capacity and utilization.
What Accounts for Variation in Capacity?
Undcrstanding supplyscnsitivc carc rcquircs an undcrstanding ol why capac
ity itscll varics so much lrom rcgion to rcgion (and lrom hospital to hospital).
!n my cxpcricncc, satislactory answcrs to thc qucstion, Vhy do somc hos
pitals in somc rcgions grow morc rapidly in rclation to thc sizc ol thc local
population than do othcrs: do not cmcrgc lrom thc .c,cccloot pcrspcctivc
or statistical corrclations. pidcmiology has in its book ol mcthods what
traditionalists call shoclcathcr rcscarchthat is, gctting out on thc strccts
and looking lor cxplanations that might solvc a mystcry. Tc most lamous
cxamplc rcmains ]ohn Snows carclul charting ol thc outbrcak ol cascs in thc
London cholcra cpidcmic ol ., whcn hc pinpointcd contaminatcd drink
ing watcr supplicd through thc 8road Strcct pump by thc \auxhall Vatcr
Company as thc sourcc ol contagion. Following in thc lootstcps ol Snow, !
havc had thc opportunity to undcrtakc two shoclcathcr invcstigations ol thc
dynamics ol hospital construction, both ol which illuminatcd how thc capac
ity ol local hcalth carc markcts bccamc cstablishcd.
Considcr rst thc cxamplc ol 8oston and Ncw Havcn, whcrc dicrcnt
rcgulatory rcgimcs inucnccd thc growth ol hospital capacity. Consistcntly
ovcr thc ycars, thc capacity ol thc acutc carc hospital scctor in Massachusctts
cxcccdcd that ol Connccticut. For cxamplc, thc numbcr ol acutc carc hos
pital bcds pcr .,ccc allocatcd to thc hcalth ol 8ostonians cxcccdcd that ol
Ncw Havcnitcs by about , thc numbcrs ol hospital cmployccs pcr .,ccc
.. :vbic~i v~vi~)iox
scrving 8ostonians gcncrally ran about oc morc, and hospital cxpcnditurcs
pcr capita wcrc about twicc thosc ol Ncw Havcn. Tcsc dicrcnccs can bc
traccd to thc pcriod shortly altcr Vorld Var !!, whcn thc hospital industry
cnjoycd a pcriod ol growth, stimulatcd in part by thc Hill8urton Act.
Passcd in .o6, thc act rcquircd statcs to dcvclop statc hcalth plans on thc
nccd lor bcds, in ordcr to rcccivc lcdcral subsidics lor hospital construction.
!n many statcs, including Massachusctts, Hill8urton grants wcrc ticd to a
planning mcthodology dcsigncd to cnsurc that thc occupancy ol hospitals
did not cxcccd a givcn lcvcl. Tus, thc morc prcssurc that was placcd on avail
ablc bcds, thc morc nccd thcrc was dctcrmincd to bc, indcpcndcnt ol thc
actual numbcrs ol hospital bcds pcr .,ccc in thc community or rcgion.
As ! lcarncd lrom a .o intcrvicw with ]ohn Tompson, who had rcccntly
rctircd lrom his prolcssorship in hospital administration at Yalc, thc cvolution
ol thc Hill8urton planning proccss in Connccticut was quitc dicrcnt lrom
Massachusctts. !n Connccticut, thc dccision proccss was dominatcd to a largc
cxtcnt by thc Cs ol thc cxisting hospitals. Tcir basic stratcgy was to kccp
ncw compctitors out ol thcir local markcts, using thc statcs Ccrticatc ol Nccd,
or CN, lcgislation to thwart attcmpts to cstablish ncw hospitals. Tompson,
who had bccn part ol thc proccss, bclicvcd that this was thc primary rcason
why ovcr thc ycars Connccticut has bccn at thc low cnd ol thc national spcc
trum in hospital bcds pcr .,ccc. Hc citcd two spccic cxamplcs ol how thc
proccss rcspondcd to kccp capacity low in thc Ncw Havcn arca. nc was thc
rcaction to a pctition by scvcral dissidcnt physicians who wishcd to lcavc thc
tcaching hospital to start a suburban hospital in a ncighboring community. Tc
othcr was a proposal to build a ]cwish hospital. 8oth wcrc turncd down during
thc CN proccss (as wcrc similar applications in othcr parts ol thc statc).
Tc CN proccss in Massachusctts, by contrast, was much morc opcn to
thc inucncc ol various intcrcsts that wantcd to cxpand thc hospital industry.
Tompson citcd compctition bctwccn 8oston tcaching hospitals as a major
rcason lor thc cxpansion ol capacity in that rcgion: cach hospital rcquircd
its lull complcmcnt ol scrviccs and obtaincd thc nccdcd approvals lrom thc
CN administrators (and capital lrom banks, bondholdcrs, and lcdcral sub
sidics) without di culty. Growth ol thc hospital scctor in thc grcatcr 8oston
arca was also susccptiblc to thc prcssurc lor a placc to practicc mcdicinc lrom
physicians who did not win, or did not want, appointmcnts at a 8oston tcach
ing hospital, but who staycd in thc arca and wcrc wclcomcd on thc stas ol
community hospitals. Tis prcssurc was particularly strong in thc 8oston arca
bccausc ol thc many acadcmic training programs that produccd ncw mcdi
cal rcsidcnts (who charactcristically scck to practicc mcdicinc in thc rcgion
whcrc thcy train).
ixbvvs)~xbixc sivviysvxsi)ivv c~vv ..
!n othcr communitics, hospital capacity is built up lor dicrcnt rcasons.
Takc Augusta and Vatcrvillc, two ncighboring communitics in ccntral
Mainc, whcrc compctitivc dynamics and rcligious prclcrcncc crcatcd thc
prcssurc to build morc bcds. Tc lollowing lacts cmcrgcd lrom our studics in
Mainc in thc .ocs. At that timc, Augusta and Vatcrvillc had about c,ccc
pcrsons cach, but vcry dicrcnt supplics ol acutc carc hospital bcds: about
.. bcds pcr .,ccc lor rcsidcnts ol Augusta and about . bcds pcr .,ccc lor
Vatcrvillc. !n Vatcrvillc, thcrc wcrc thrcc hospitals: onc an ostcopathic hos
pital, thc sccond an allopathic Catholic hospital, and thc third nonscctarian
and allopathic. (Tc Catholic hospital and nonscctarian allopathic hospital
havc sincc mcrgcd.) !n Augusta, history produccd but onc nonscctarian hos
pital that, lrom thc bcginning, wclcomcd allopathic and ostcopathic physi
cians as wcll as all rcligions. Having thrcc hospitals ncttcd 6c morc bcds pcr
capita lor Vatcrvillcand highcr pcr capita spcnding and utilization.
Vhy did thc thrcc hospitals in Vatcrvillc not comc to somc markct
cquilibrium, with cach taking carc ol its sharc ol thc population, and nonc
building morc bcds than ncccssary: ! havc alrcady madc thc casc that thc
physician is inccctivc as socictys agcnt lor constraining thc ovcrusc ol
supplyscnsitivc carc, largcly bccausc hc or shc is almost cntircly unawarc ol
thc ccct ol supply on his or hcr discrctionary dccisions, and bccausc clinical
scicncc imposcs no signicant constraint on physician dccision making in
ways that might also placc limits on thcir usc ol rcsourccs. nc can bc quitc
surc that in .oc, thc administrators and boards ol trustccs ol thc thrcc hospi
tals in Vatcrvillc, or anyonc clsc in a position to inucncc dccisions on capac
ity, wcrc not at all conccrncd about thc possibility ol cxccss bcds pcr capita in
thcir community, it would ncvcr havc crosscd thcir minds, lor any numbcr ol
rcasons. Tcrc was littlc rccognition that supply could drivc utilization, and
a widcsprcad assumption that morc mcdical scrviccs lcd to bcttcr outcomcs.
!n addition, scvcral systcmlcvcl lactors wcrc at work to rcducc awarcncss
ol thc conscqucnccs ol any dccision to incrcasc capacity. First, kcy inlorma
tion was lacking: bccausc populationbascd data on rcsourcc capacity was
unavailablc, administrators and boards ol trustccs ol hospitals wcrc unawarc
ol hospital capacity rclativc to thc sizc ol thc rcsidcnt population in thcir own
rcgion, much lcss thc numbcr ol bcds thcir own hospital uscd in caring lor its
loyal population. Sccond, thc capital lor cxpanding thc acutc carc scctor was
rcadily availablc, no mattcr how many hospital bcds pcr capita thcrc alrcady
wcrc. uring thc .ocs and cs, thc lcdcral Hill8urton Act subsidizcd thc
construction ol hospitals, but its planning mcthods wcrc awcd. Again, thc
problcm can bc traccd in part to lack ol population data: thc signal that plan
ncrs rclicd upon lor mcasuring scarcity ol bcds was thc occupancy ratcthc
..6 :vbic~i v~vi~)iox
pcrccntagc ol availablc bcds that on avcragc arc llcd. 8ut thc occupancy ratc
is an unrcliablc mcasurc ol thc nccds ol thc population, bccausc it is largcly
uncorrclatcd with cithcr prcvalcncc ol illncss or thc cxisting bcd supply. !n
\crmont, lor cxamplc, as wc documcntcd in our .o. papcr in Science, thc usc
ol this mcasurc to dctcrminc nccd rcsultcd in paradoxical dccisions on thc
part ol thc statc hcalth planning agcncy, calling lor additional bcd construc
tion in rcgions that alrcady had a high pcr capita numbcr ol bcds.
Finally, thcrc wcrc no dircct cconomic conscqucnccs to cmploycrs and
individuals living in Vatcrvillc in tcrms ol thc pricc thcy paid lor hcalth
insurancc. Tosc who buy insurancc arc insulatcd lrom thc truc cost ol carc
in thcir local communitics, so thcy do not put prcssurc on hospitals to con
strain utilization or thc growth in capacity that can drivc it. !n thc latc .ocs,
8luc Cross was thc dominant providcr ol hcalth insurancc in Mainc and thc
pricc 8luc Cross chargcd lor a policy was thc samc throughout thc statc, no
mattcr what thc actual lcvcl ol pcr capita utilization, and thus spcnding, was
in a givcn rcgion. Furthcrmorc, hospitals arc vicwcd as dcsirablc to thc com
munity, both in gcncrating local jobs and in attracting ncw rcsidcnts.
!n our Mainc rcscarch, wc documcntcd striking dicrcnccs in pcr capita
rcimburscmcnts by 8luc Cross in Mainc and thcn comparcd how much thc
rcsidcnts in dicrcnt communitics had paid out lor insurancc vcrsus how
much carc thcy rcccivcd. !n .oo, 8luc Cross paid thc providcrs in Vatcrvillc
s::. pcr subscribcr on avcragc, ..6 timcs grcatcr than thc s.. it paid pcr sub
scribcr in Augusta, mcaning that thc ::,cc Vatcrvillc subscribcrs rcccivcd
ncarly s. million worth ol carc morc than thcy (or thcir cmploycrs) paid to
8luc Cross. Rcsidcnts ol Augusta, by contrast, rcccivcd sc,ccc lcss carc
than thcy paid lor.
8
nc has to wondcr, il thc pricc ol hcalth insurancc had
bccn adjustcd to rccct local markct pcr capita costs, would thc citizcns ol
Vatcrvillc havc comc to a dicrcnt conclusion conccrning thc nccd lor thrcc
hospitals, and takcn stcps to rcducc thcir cxccss capacity: Tcsc may sccm
likc small numbcrs today, but givcn thc dramatic incrcasc in thc cost ol hcalth
carc, both in tcrms ol utilization and pricc pcr unit ol scrvicc, thc magnitudc
ol dollar translcrs lrom low to high cost communitics now rcachcs into thc
billions ol dollars. (!n Chaptcr .:, ! providc an cstimatc ol thc amount ol
translcr paymcnts undcr traditional Mcdicarc.)
Te Patterns of Practice Today
Tc pattcrn ol practicc lor supplyscnsitivc carc today is vcry much thc samc
as it was whcn ! rst bcgan my studics in Ncw ngland somc .c ycars ago. !n
ixbvvs)~xbixc sivviysvxsi)ivv c~vv ..
prcparing this chaptcr, ! rcpcatcd as closcly as ! could thc .oc.o: Mainc
study ol variation in mcdical conditions discusscd carlicr in this chaptcr, using
Mcdicarc data lrom :cc. ! lookcd at thc pattcrn ol variation in dischargc
ratcs among thc .c6 Atlas hospital rclcrral rcgions lor o mcdical conditions
idcnticd through thc RG coding systcm. Vith onc cxccption, thc story
across thc nation in :cc is csscntially thc samc as it was in Mainc in thc .ocs.
8ack thcn, oc ol mcdical dischargcs in Mainc wcrc high variationas vari
ablc or morc so than hystcrcctomy, in :cc, most Mcdicarc paticnts in thc
country ol Mcdicarc dischargcs lor mcdical conditionswcrc hos
pitalizcd with high variation mcdical conditionsmorc variablc than kncc
rcplaccmcnt.
9
Figurc . illustratcs thc pattcrn ol variation lor cight mcdical conditions,
sclcctcd bccausc thcy arc thc most common in tcrms ol lrcqucncy ol hospi
talization: cach accounts lor about :c,ccc or morc ol paticnts hospitalizcd
lor mcdical RGs in :cc among Mcdicarc rccipicnts. Togcthcr, thc cight
conditions account lor c.o ol all mcdical conditions. ischargc ratcs lor
strokc and blccding lrom thc gastrointcstinal tract cxhibit modcratc varia
tion among thc .c6 rcgions, with a coc cicnt ol variation that lics bctwccn
hip lracturc hospitalizations and kncc rcplaccmcnt. Tc dischargc ratc lor
Figurc .. Tc pattcrn ol variation ol hospitalization lor cight common mcdical
conditions among hospital rclcrral rcgions in :cc. (Sourcc: artmouth Atlas Projcct
databasc.)
Stroke Gastro-
intestinal
hemorr-
hage
Cardiac
arrhythmia
Simple
pneu-
monia
Gastro-
enteritis
Conges-
tive heart
failure
Septi-
cemia
COPD
Ratio highcst to
lowcst rcgion
:.6 :.o .: .: 6.: . 6. o.:
Coclcicnt ol
variation (x+oo)
+6.o +6. :o. :.: :.+ :.6 :.+ :.:
o.:
+.o
.o
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cardiac arrhythmia is on thc boundary bctwccn high and mcdium variation,
with a coc cicnt ol variation similar to kncc rcplaccmcnt. ischargc ratcs
lor paticnts with pncumonia, gastrocntcritis, and congcstivc hcart lailurc arc
morc variablc than kncc rcplaccmcnt, dischargc ratcs lor chronic pulmonary
obstructivc discasc and scpticcmia arc morc variablc than back surgcry.
Tc cxccption was thc changc ! notcd in thc pattcrn ol variation lor paticnts
with acutc myocardial inlarction. !n thc Mainc study, hcart attack dischargc
ratcs lollowcd thc modcratc variation pattcrn. !n thc :cc Mcdicarc study,
howcvcr, hcart attacks classicd as mcdical conditions wcrc highly variablc,
in lact morc variablc than thc ratcs lor kncc rcplaccmcnts. Tc incrcasc is
cxplaincd in part by thc RG coding convcntion. Tc Mainc study was con
ductcd bclorc thc advcnt ol pcrcutancous coronary intcrvcntion, or PC!a
proccdurc involving using a cathctcr to cxpand a coronary artcry, such as
stcnts. 8y :cc, hcart attack victims wcrc oltcn trcatcd with PC! and thus,
undcr thc RG convcntion, thcy bccamc classicd as surgical paticnts. 8ut
this is not thc only rcason why variation incrcascd. iagnostic practicc also
changcd. !n thc .ocs in Mainc, thc diagnosis ol a hcart attack was madc
primarily on thc basis ol a blood tcst and changcs in thc clcctrocardiogram
causcd by damagc to thc hcart musclc. 8y :cc, thc availability ol mcthods
to improvc blood ow and prcvcnt damagc to thc hcart musclc, and morc
scnsitivc blood tcsts, had lcd to carlicr intcrvcntions, oltcn in paticnts lor
whom thc diagnosis ol acutc myocardial inlarction is lcss ccrtain. cpcnding
on how hard thcy look, morc paticnts will bc diagnoscd with a hcart attack in
somc hospitals than in othcrs.
!0
Rcccnt ycars havc brought about somc intcrcsting changcs in dischargc
ratcs lor mcdical conditions in Ncw Havcn. Across thc Unitcd Statcs, dis
chargc ratcs lor mcdical conditions rosc lrom :: pcr .,ccc in .oo to : pcr
.,ccc in :cc, a o.c incrcasc. uring thc samc pcriod ol timc, dischargc
ratcs lor rcsidcnts ol 8oston incrcascd 6.a roughly similar incrcasc. Ncw
Havcn ratcs, howcvcr, rosc dramatically. !n .oo, thc dischargc ratc was .66
dischargcs pcr .,ccc, by :cc, thc ratcs had riscn .. to :. pcr .,ccc. Tc
high ratc ol growth in utilization among Ncw Havcn hospitals wcnt a long
way to closing thc 8ostonNcw Havcn gap: in .oo, dischargc ratcs in 8oston
wcrc o highcr than Ncw Havcn, by :cc, thcy wcrc only :c highcr.
At thc timc ol this writing, wc arc still invcstigating thc qucstion ol
why, altcr ycars ol stability, thc Ncw Havcn prolc changcd so dramatically.
8ctwccn thcn and now, Ncw Havcn built morc bcds, incrcasing its capac
ity by about .6, cvcn though thc Mcdicarc population did not grow. Tc
Ncw Havcn incrcasc in dischargc ratcs was associatcd with a :o dcclinc in
lcngth ol stay. (Tc drop in lcngths ol stay in csscncc rclcascd bcds that wcrc
ixbvvs)~xbixc sivviysvxsi)ivv c~vv ..o
thcn uscd lor ncw admissions.) Tc changcs in traditional Mcdicarc wcrc
also associatcd with a striking risc, and thcn a lall, in Mcdicarc HM cnroll
mcnt in thc intcrvcning ycars, rising lrom csscntially zcro in .oo, pcaking
at .c ol thc Mcdicarc population in .ooo:ccc, and lalling back to o by
:cc.:cc. Unlortunatcly wc do not havc rccords lor hospitalizations lor thc
HM population, nor lor thc paticnt population undcr 6, which arc likcly
csscntial lor lully undcrstanding thc suddcn shilt in practicc pattcrns.
8y thc cnd ol thc .ocs, our rcscarch projccts wcrc wcll on thc way to
building thc lactual basis lor undcrstanding practicc variations lor supply
scnsitivc carc. 8cginning with thc \crmont survcy, wc saw that whilc illncss
obviously inucnccd paticnt bchavior in sccking mcdical carcand sickcr
paticnts on avcragc got morc carc than thc lcss sickillncss did not cxplain
thc variation in thc amount ol carc paticnts rcccivcd in dicrcnt rcgions ol
thc statc. !n Mainc, wc saw that hospitalization ratcs lor conditions such
as hip lracturcs, which clinicians all agrcc nccd to bc hospitalizcd, showcd
littlc variation. n thc othcr hand, hospitalizations lor conditions such as
pncumonia, chcst pain, and congcstivc hcart lailurc varicd substantially,
much morc than sccmcd plausiblc on thc basis ol dicrcnccs in lung or
hcart discasc.
Vc continucd thcsc studics in 8oston and Ncw Havcn, whcrc wc lollowcd
paticnts whcn thcy wcrc hospitalizcd lor hcart attacks, hip lracturcs, and a lcw
othcr conditions lor which thc initial hospitalization was considcrcd manda
tory. Although it was unlikcly that 8ostonians with thcsc conditions wcrc
sickcr than Ncw Havcnitcs, thcy noncthclcss cxpcricnccd 6c morc hospital
izations ovcr a thrccycar pcriod ol lollowup altcr thc indcx hospitalization,
mostly lor such mcdical conditions as pncumonia, chcst pain, and congcstivc
hcart lailurc, lor which thcrc is no guidancc lor physicians about whcn to
hospitalizc.
Vc also accumulatcd cvidcncc that paticnts living in rcgions with lcwcr
rcsourccs and lowcr utilization ol hospitals wcrc not cxpcricncing worsc
outcomcs. !n \crmont, wc lound no corrclation bctwccn hospitalization or
mcdical spcnding and mortality, in 8oston and Ncw Havcn, mortality ratcs
wcrc similar, cvcn though hospitalization ratcs wcrc much lowcr in Ncw
Havcn. And whcn wc lollowcd victims ol hcart attacks, strokc, hip lracturc,
gastrointcstinal blccding, and colon canccr lor up to thrcc ycars, wc lound
no dicrcnccs in survival bctwccn 8oston and Ncw Havcn paticnts, dcspitc
dramatic dicrcnccs in thcir hospitalization ratcs lor high variation mcdical
conditions.
.c :vbic~i v~vi~)iox
Morc rcccntly, thanks to thc artmouth Atlas Projcct, thc scopc ol our
rcscarch has cxpandcd. ur ndings, summarizcd in thc ncxt two chaptcrs,
conrm that thc prcvalcncc ol illncss plays only a minor rolc in driving prac
ticc variation across thc Unitcd Statcs, that paticnt prclcrcnccs do not cxplain
carc intcnsity, and that paticnt survival, paticnt satislaction, and quality ol
carc tcnd to bc worsc in rcgions whcrc carc is morc intcnsc.
..
Tc idca that thc supply ol mcdical rcsourccs can inucncc utilization is
not ncwMilton Rocmcr said it in thc .o6csyct it has provcd to bc onc
ol thc most contcntious aspccts ol our rcscarch. Physicians arc oltcn dccply
thrcatcncd by thc notion that thc supply ol cvcrything lrom hospital bcds
to slots in thcir appointmcnt books can inucncc thcir daytoday dccisions
about thcir paticnts, dccisions thcy prclcr to bclicvc arc groundcd in rational
mcdical judgmcnt and sound scicncc. Hospital administrators and boards ol
trustccs do not want to acknowlcdgc that thcir cxpcnsivc cxpansion plans
may not always bc in thc bcst intcrcsts ol paticnts, or socicty. Nor havc
cconomists always bccn rcccptivc to thc spcctcr ol systcmatic markct lailurc
rcsulting lrom a mismatch bctwccn thc supply ol mcdical rcsourccs and thc
mcdical nccds and wants ol paticnt populations.
Tc principal argumcnt madc against our charactcrization ol thc rolc ol
supply lactors in inucncing utilization has bccn that rcgions and hospitals
that dclivcr morc scrviccs do so bccausc thcy havc sickcr paticnt populations,
or thcy havc morc dcmanding paticnts than rcgions and hospitals that dclivcr
lcwcr scrviccs pcr capita. !t is ccrtainly possiblc that rcsidcnts ol a rcgion likc,
say, Los Angclcs want morc carc than rcsidcnts ol San Francisco. 8ut can
paticnt dcmand cxplain thc cxtraordinary variation in utilization that wc scc
bctwccn rcgions: And it is truc that sickcr paticnts acccss thc hcalth carc sys
tcm morc lrcqucntly than lcss sick paticnts. Tis has bccn cvidcnt sincc thc
o
Chronic Illness and Practice Variation
.: :vbic~i v~vi~)iox
.o6cs, as shown in thc rcscarch by Andcrscn and Ncwman
!
at thc Univcrsity
ol Chicago. ]ack Fowlcrs study,
2
rcportcd in Chaptcr :, conrmcd this to bc
thc casc in \crmont.
8ut what mattcrs most in tcrms ol thc utilization and costs ol carc is what
happcns to paticnts altcr thcy acccss thc systcm, as with, lor cxamplc, paticnts
lrom 8oston and Ncw Havcn who havc hcart attacks and hip lracturcs. As
wc havc cxtcndcd our studics to thc national Mcdicarc program, wc havc
lound that similarly ill paticnts usc vastly dicrcnt amounts ol carc, dcpcnd
ing on whcrc thcy livc and thc providcrs thcy usc. \ariations in utilization,
rcsourcc capacity, and costs among rcgions arc only looscly linkcd with thc
prcvalcncc ol illncss.
!n cvaluating how thc nccds and dcsircs ol paticnts inucncc thc uti
lization ol acutc hospital carc, it is usclul to vicw thc qucstion lrom thrcc
pcrspcctivcs. How much carc do thosc who arc similarly ill gct, dcpcnding
on whcrc thcy livc or thc providcrs thcy usc: (Tis qucstion addrcsscs thc
amount ol scrviccs consumcd, conditional upon illncss.) How much illncss
is thcrc in a paticnt populationor what is thc prcvalcncc ol illncssand
how docs this inucncc utilization: Finally, do thosc who gct morc carc,
particularly at thc cnd ol lilc, actually want morc carcand do thcy gct thc
carc thcy want: Tis chaptcr looks at how wc answcr thcsc thrcc qucstions,
and it builds thc casc that illncss and paticnt prclcrcncc do not cxplain thc
variation wc scc in supplyscnsitivc carc.
How Much Care Do Similarly Ill Patients Get?
Tis turns out to bc a di cult qucstion to answcr, bccausc it is hard to adjust
lor scvcrity ol illncss. Tc stratcgy wc hit upon lor addrcssing this qucstion
was to comparc thc pattcrns ol scrviccs rcccivcd by chronically ill Mcdicarc
cnrollccs during xcd intcrvals prior to dcath. Tcrc wcrc scvcral rcasons to
usc this mcthod. First, virtually all chronically ill Mcdicarc paticnts arc quitc
sick in thc months lcading up to dcath. Tis is thc naturc ol chronic discasc,
paticnts grow sickcr and sickcr ovcr timc, and whilc somc may dic rclativcly
rapidly lrom onc discasc or anothcra catastrophic strokc or hcart attack, lor
cxamplcmost paticnts with chronic illncss cxpcricncc an incvitablc wors
cning ol symptoms and gradual dcclinc in lunctional status that ultimatcly
lcads to dcath. Sccond, thc chronically ill by ncccssity acccss thc hcalth carc
systcm in thc months prior to dcath. Tcy arc sick and in distrcss. Tcy sul
lcr acutc cxaccrbations ol thcir conditions that may lcavc thcm unablc to
brcathc, or cat, or walk. Tat mcans wc arc ablc to capturc thc hcalth carc
cnvoxic iiixvss ~xb vv~c)icv v~vi~)iox ..
cxpcricncc ol virtually all paticnts in a givcn rcgion who dic in a givcn pcriod
ol timc. Tird, by rcstricting thc cohort to thosc who dicd, cvcry paticnt in
thc samplc population is idcntical along at lcast onc vcry important mcasurc
ol hcalth status: all arc dcad at thc cnd ol thc pcriod ol obscrvation. Fourth,
by adjusting lor agc, scx, racc, and typc ol illncsslactors known to bc asso
ciatcd with thc utilization ol carcwc rcmovc thc possiblc contribution ol
dicrcnccs in thc lrcqucncy ol thcsc lactors to variation in carc intcnsity.
Hcrc is how wc constructcd our cohorts. First, wc scarchcd Mcdicarc
rccords to idcntily all Mcdicarc paticnts who dicd within a givcn pcriod ol
timc (most oltcn, ovcr a calcndar ycar). Tcn wc mcasurcd thcir utilization
bascd on thc bills that Mcdicarc paid lor thc scrviccs thcy had incurrcd ovcr
xcd intcrvals ol timc prior to dcaththc last six months ol lilc, lor cxamplc.
8y lurthcr rcstricting thc cohort to paticnts who succumbcd to onc or morc
ol ninc chronic discascs
1
and adjusting lor agc, scx, racc, and thc typc ol
chronic illncss, wc bclicvc it is vcry unlikcly that variations in scvcrity ol ill
ncss lrom placc to placc would rcmain a likcly cxplanation lor thc variations
in thc usc ol acutc carc hospital and physician scrviccs obscrvcd during this
pcriod ol timc.
Using this population, wc lound widc variation in thc intcnsity ol carc
Mcdicarc cnrollccs rcccivcd according to thc rcgion whcrc thcy livcd. To
illustratc, ! will usc thc artmouth Atlas Projccts mcasurc lor hospital carc
intcnsity, callcd thc hospital carc intcnsity indcx (HC! indcx), which rcccts
both thc amount ol timc spcnt in thc hospital and thc intcnsity ol intcrvcn
tions dclivcrcd during hospitalization (8ox o..). As shown carlicr in Figurcs
.: and .., variation in hospital utilization and physician visits is highly cor
rclatcd with thc supply ol hospital bcds and physicians.
Vc lound a four-fold variation in inpaticnt carc intcnsity among thc .c6
hospital rclcrral rcgions lor scrviccs providcd during thc last two ycars ol
lilc. !npaticnt carc intcnsity was grcatcst in thc Ncwark, Ncw ]crscy, rcgion,
whcrc thc HC! indcx was ncarly doublc thc national avcragc. Paticnts living
thcrc avcragcd almost vc wccks in thc hospital and cxpcricnccd on avcragc
6 inpaticnt physician visits ovcr thcir nal two ycars ol lilc. !n Los Angclcs
and Miami, thc HC! indiccs wcrc about c abovc thc national avcragc,
Mcdicarc cnrollccs spcnt about : days in thc hospital ovcr thc last two ycars
ol lilc and incurrcd morc than c inpaticnt physician visits. Tc indcx lor
ctroit was about : abovc avcragc, and paticnts thcrc cxpcricnccd :. days
in thc hospital and o physician visits. For Clcvcland, 8oston, San Francisco,
and 8altimorc, it was ncar thc national avcragc, paticnts living thcrc avcragcd
about :c days in hospital and about . inpaticnt physician visits pcr paticnt.
Tc indcx lor cnvcr and Minncapolis was about : bclow thc national
. :vbic~i v~vi~)iox
avcragc, and paticnts spcnt on avcragc . days in thc hospital and incurrcd
about : physician visits. Hcalth carc in Portland, rcgon, and Salt Lakc
City, Utah, was at thc low cnd ol thc carc intcnsity spcctrum: thc HC! indcx
was, rcspcctivcly, 6 and o bclow thc national avcragc, and on avcragc,
paticnts spcnt about .: days in thc hospital and cxpcricnccd .6 inpaticnt phy
sician visits during thc last two ycars ol lilc.
Vcrc rcsidcnts ol Ncwark bcing givcn morc carc bccausc thcy wcrc sickcr:
Ccrtainly a largc scgmcnt ol thc citys population is impovcrishcd, uninsurcd,
and black, thrcc charactcristics that oltcn go hand in hand with poor hcalth
outcomcs. And whilc mortality ratcs wcrc highcr in Ncwark than in othcr
parts ol thc country, rcmcmbcr that wc wcrc comparing only thc pcoplc who
dicd. vcn pcoplc who livc in Grand ]unction, Colorado (onc ol thc hcalthicr
rcgions ol thc Unitcd Statcs), who wcrc sucring lrom chronic illncss in
thc two ycars lcading up to thcir dcath wcrc vcry sick indccd. Furthcrmorc,
cvcryonc in our samplc had at lcast thc basic Mcdicarc insurancc covcragc,
and wc adjustcd lor racial, agc, and gcndcr dicrcnccs and dicrcnccs in thc
lrcqucncy ol chronic illncss in our calculations, allowing us to comparc utili
zation mcasurcs across divcrsc rcgions.
8ox o... How the Hospital Care Intensity (HCI) Index Is
Constructed
Tc HC! indcx is a summary mcasurc ol thc intcnsity ol inpaticnt
carc. !t is bascd on two supplyscnsitivc utilization mcasurcs: thc avcr
agc numbcr ol days paticnts spcnt in hospital and thc avcragc numbcr
ol physician visits paticnts cxpcricnccd. Tcsc arc highly corrclatcd
with hospital bcds, physician supply, and Mcdicarc spcnding but
arc not biascd by dicrcnccs across rcgions in priccs or in thc way
Mcdicarc pays lor its scrviccs. Tc indcx is computcd as thc avcragc
ol two ratios: thc ratio ol thc numbcr ol inpaticnt days in a rcgion or
hospital cohort, comparcd to thc national avcragc, and thc ratio ol
thc numbcr ol inpaticnt physician visits pcr paticnt, also comparcd to
thc national avcragc. Tc HC! indcx can bc calculatcd lor any cohort
ol paticnts and lor any xcd intcrval ol timc. !n thc cxamplcs in this
chaptcr, thc HC! indcx is constructcd lor cohorts ol chronically ill
paticnts during sixmonth intcrvals prior to dcath and during thc last
two ycars ol lilc.
cnvoxic iiixvss ~xb vv~c)icv v~vi~)iox .
vidcncc to support our contcntion that thcsc dicrcnccs in thc intcnsity
ol carc dclivcrcd arc not a rccction ol rcgional dicrcnccs in illncss in thc
population can bc sccn in thc lact that it docs not mattcr which spccic
chronic illncsscs paticnts havc. Tc pattcrn is consistcnt across virtually all
chronic illncsscs in any givcn rcgion comparcd to anothcr. As wc saw in thc
last chaptcr, lor ncarly thrcc dccadcs hospitalization ratcs lor a numbcr ol
chronic illncsscs in highbcddcd 8oston wcrc unilormly clcvatcd ovcr thc
ratcs lor lowbcddcd Ncw Havcn, crcating thc mcdical signaturc. !n othcr
words, consistcnt with our thcory rcgarding thc thrcshold ccct that capac
ity cxcrts on clinical dccision making, a rcgions pattcrn ol carc lor onc typc
ol paticntsuch as canccr paticntstcnds to bc similar lor othcr typcs ol
chronic illncss, such as congcstivc hcart lailurc (CHF) or chronic obstructivc
pulmonary discasc (CP). Tis turns out to bc a gcncral phcnomcnon,
typical ol hcalth carc across thc cntirc Unitcd Statcs. Among thc .c6 hospital
rclcrral rcgions, thosc with a low HC! indcx lor onc chronic condition havc
low HC! indiccs lor othcr chronic conditions, and vicc vcrsa. !n thc casc ol
Ncwark, lor cxamplc, paticnts with canccr wcrc as likcly to cxpcricncc morc
days in thc hospital with multiplc physician visits as paticnts with chronic
hcart lailurc. !n Minncapolis, just thc oppositc was thc casc.
Tc national pattcrn ol variation lor paticnts with common chronic
illncsscs is illustratcd in Figurc o... !t docs not mattcr which chronic condi
tion a paticnt hasin a givcn rcgion (and hospital), thc propcnsity to usc
inpaticnt carc in managing scvcrc chronic illncss is thc samc, as illustratcd by
thc strong corrclation bctwccn thc HC! indcx lor paticnts with canccr and
o.
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Figurc o... Tc association bctwccn thc intcnsity ol inpaticnt carc mcasurcd by
thc HC! indcx lor paticnts with sclcctcd chronic illncsscs during thc last two ycars
ol lilc among hospital rclcrral rcgions (dcaths occurring :cc. through :cc). CHF,
congcstivc hcart lailurc, CP, chronic obstructivc pulmonary discasc. (Sourcc:
artmouth Atlas Projcct databasc.)
.6 :vbic~i v~vi~)iox
paticnts with CHF, and lor paticnts with canccr and paticnts with CP.
Tc samc is truc lor othcr chronic illncsscs. For cxamplc, thc HC! indcx lor
CP and CHF is highly corrclatcd (R
2
- c.o.).
Tc samc story holds lor paticnts with dicrcnt sociocconomic charac
tcristics. ]ust as wc had sccn in thc .ocs lor 8oston and Ncw Havcn, thc
pattcrn ol variation indicatcs a systcmslcvcl or rcgionallcvcl ccct that
inucnccs thc amount ol carc, indcpcndcnt ol lactors associatcd with thc
lcvcl ol illncss. 8lacks consistcntly rcccivc morc carc than othcrs living within
thc samc rcgion, cvcn altcr adjusting lor agc, scx, and illncss. For cxamplc,
blacks in Ncwark, Los Angclcs, ctroit, 8altimorc, Atlanta, and Minncapolis
all spcnd . to morc days in thc hospital and incur : to 66 morc
inpaticnt visits than do thosc ol othcr racial backgrounds (Tablc o..). 8ut
thc tablc makcs two othcr important points. First, thc intcnsity ol inpaticnt
carc lor blacks varics substantially among major mctropolitan arcas. Tis is so
cvcn lor citics that havc a high proportion ol blacks such as Ncwark, ctroit,
8altimorc, and Atlanta. 8lacks in Ncwark spcnt morc days in thc hospi
tal than thcir countcrparts in ctroit, . morc than in 8altimorc, and
Tablc o... Usc ol Acutc Carc Hospitals by 8lacks and Nonblacks Living in Sclcctcd
Hospital Rclcrral Rcgions uring thc Last Two Ycars ol Lilc
Region
Percent Black
Days in Hospital Inpatient Visits
Black Nonblack Black Nonblack
Ncwark :. .. ...
Manhattan . . ... .
Los Angclcs .c .o : o :
Miami . : 6
Philadclphia . .. : 6
Chicago . .: :6 o
St. Louis .c :o :c . ..
8altimorc :c : .o o .
Atlanta .6 :6 . ..
Clcvcland .: : .o .c
8oston . : :c c .
San Francisco .c : . c ..
ays in hospital pcr .,ccc and inpaticnt visits pcr paticnt, data arc lor chronically ill paticnts who
dicd :cc. to :cc and arc agc, scx, and illncss adjustcd.
Source: artmouth Atlas Projcct databasc.
cnvoxic iiixvss ~xb vv~c)icv v~vi~)iox .
morc than in Atlanta. Sccond, thc samc pattcrn ol variation is occurring lor
thosc ol othcr racial backgrounds (thc majority ol whom in most rcgions
arc whitc
4
). Nonblacks living in Ncwark spcnt ., 6., and morc days
in thc hospital than thosc in, rcspcctivcly, ctroit, 8altimorc, and Atlanta.
!ndccd, thc rcgional dicrcnccs arc so pronounccd that nonblacks in Ncwark
and Los Angclcs rcccivc morc carc than blacks in Atlanta.
Nationally, a consistcnt pattcrn was sccn among thc .c6 hospital rclcrral
rcgions (Figurc o.:). Tc HC! indcx lor blacks tcndcd to bc about thc samc
as it was lor thc othcr scgmcnts ol a rcgions population (as indicatcd by
thc clustcring ol dots along thc dcgrcc linc), cvcn though within a givcn
rcgion, blacks tcndcd to usc about morc inpaticnt carc. Tc samc pattcrn
was sccn lor Mcdicaid (lowincomc) paticnts comparcd to nonlowincomc
paticnts living in thc samc rcgion.
Finally, as discascs progrcss, thc pattcrn ol carc dclivcrcd in dicrcnt
rcgions is consistent over time. As ! showcd in Chaptcr , whcn wc lollowcd
paticnts with hip lracturc, hcart attack, and colon canccr ovcr sixmonth
pcriods ol timc, hospitalization ratcs wcrc consistcntly highcr lor rcsidcnts
ol 8oston during cach sixmonth pcriod ol lollowup altcr dischargc lrom
thc initial hospitalization. Vc now havc data to show that consistcncy ovcr
timc in thc rclativc intcnsity ol carc lor supplyscnsitivc carc is typical ol
thc cntirc nation. Using artmouth Atlas Projcct data, wc lollowcd paticnts
with chronic illncss back in timc lrom dcath in sixmonth intcrvals and
Figurc o.:. Tc association bctwccn thc intcnsity ol inpaticnt carc mcasurcd by
thc HC! indcx lor Mcdicarc paticnts according to povcrty status (Mcdicaid buyin
paticnts vcrsus all othcrs) (left) and racc (black vcrsus all othcrs) (right) during thc last
two ycars ol lilc among hospital rclcrral rcgions (dcaths occurring :cc. through :cc).
(Sourcc: artmouth Atlas Projcct databasc.)
R
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HC! indcx among Mcdicaid paticnts HC! indcx among black paticnts
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corrclatcd thc HC! indcx in months c through 6 prcccding dcath with thc
HC! indcx in months to .:, .. to ., and .o to :. Vc lound a strong corrcla
tion within rcgions in thcir pattcrns ol carc bctwccn cach sixmonth intcrval,
cvcn though paticnts who wcrc lurthcr lrom dcath wcrc, on avcragc, lcss
scvcrcly ill. Figurc o.. illustratcs thc closc corrclation bctwccn lrcqucncy ol
carc among rcgions during thc last six months ol lilc (mcasurcd by hospital
ization and inpaticnt physician visits) and lrcqucncy ol carc bctwccn months
.o and : bclorc dcath. Tat paticnts wcrc lcss ill during this carlicr pcriod
is rccctcd in thc lact that hospitalization and physician visits wcrc roughly
. to timcs lowcr than during thc last six months ol lilc. 8ut thc variation
in ratcs among rcgions was striking during both pcriods ol timc, and it was
highly corrclatcd.
Physicians and hospital administrators havc lound it di cult to acccpt
that similarly ill paticnts can rcccivc such dicrcnt amounts ol carc, dcpcnd
ing on whcrc thcy livc, and somc arguc that thc variation must somchow bc
cxplaincd by dicrcnccs in illncss, dcspitc all our corts to account lor that
possibility. ! will addrcss this argumcnt shortly. 8ut rst ! want to cxaminc
a criticism madc by Pctcr 8ach and his collcagucs in a :cc articlc in thc
Journal of the American Medical Association.
providc an cxamplc: a typical paticnt ycars ol agc who is ncwly
diagnoscd with advanccd (stagc ) canccr ol thc colon livcs about vc
months altcr diagnosis. Spcnding calculatcd according to thc cohort
mcthod yiclds an accuratc cstimatc ol thc cost ol managing dying
paticnts bccausc it is calculatcd by mcasuring pcr capita spcnding pcr
paticnt month ol survival altcr diagnosis. Tis is a much highcr csti
matc lor thc cost ol dying lrom stagc lour canccr ol thc colon ovcr
timc than would bc casc il spcnding wcrc bascd on thc last ycar ol
lilc, whcrc only vc ol thc twclvc months ol lollowback would bc lor
thc timc whcn thc paticnt was actually sick with canccr. 8y contrast,
thc typical paticnt with thc samc diagnosis who is 6 ycars ol agc
livcs longcrthc authors cstimatc clcvcn monthsso thcir accumu
latcd cxpcnditurcs ovcr thc last ycar ol lilc arc considcrably grcatcr,
not ncccssarily bccausc thcy wcrc trcatcd morc intcnscly during thc
ycar prcccding dcath, but bccausc thcy livcd longcr altcr bcing diag
noscd. Tus studics using thc lollowback lrom dcath mcthod might
crroncously bc intcrprctcd as showing agcrclatcd bias: much lowcr
spcnding lor oldcr paticnts that in rcality rcccts lilc cxpcctancy dil
lcrcnccs, not carc intcnsity dicrcnccs.
.c :vbic~i v~vi~)iox
How do wc dclcnd thc artmouth usc ol lollowback lrom dcath studics:
First and most important, our rcsults adjust lor thc diagnosis ol thc paticnt,
which can acct prognosis, as wcll as agc, scx, and racc. !l in somc rcgions
pcoplc arc morc likcly to dic lrom discascs with a vcry poor prognosis (which
could mcan that thcy arc sick and in nccd ol trcatmcnt lor a shortcr portion
ol thcir last two ycars), thcn our mcasurcs ol utilization and spcnding arc
adjustcd lor thosc dicrcnccs. Finally, it is important to notc that whcn wc
usc thc gold standard cohort mcthod to lollow paticnts with hcart attacks,
hip lracturc, colon canccr, and othcr conditions lor which wc arc rcasonably
ccrtain wc can idcntily thc initial (indcx) hospitalization, wc nd virtually
thc samc pattcrn ol variation in utilization among rcgions ovcr thrcc ycars ol
lollowup as wc do using thc lollowback lrom dcath mcthod.
6
What Is the Prevalence of Chronic Illness, and How Does Tis Inuence
Regional Variation in Per Capita Utilization and Spending?
Lct mc now turn to thc qucstion ol thc rolc ol illncss as a drivcr ol variation
in utilization and spcnding among rcgions. Tc Fowlcr intcrvicw studics in
\crmont cstablishcd that paticntrcportcd illncss ratcs wcrc not vcry dicr
cnt lrom onc \crmont community to anothcr, and that illncss was thcrclorc
not likcly to bc an important lactor in thc twolold or grcatcr variation in
ratcs ol hcalth carc utilization in \crmont. Vhcn wc cxtcndcd thc scopc
ol our study to a national scalc, wc uscd thc Mcdicarc Currcnt 8cncciary
Survcy (MC8S), which asks paticnts to ratc thcir hcalth carc along a scalc
lrom poor to cxccllcnt. !n a study rcportcd in thc .ooo artmouth Atlas,
7
wc lound that sickcr paticnts uscd morc hospital carc, thosc rcporting poor
hcalth status spcnt :. timcs morc days in hospital on avcragc than thosc
rcporting thcmsclvcs to bc in cxccllcnt hcalth. 8ut what was intcrcsting
was that, just as wc saw in \crmont, thcrc was littlc corrclation bctwccn thc
pcrccntagc ol Mcdicarc cnrollccs who rcportcd thcy wcrc in poor, good, or
cxccllcnt hcalth, and thc numbcr ol hospital bcds in thcir rcgions. Finally,
wc cstimatcd thc nccd lor hospital bcds in a rcgion according to how sick
paticnts wcrc.
8
Tcrc was virtually no dicrcncc in thc prcdictcd nccd lor
hospital bcds among thc dicrcnt rcgions bascd on rcportcd lcvcl ol illncss
ol Mcdicarc cnrollccs. 8ut thcrc was a lot ol variation in both thc supply ol
bcds and thc ratcs at which thcy wcrc actually uscd. Survcy rcspondcnts who
livcd in thc lowcstbcddcd rcgions (lcss than :.o bcds pcr .,ccc), had, bascd
on illncss lcvcl, a prcdictcd usc ol :.: hospital days pcr pcrson, and an actual
usc ol only ..6 days. Tosc living in thc highcstbcddcd rcgions (morc than
cnvoxic iiixvss ~xb vv~c)icv v~vi~)iox ..
..o bcds pcr .,ccc) had thc samc prcdictcd usc:.: days pcr .,cccbut an
actual usc ol :.6 days, ..6 timcs grcatcr than thosc living in thc lowcstbcddcd
rcgion. Tis is not mcant to suggcst that avcragc utilization ratcs arc thc samc
as optimum utilization, sincc thcrcs virtually no scicncc to show which ratc is
right. Vhat thcsc dicrcnccs do say is that thc supply ol bcds has a powcrlul
ccct on hospitalization, rcgardlcss ol how sick paticnts arc.
Vhat about Mcdicarc spcnding pcr capita, hospital carc intcnsity, and
thc prcvalcncc ol chronic illncss: Not surprisingly, spcnding gocs up whcn
utilization and intcnsity ol carc go up. Spcnding in :cc varicd morc than
:.lold among thc .c6 hospital rclcrral rcgions, lrom an annual avcragc ol
s,:. in Rapid City, South akota, to s.,.o in thc Miami, Florida, rcgion.
Tc variation in spcnding was csscntially uncorrclatcd with thc ratcs ol such
prclcrcnccscnsitivc scrviccs as clcctivc surgcry. Tc primary clinical drivcr
ol variation in ovcrall Mcdicarc spcnding among rcgions is thc intcnsity
ol thc usc ol supplyscnsitivc carc, particularly thc usc ol acutc carc hospi
tals lor paticnts with chronic illncss. !npaticnt carc intcnsity lor thosc with
chronic illncss, as mcasurcd by thc HC! indcx during thc last two ycars ol
lilc, cxplains about 6 ol thc variation in pcr capita Mcdicarc spcnding, at
lcast lor lcclorscrvicc paticnts (Figurc o., lclt).
8y contrast, thc prevalence ol chronic illncss cxplains vcry littlc ol thc var
iation in Mcdicarc spcnding. !n thc :cc cdition ol thc artmouth Atlas,
9
wc showcd that thc prcvalcncc ol scvcrc chronic illncss, mcasurcd by thc
Figurc o.. Tc association bctwccn pcr capita spcnding undcr traditional Mcdicarc
(:cc.) and thc hospital carc intcnsity (HC!) indcx mcasurcd ovcr thc last two ycars
ol lilc (left) and thc prcvalcncc ol scvcrc chronic illncss (:cc: through :cc.) (right).
(Sourcc: artmouth Atlas Projcct databasc.)
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pcrccntagc ol Mcdicarc cnrollccs who wcrc in thcir last two ycars ol lilc,
varicd substantially lrom rcgion to rcgion, ranging lrom . ol Mcdicarc
lcclorscrvicc cnrollccs living in Honolulu, Hawaii, to ...6 lor thosc liv
ing in Slidcll, Louisiana. Sickcr rcgions tcnd to spcnd morc: prcvalcncc ol
chronic illncss accounts lor about a s.,cc pcr capita dicrcncc in spcnding
bctwccn rcgions whcrc paticnts arc thc sickcst comparcd to rcgions whcrc
paticnts arc thc hcalthicst. But only a small proportion of the 2.7-fold variation
in Medicare per capita spending in 2005about 3was associated with vari-
ation in the prevalence of chronic illness (scc Figurc o., right). !n othcr words,
sickncss docs not cxplain thc variation in spcnding.
Do Tose Who Get More Care Actually Want More Care?
Nonc ol thc studics rcvicwcd so lar in this chaptcr havc addrcsscd dircctly
thc qucstion ol paticnt prclcrcnccs lor carc at thc cnd ol lilcthc dcsirc ol
paticnts and lamilics lor a pcacclul passing, as lrcc lrom pain as possiblc,
on thc onc hand, or to havc cvcrything possiblc donc to postponc dcath. !n
considcring thc issuc ol intcnsity ol cnd ol lilc carc, it is important to rcalizc
that such carc is managcd vcry dicrcntly lrom onc rcgion to anothcr. For
cxamplc, lor dcaths among paticnts with chronic illncss occurring in :cc
among thc .c6 hospital rclcrral rcgions, thc intcnsity ol tcrminal carc, mca
surcd by thc pcrccntagc ol paticnts whosc dcath was associatcd with a stay in
an intcnsivc carc unit, varicd morc than :.lold, lrom .: in Minncapolis,
Minncsota, and cs Moincs, !owa, to .c in Los Angclcs, Calilornia, and
Ncw 8runswick, Ncw ]crscy.
Such dicrcnccs raisc a numbcr ol qucstions ol prolound importancc to
paticnts and thcir lamilics. o paticnts and lamilics want morc carc: o
thcy want physicians to cxhaust all rcmcdics as thc paticnt approachcs dcath:
r would thcy rathcr dic at homc or in somc othcr lamiliar placc with lots
ol lamily support: Pcrhaps most important, do paticnts gct thc carc thcy
prclcr:
Tc answcr to this last qucstion is that thcy may not. For mc, thc most
convincing cvidcncc comcs lrom a largcscalc intcrvcntion study lundcd by
thc Robcrt Vood ]ohnson Foundation that bccamc known by its acronym,
as thc SUPPRT study.
!0
Tc lcvcl ol carc intcnsity that paticnts prclcrrcd
at thc cnd ol lilc was lcss than thc amount actually providcd, cvcn altcr an
cxtcnsivc cort was madc both to cstablish how intcnscly individual paticnts
with a high probability ol dying actually wantcd to bc trcatcd and to cnsurc
that providcrs kncw thcir paticnts wishcs.
cnvoxic iiixvss ~xb vv~c)icv v~vi~)iox ..
Hcrc arc somc ol thc dctails. !n thc carly .oocs, hcalth scrviccs rcscarchcrs
8ill Knaus and ]oannc Lynn organizcd thc SUPPRT study to improvc cnd
ol lilc carc at vc major tcaching hospitals (locatcd in vc dicrcnt hospital
rclcrral rcgions). Tc rst phasc ol thcir study documcntcd shortcomings in
clinical carc at thcsc hospitals. Paticnts oltcn cxpcricnccd unncccssary pain
and thcir physicians wcrc oltcn unawarc ol paticnts prclcrcnccs with rcgard
to cnd ol lilc carc, including cardiorcsuscitation. Advanccd planning lor cnd
ol lilc carc was clcarly inadcquatc. Tc sccond phasc ol thc study consistcd ol
an intcrvcntion to improvc carc.
!!
Tc hypothcsis was that providing paticnts
and lamilics with inlormation about paticnt prognosis and improving com
munication among paticnts, physicians, nurscs, and lamily mcmbcrs would
lcad to cnd ol lilc carc dccisions that promotcd paticnt prclcrcnccs and
autonomy.
Tc study rcsults wcrc dccply disappointing. Knaus and Lynns conclu
sion, publishcd in Novcmbcr ol .oo in the Journal of the American Medical
Association, camc as a shock to many advocatcs lor thc rclorm ol cnd ol
lilc carc:
Tc intcrvcntion lailcd to improvc carc or paticnt outcomcs.
nhancing opportunitics lor morc physicianpaticnt communication,
although advocatcd as thc major mcthod lor improving paticnt out
comcs, may bc inadcquatc to changc cstablishcd practiccs. To improvc
thc cxpcricncc ol scriously ill and dying paticnts, grcatcr individual and
socictal commitmcnt and morc proactivc and lorcclul mcasurcs may
bc nccdcd.
nc mark ol lailurc was thc study intcrvcntions lack ol impact on improv
ing compliancc with thc paticnts prclcrcncc to dic at homc. Among thc
paticnts who indicatcd that thcy prclcrrcd to dic at homc, thc majority, ,
actually dicd in thc hospital. At thc samc timc, thosc who wantcd to dic in
thc hospital oltcn did not, lcss than hall (6) ol thosc who prclcrrcd to dic
in thc hospital actually did.
!2
8ut thc chanccs ol dying in thc hospital varicd
strikingly among thc vc tcaching hospitals, ranging lrom :6 to 66 ol
dcaths.
!n a subscqucnt analysis, Rob Pritchard and his artmouth collcagucs
providcd an cxplanation lor thc variation.
!1
!n multivariatc analyscs, thcy
showcd that thc supply ol hospital bcds in thc rcgion whcrc thc hospitals
participating in thc SUPPRT study wcrc locatcd was highly prcdictivc ol
thc chancc that a paticnt participating in thc SUPPRT would dic in thc
. :vbic~i v~vi~)iox
hospital, cvcn altcr claboratc stcps had bccn takcn to cnsurc that paticnt
prclcrcnccs wcrc rcspcctcd. (Tis was cspccially thc casc whcn thcy mcasurcd
thc actual usc ol thcsc bcds bascd on thc avcragc numbcr ol occupicd bcds or
paticnt days ol carc.) !n othcr words, thc capacity ccct sccmcd to dominatc
clinical dccision making, dcspitc paticnt prclcrcnccs. Tc association bctwccn
paticnt days ol carc and placc ol dcath is cvidcnt in Figurc o..
!t is ol coursc quitc possiblc that paticnt prclcrcnccs as statcd at onc point
in timc in thc coursc ol a scrious illncss might changc, oncc dcath is ncar,
a paticnt might bccomc a strong advocatc lor thc morc is bcttcr assump
tion. At thc minimum, howcvcr, wc lcarncd lrom thc SUPPRT study that
paticnt prclcrcnccs lor placc ol dcath, statcd at a point in timc whcn thcy
wcrc alrcady scriously ill lrom a condition that soon provcd latal, did not
prcdict thc actual placc ol dcath.
Givcn thc supplyscnsitivc naturc ol such carc, it is hard to addrcss thc
qucstion ol cnd ol lilc carc outsidc ol thc gcncral contcxt ol how intcnscly
physicians usc thc acutc carc hospital in managing chronic illncss. As wc
havc sccn, carc during thc tcrminal phasc ol lilc is part ol thc ovcrall pattcrn
Figurc o.. Tc association bctwccn ovcrall usc ol hospitals mcasurcd by hospital
days ol carc and thc pcrccntagc ol dcaths in thc rcgion that occurrcd in hospitals. Tc
vc largc circlcs indicatc thc rcgions in which thc vc hospitals participating in thc
SUPPRT clinical trial arc locatcd. (Sourcc: Pritchard, R. S., . S. Fishcr, ]. M. Tcno,
ct al. .oo. !nucncc ol paticnt prclcrcnccs and local hcalth systcm charactcristics on
placc ol dcath. Journal of the American Geriatrics Society 6:.::.:c. Rcproduccd with
thc pcrmission ol thc Journal of the American Geriatrics Society, ]ohn Vilcy & Sons
Ltd., publishcrs.)
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ol usc ol inpaticnt carc in managing chronic discasc. Tc timc ol dcath can
not bc prcdictcd vcry accuratcly, so cvcn il paticnts and physicians agrcc in
thcory on thc coursc ol tcrminal carc, thosc using hospitals with a habitual
pattcrn ol highcr carc intcnsity will dic morc oltcn in an intcnsivc carc unit
than thosc using hospitals with lowcr carc intcnsity, simply bccausc ol dil
cultics in knowing whcn dcath is likcly to occur. Tc Pritchard rcanalysis ol
thc SUPPRT data supports this intcrprctation. Reducing exposure to high
intensity, futile care at the end of life will require paying attention to reducing the
overuse of acute care hospitals in managing acute and chronic illness over the course
of the patients illness, not just at the end of life.
Tcsc ndingsthat paticnt wishcs arc trumpcd by practicc pattcrns and thc
supply ol rcsourccshavc prolound implications lor both hcalth carc policy
and lor paticnts livcs. !n Chaptcr .c, ! will discuss cvidcncc that appcars to
show that grcatcr carc intcnsity may not only bc wastclul but also bc harmlul.
Tis would suggcst that paticnts with chronic illncss should bc cncouragcd
to scck carc lrom hospitals with low carc intcnsity scorcs on thc HC! scalc,
with good tcchnical quality mcasurcs, and with high satislaction ratings lrom
thosc who usc thcm. As wc will scc in subscqucnt chaptcrs, thc wastc and
harm in thc currcnt systcm bchoovc policy makcrs to comc up with rclorms
that will spur providcrs with cvidcncc ol ovcrusc to achicvc thc bcnchmarks
lor c cicncy ol such hospitals.
.6
For paticnts with chronic illncss, gcography mattcrs. cpcnding on whcrc
thcy livc, and which hospital or hcalth carc organization thcy arc loyal to,
thcy rcccivc vcry dicrcnt lcvcls ol carc. Tc lcvcl varics with thc availability
ol rcsourccs. Supplyscnsitivc carc providcd to chronically ill Amcricans
primarily visits to physicians, hospitalizations lor mcdical conditions, usc ol
cxtcndcd carc lacilitics, and homc hcalth agcncy scrviccsaccounts lor wcll
ovcr c ol Mcdicarc spcnding. \ariation in thc usc ol acutc carc hospitals
by thosc with chronic illncss is thc primary rcason lor thc morc than twolold
variation in spcnding among rcgions ol thc country in Mcdicarc pcr capita.
Tis much wc know.
But is more care better: o Mcdicarc paticnts living in rcgions with highcr
pcr capita spcnding that dclivcr grcatcr amounts ol supplyscnsitivc carc havc
bcttcr outcomcs than thosc living in rcgions whcrc thcy rcccivc lcss carc: o
thcy livc longcr bccausc thcy rcccivc morc scrviccs: !s thc quality ol thcir carc
bcttcr: Arc thcy morc satiscd with thcir carc:
conomists would say that thcsc arc all qucstions about marginal valuc,
and onc way to think about thc marginal valuc ol thc incrcascd usc ol hcalth
carc is with a graph. Figurc .c.. will bc instantly lamiliar to hcalth carc policy
analysts. Supposc that all rcgions ol thc Unitcd Statcs could bc dcscribcd by
an association bctwccn hcalth carc inputs (on thc horizontal axis) and hcalth
outcomcs (on thc vcrtical axis). !n thc convcntional vicwpoint, spcnding
.c
Is More Better?
is :ovv nv))vv- .
morc gcts us bcttcr hcalth. Lcts call this Sccnario .. So il wc comparc, say,
Minncapolis (which might lall on thc curvc at Point A) and Miami (Point
8), wc should obscrvc bcttcr hcalth outcomcslongcr survival, bcttcr lunc
tioning, and grcatcr satislactionin Miami. Vhilc wc might scc diminish
ing marginal rcturns lor cach additional hcalth carc dollar spcnt, as long as
spcnding is costccctivc on avcragc, wc would cxpcct that thc highcr spcnd
ing in Miami (Point 8) would bc worth it in thc scnsc ol providing additional
hcalth bcncts at a rcasonablc cost. Furthcrmorc, thc implication lor hcalth
carc policy would bc that valuablc hcalth carc is bcing withhcld or rationcd
in Minncapolis, cvcn il thc clinicians thcrc arc not awarc ol it.
An altcrnativc sccnario, lcts call it Sccnario :, is that Minncapolis is
locatcd at point 8, and Miami is locatcd at point C. Now, Miami still providcs
morc carc lor similarly ill paticnts. Undcr this sccnario, thcrc is no rationing
ol valuablc carc, but incrcmcntal incrcascs in carc intcnsity (and spcnding)
bring no gain in hcalth outcomcs. Tis might occur, lor cxamplc, bccausc thc
potcntial gains lrom incrcascd ratcs lor hospitalizing chronically ill paticnts
arc osct by advcrsc cvcnts such as a scrious hospitalacquircd, drugrcsistant
inlcction. Tis sccnario corrcsponds to what Alain nthovcn, thc Stanlord
Univcrsity hcalth carc cconomist, has callcd at ol thc curvc mcdicincthc
incrcmcntal hcalth gains lrom spcnding morc on hcalth carc arc csscntially
zcro.
!
Tc associatcd policy prcscription is that simply cutting back on hcalth
carc utilization in highcost rcgions likc Miami would yicld substantial cost
savings, and at no cost to paticnt outcomcs.
Figurc .c... Rclationship bctwccn hcalth carc inputs and hcalth outcomcs:
hypothctical curvc !.
A
8
C
Better
Sccnario + and :
Health
outcomes
Health care inputs
Worse
Low High
. :vbic~i v~vi~)iox
Tc problcm with Sccnarios . and : is that ncithcr sccms to t thc lacts.
As ! dcscribc latcr, thcrc is growing cvidcncc ol a small but negative asso
ciation bctwccn hcalth carc intcnsity and hcalth outcomcs mcasurcd in tcrms
ol survival. Undcr Sccnario ., physicians do not knowingly cxposc thcir
paticnts to harm, yct thc incidcncc ol mcdical crrors and othcr unintcndcd
conscqucnccs ol incrcascd trcatmcnts cxcccd any bcnct lrom incrcascd carc
intcnsity. Figurc .c.:, which is not so lamiliar to hcalth policy analysts, allows
lor ncgativc marginal rcturns lrom thc incrcascd usc ol hcalth carc. Undcr
Sccnario ., Minncapolis might bc at point C, and Miami at point whcrc
morc carc indicatcs worsc outcomcs and highcr costs. !n this casc, thc policy
prcscription is a nobraincrby rcducing thc intcnsity ol carc in highratc
rcgions, wc could rcducc thc risk lor iatrogcnic illncss by lowcring thc cxpo
surc ol thc population to hospitalization and othcr intcrvcntions pronc to
mcdical crror.
My collcaguc ]onathan Skinncr has drawn my attcntion to anothcr intcr
prctation ol thc obscrvcd ncgativc corrclation bctwccn cxpcnditurcs and
hcalth outcomcs: that is, at any givcn point in timc, two rcgions arc on dil
lcrcnt production lunctions (Sccnario ). Tus, in Figurc .c.., Point cor
rcsponds to Minncapolis on PF(.), and Point F to Miami on PF(:). Vhat is
mcant by a dicrcnt production lunction: !n its simplcst lorm, it might bc
that pcoplc in Miami arc intrinsically sickcr than thcir cldcrly countcrparts
in Minncapolis, thus, lor a givcn lcvcl ol spcnding, wc would cxpcct to nd
thosc in Miami to larc lcss wcll bccausc thcy sucr lrom (lcts say) morc
chronic discasc. Howcvcr, artmouth studics havc bccn carclul to control lor
this sourcc ol bias, whcthcr by locusing only on pcoplc with hcart attacks or
hip lracturcs and controlling lor comorbiditics and othcr lactors that would
acct thcir lcvcl ol sickncss at basclinc or by controlling lor thc typc and
naturc ol chronic illncss.
Tcrc could bc anothcr rcason lor highintcnsity, pooroutcomcs rcgions
to bc on a lowcr production curvc whcrc it takcs many morc inputs to achicvc
morc bcnct: thc organization ol hcalth carc in Miami may bc lcss c cicnt.
Providcrs may bc ncglccting to providc low cost but highly ccctivc trcat
mcnts, or paticnts may bc subjcctcd to crrors ol omission or commission
bccausc ol poorly coordinatcd carc. For cxamplc, onc rcccnt study lound
that most ol thc hospitallcvcl dicrcncc in survival lollowing a hcart attack
could bc cxplaincd by dicrcnccs in thc usc ol incxpcnsivc yct highly ccc
tivc trcatmcnts such as bctablockcrs and aspirin.
2
Tus, rcgions or hospitals
with highcr spcnding ratcs could cxpcricncc worsc outcomcs not bccausc ol
thc highcr utilization pcr sc but rathcr bccausc thcy undcrusc ccctivc carc
thcy ncglcct to providc thc aspirin or bctablockcrs in thc rst placc. To put
is :ovv nv))vv- .o
it in thc languagc ol social scicnccs, high spcnding lcvcls and poor outcomcs
may bc thc conscqucncc ol a third lactorpoor organization and systcmic
coordination lailurc, which wc know arc cndcmic in our hcalth carc systcm.
Vc nccd not takc a stand on what causcs whatwhcthcr poor coordination
lcads to an ovcrsupply ol rcsourccs, or ovcrsupply lcads to poor coordination
ol carc. 8oth can bc happcning at thc samc timc. An ovcrsupply ol hospi
tal bcds and intcrlocking nctworks ol spccialists could combinc to gcncratc
both complcx and ovcrlapping hcalth carc trcatmcnt stratcgics, couplcd with
poorly organizcd hcalth carc and worsc outcomcs.
Figurc .c.:. Rclationship bctwccn hcalth carc inputs and hcalth outcomcs:
hypothctical curvc !!.
C
Better
Sccnario :
Health
outcomes
Health care inputs
Worse
Low High
Figurc .c... Rclationship bctwccn hcalth carc inputs and hcalth outcomcs:
hypothctical curvc !!!.
G
F
Better
Sccnario
Health
Outcomes
Health Care Inputs
Worse
Low
Production function +
Production function :
High
.6c :vbic~i v~vi~)iox
Tc important distinction bctwccn this ncw Sccnario and Sccnarios
: and . lics in what it implics, wcrc highintcnsity rcgions to cut back on
scrviccs. !n thc carlicr sccnarios, wc can simply curtail hcalth carc utiliza
tion and gain bcttcr outcomcs, or at lcast no worsc outcomcs, whilc saving
moncy and rcducing thc incidcncc ol mcdical crrors and othcr iatrogcnic
cvcnts by rcducing cxposurc to too much mcdical carc, a winwin situation.
8ut in this lourth sccnario, cutting back on spcnding in Miami at Point F,
on thc lowcr production lunction, would not suddcnly turn disorganizcd
Miami providcrs into highly organizcd group practiccs likc thc Mayo
Clinic. (! will talk morc about thc ccct that organization ol hcalth carc
dclivcry has on thc pattcrns ol practicc and utilization in luturc chaptcrs.)
!nstcad, hcalth outcomcs would likcly dcclinc, pcrhaps to Point G. !n prac
ticc, thc various sccnarios arc not mutually cxclusivcwc could obscrvc
that our third sccnario indicatcs a consistcnt lailurc to providc ccctivc carc
to hcart attack victims, say, whilc Sccnarios : and . indicatc thc ovcrusc ol
supplyscnsitivc carc, particularly inpaticnt carc, lor thosc with acutc and
chronic illncsscs.
ur rcscarch nds support lor both hypothcscs: grcatcr carc intcnsity
is associatcd with highcr mortality ratcs and poorcr objcctivc mcasurcs ol
proccss quality, and organizcd carc systcms arc associatcd with lowcr carc
intcnsity and highcr quality. Lct mc now turn to somc ol thc cvidcncc that
suggcsts whcrc thc Unitcd Statcs currcntly sits on our hypothctical produc
tion lunction curvcs with rcspcct to thc marginal and avcragc valuc ol hcalth
carc spcnding.
Care Intensity and Mortality
Vhcn physicians dclivcr supplyscnsitivc carc, particularly inpaticnt carc,
thcir principal clinical objcctivc is most oltcn a rcduction in mortality. l
coursc that is not always thc casc. Tcy also dclivcr carc to rclicvc sucr
ing and improvc thc quality ol lilc. 8ut most ol thc timc thcy arc trying to
hclp thcir paticnts livc as long as possiblc. (Prclcrcnccscnsitivc carc, by con
trast, is oltcn aimcd at rcducing morbidityimproving thc quality ol lilc.)
Conscqucntly, our tcams rcscarch has conccntratcd on cvaluating thc mar
ginal impact ol supplyscnsitivc scrviccs on survival. Tc stratcgy has bccn
to cxploit thc natural cxpcrimcnts aordcd by thc apparcnt randomncss in
thc lrcqucncy ol usc ol supplyscnsitivc scrviccs, using mcasurcs lor which
a strong a priori argumcnt can bc madc that thc dicrcnccs arc not duc to
dicrcnccs in illncss.
is :ovv nv))vv- .6.
Supplyscnsitivc carc during thc last six months ol lilc has provcd to bc
a rcliablc mcasurc. 8y dcnition, thcsc paticnts arc similar across rcgions in
onc primary indicator ol hcalth statusall arc dcad at thc cnd ol a sixmonth
pcriod ol obscrvation. Tcrc is grcat variation among hospital rclcrral rcgions
in thc intcnsity ol supplyscnsitivc scrviccs dclivcrcd to paticnts during this
pcriod ol thcir livcs. bviously, thc amount ol carc cannot bc uscd to makc
inlcrcnccs about thc outcomcs lor thcsc paticntsall arc dcad. !nstcad, mca
surcs ol intcnsity ol carcpcr capita Mcdicarc spcnding, physician visits,
hospitalizations, and intcnsivc carc unit admissionscan bc uscd to dcnc
whcrc cach rcgion is locatcd along a spcctrum ol carc dclivcry that is not
cxplaincd by illncss dicrcnccs. Tink ol thcsc indicators as a gaugc mca
suring thc propcnsity ol thc providcrs in a rcgion to dclivcr supplyscnsitivc
carc, rcgardlcss ol how ill paticnts arc. !n vicw ol thc high corrclation in carc
intcnsity among rcgions ovcr dicrcnt pcriods ol timc prior to dcath (scc, lor
cxamplc, Figurc o.. in thc prcvious chaptcr), wc considcr carc intcnsity dur
ing thc last six months ol lilc an illncssindcpcndcnt indicator ol a rcgions
tcndcncy to dclivcr morc or lcss carc, not just to its dying paticnts but in lact
to all paticnts with scvcrc chronic illncss.
nc ol our rcscarch goals has bccn to cvaluatc thc powcr ol supply
scnsitivc scrviccs to dccrcasc thc mortality ratcs ol thc rcsidcnt population.
Vc havc undcrtakcn scvcral studics whosc rcsults consistcntly show that, at
bcst, thc Unitcd Statcs is on thc at ol thc hypothctical production lunction
curvcs. Nonc ol our studics havc ocrcd cvidcncc in support ol thc convcn
tional wisdom that morc spcnding and morc utilization ol scrviccs is bcttcr,
at lcast among thc insurcd. My carly rcscarch, which comparcd population
bascd mortality in \crmont,
1
and subscqucnt studics comparing 8oston and
Ncw Havcn,
4
showcd no cvidcncc that carc intcnsity was associatcd with
population mortality ratcs. Anothcr study lound csscntially no association
bctwccn spcnding and outcomcs, thc rcscarchcrs cstimatcd thcsc cccts by
comparing outcomcs lor rcgions cxpcricncing both high and low lcvcls ol
hcalth carc intcnsity, as mcasurcd by physician visits and intcnsivc carc unit
days in thc last six months ol lilc and spcnding lor hcart attack paticnts.
Tis study controllcd lor a battcry ol possiblc lactors that might conlound
thc rcsults such as disability, povcrty, and thc undcrlying incidcncc ol illncss
as mcasurcd by hospitalizations lor hip lracturcs, hcart attacks, colon canccr,
and othcr conditions whosc ratcs ol hospitalization vary littlc, rcgardlcss ol
thc supply ol bcds.
Tc strongcst cvidcncc to datc rcsts in a study by r. lliott Fishcr and
his collcagucs, who uscd thc cohort mcthod to cvaluatc survival up to vc
ycars altcr an initial hospitalization lor hip lracturc, colon canccr rcscction,
.6: :vbic~i v~vi~)iox
or hcart attack.
6
8y linking claims ovcr timc, paticnt comorbidity at thc timc
ol cnrollmcnt in thc study could bc controllcd lor, and thc intcrval to dcath
asccrtaincd lor thosc paticnts who dicd within vc ycars. !t thus bccamc pos
siblc to study paticnts with spccic discascs and to cvaluatc thc marginal
ccct ol incrcasing carc intcnsity on survival whilc controlling lor morbidity
at thc paticnt lcvcl.
!n this study, thc rcscarchcrs uscd a mcasurc ol carc intcnsity thcy callcd
thc nd ol Lilc xpcnditurc !ndcx, which is a priccadjustcd cstimatc
ol Mcdicarc spcnding lor hospitals and physician scrviccs ovcr thc last six
months ol lilc. For cach ol thc thrcc cohorts, thc rcscarchcrs lound a highcr
mortality ratc in high spcnding rcgions. For cxamplc, comparcd to thc lowcst
:c ol rcgions in pcr capita spcnding, survival in thc rcgions ranking in thc
top :c was worsc: mortality lor paticnts who had hip lracturcs was ..o
highcr, and lor colon canccr and hcart attack paticnts, it was .: highcr.
Fishcr and his collcagucs could nd no compcnsating improvcmcnts in thc
quality ol lilc or lunctional status as mcasurcd by thc Mcdicarc Currcnt
8cncciary Survcy, cvcn though Mcdicarc spcnding pcr capita in thc high
cost rcgions was ..6: timcs that ol thc lowcost rcgions.
7
How should thcsc associations bc intcrprctcd: First, it is important to rcc
ognizc thc limitations ol obscrvational studics, cvcn whcn conductcd using
cohort mcthodology. bscrvational studics dcsigncd to cvaluatc thc rclation
ship bctwccn mcdical trcatmcnts and outcomcs arc, by thcir naturc, subjcct
to thc criticism that thc rcsults could bc cxplaincd on thc basis ol an omit
tcd variablcsomc unrccognizcd but noncthclcss important lactor rclatcd
to outcomcs that thc rcscarchcrs lailcd to takc into account. Tc idcal study
dcsign lor dcaling with this problcm is, ol coursc, thc randomizcd clinical
trial (RCT).
8
RCTs arc dcsigncd to tcst wcllspccicd mcdical thcorics and
outcomcslor cxamplc, whcthcr thcrc is a rcduction in vcycar mortality
lrom brcast canccr duc to a ncw canccr trcatmcnt comparcd to usual prac
ticc. 8ut wc could not vcry wcll conduct a classic RCT ol supplyscnsitivc
scrviccs. For onc thing, mcdical thcory rcgarding thc appropriatc lrcqucncy
ol usc is vaguc at bcst, so thcrc is no clcar hypothcsis to bc tcstcd. For anothcr,
thc cvaluation problcm involvcs cstimating thc marginal impact on lilc
cxpcctancy ol varying lcvcls ol lrcqucncy ol carc. !t would bc vcry di cult, to
say thc lcast, to randomizc paticnts to a control and trcatmcnt group whcn
thc group is dcncd by location along a continuum ol varying intcnsity and
whcrc mcmbcrship in a group is bascd on gcographic location.
To gct ovcr thcsc limitations whilc simultancously adhcring as closcly as
possiblc to thc logic ol cxpcrimcntation, our stratcgy has bccn to look lor
natural cxpcrimcnts, to cvaluatc thc outcomcs ol carc among rcgions (and
is :ovv nv))vv- .6.
hospitals) whcrc carc intcnsity varics and whcrc carc intcnsity (thc trcat
mcnt) is not corrclatcd with illncss. ]on Skinncrs skill in thc statistical mcth
ods uscd by cconomists to dcnc and cvaluatc natural cxpcrimcnts has provcd
invaluablc to our progrcss. Hc has shown that carc intcnsity during thc last
six months ol lilc mccts thc critical critcrion lor a good trcatmcnt variablc,
although in somc studics at thc arca lcvcl, modcst corrclations wcrc lound
with prcdictcd mortality.
9
!t is ccrtainly possiblc that thc cvidcncc in support
ol Sccnario . (whcrc morc spcnding rcsults in a dcclinc in hcalth outcomcs)
may bc acctcd by undctcctcd dicrcnccs in illncss among rcgions, although
thc consistcncy ol thc nding ol a positivc association bctwccn highcr carc
intcnsity and highcr mortality (and thc strcngth ol thc paticnt lcvcl cohort
mcthod) rcmains disturbing, cvcn il thc magnitudc ol our ndings is slightly
o. ! do bclicvc, howcvcr, that our ndings tcll us that thc convcntional wis
dom is wrong. Grcatcr carc intcnsity docs not dccrcasc mortality lor thosc
with chronic illncss. Givcn thc conscrvativc naturc ol our mcthods, it sccms
highly unlikcly that thc hypothcsis that grcatcr intcnsity dccrcascs mortality
has bccn mistakcnly rcjcctcd bccausc ol thc inucncc ol unmcasurcd lactors
associatcd with paticnt illncss. For this to happcn, thc distribution ol unmca
surcd illncss would havc to bc largcly, il not almost cntircly, uncorrclatcd with
thc array ol illncss variablcs wc havc uscd in our analyscs. !n othcr words, wc
would havc to havc ignorcd a variablc that has a vcry largc impact on lcvcls ol
illncss in a population but which also shows no corrclation to variablcs that
arc widcly rccognizcd to acct hcalth. For thcsc rcasons wc arc condcnt in
our conclusion that, whcn mortality is thc cndpoint ol carc, thc Unitcd Statcs
is, at bcst, on thc at ol thc curvc.
Is the Quality of Care Better in High-Cost States and Regions?
vcr thc last ltccn or so ycars, conccrns about thc quality ol U.S. hcalth
carc havc locuscd on thc undcrusc ol ccctivc scrviccscvidcnccbascd
intcrvcntions such as lilcsaving mcdications lor hcart attack victims.
Scvcral mcmbcrs ol our rcscarch group bccamc intcrcstcd in looking at
thc association bctwccn Mcdicarc spcnding and undcrusc: o paticnts
living in arcas (or using hospitals) with grcatcr Mcdicarc spcnding and
morc rcsourccs such as mcdical spccialists scorc bcttcr on objcctivc proccss
quality mcasurcs that quantily providcr procicncy in dclivcring ccctivc
carc: Tc rst two studics, undcrtakcn by Kathcrinc 8aickcr and Amitabh
Chandra, comparcd pcrlormancc among thc lty statcs, and among thc .c6
rcgions.
!0
Tc rcsults in both studics wcrc csscntially thc samc, both statcs
.6 :vbic~i v~vi~)iox
and rcgions with highcr lcvcls ol Mcdicarc spcnding had worsc quality
scorcs on mcasurcs ol ccctivc carc. Spcnding morc sccmcd to lcad para
doxically to grcatcr undcrusc. Morcovcr, statcs and rcgions with a prcdomi
nancc ol mcdical spccialists comparcd to primary carc physicians tcndcd to
havc worsc scorcs. As ! will show, such rcgions also havc highcr acutc carc
hospital intcnsity as mcasurcd on thc hospital carc intcnsity (HC!) indcx,
as wcll as highcr costs.
As thc quality movcmcnt has cvolvcd and thc paticnt choicc movcmcnt
has takcn hold, thc Ccntcrs lor Mcdicarc & Mcdicaid Scrviccs (CMS) has
lcd thc way to cnsurc that quality mcasurcs arc availablc to thc public, in thc
hopc that paticnts will bc inucnccd by such inlormation in choosing whcrc
to scck carc. 8cginning in :cc, CMS has postcd hospitalspccic quality
scorcs on its wcbsitc lor hcart attack, pncumonia, and congcstivc hcart lailurc
paticnts. Rcccntly, onc ol our graduatc studcnts, Laura Yasaitis, working with
scvcral laculty mcmbcrs, linkcd this inlormation to thc artmouth Atlas
Projcct databasc to conduct anothcr cxamination ol thc association bctwccn
Mcdicarc spcnding and qualitythis timc at thc individual hospital lcvcl.
!!
Tc rcsults conrmcd thc prcvious nding, hospitals with highcr pcr capita
spcnding, as indicatcd by thcir spcnding lcvcl in managing chronically ill
paticnts during thc last two ycars ol lilc, had worsc quality scorcs lor paticnts
sucring lrom hcart attack and pncumonia. ! will discuss why this could bc
so a littlc lurthcr along in this chaptcr.
What About the Patients Experience?
Tus lar, wc havc not considcrcd thc quality ol carc lrom thc pcrspcctivc ol
thc paticnt. Arc pcoplc living in highcost rcgions, whcrc thcy arc likcly to
rcccivc highintcnsity carc, gctting thc carc thcy want: Vhat about paticnts
who livc in lowcr cost rcgions: o paticnts in highcost rcgions havc bcttcr
acccss to spccialists whcn thcy nccd thcm: Arc thcy happicr with thcir trcat
mcnts, cvcn though, as wc havc shown abovc, objcctivc mcasurcs ol both qual
ity and outcomcsincluding survivalmay bc worsc: ur rcscarch group
rcccntly undcrtook two studics that dircctly mcasurc thc paticnt cxpcricncc.
Tc rst, by ]ack Fowlcr and his collcagucs, was a national intcrvicw study
to cxaminc thc rclationship bctwccn Mcdicarc spcnding and paticnt pcrccp
tions ol thc quality ol thcir carc.
!2
Tc sccond uscd thc rcsults ol a national
survcy ol thc paticnts cxpcricncc to cxaminc thc rclationship bctwccn thc
paticnts pcrccption ol thc quality ol thcir hospital cxpcricncc and thc intcn
sity ol inpaticnt carc as mcasurcd by thc HC! indcx.
!1
8oth studics suggcst
is :ovv nv))vv- .6
that morc carc is not producing morc satiscd or happicr paticnts. Hcrc is a
summary ol what thcsc studics show:
Tc Fowlcr study, publishcd in thc Journal of the American Medical
Association in thc spring ol :cc, intcrvicwcd ovcr :,cc Mcdicarc cnrollccs,
asking thcm to ratc thcir carc as to its quality. Rcsponscs to two ol thc thrcc
rating qucstions showcd no corrclation with rcgional spcnding. Howcvcr, thc
study uncovcrcd a signicant invcrsc rclationship bctwccn Mcdicarc spcnd
ing and thc paticnts global rating ol thcir carc. For cxamplc, 6. ol rcspon
dcnts living in rcgions whcrc Mcdicarc spcnt thc lcast gavc thcir carc a high
rating (a scorc ol o or .c), comparcd with ol thosc living whcrc Mcdicarc
spcnt thc most. !n rcporting thcir rcsults, Fowlcr and his collcagucs rcachcd
thc lollowing ovcrall conclusion: No consistcnt association was obscrvcd
bctwccn thc mcan pcr capita cxpcnditurc in a gcographic arca and thc pcr
ccptions ol thc quality ol mcdical carc ol thc pcoplc living in thosc arcas. !n
othcr words, lrom thc paticnts point ol vicw, lor most ol thc lactors mca
surcd, hcalth carc in thc Unitcd Statcs was on thc at ol thc curvc. Morc carc
ccrtainly was not associatcd with grcatcr satislaction with that carc, at lcast
among Mcdicarc rccipicnts.
Tc rcscarchcrs also askcd qucstions conccrning thc paticnts pcrccp
tions about unmct nccd lor spccialist carc and lound an inverse corrclation
bctwccn spcnding and acccss: ol rcspondcnts in thc highcst pcr capita
spcnding rcgions rcportcd unmct nccd lor spccialists comparcd to only .
ol thosc who livcd in thc lowcst spcnding rcgions. Tc grcatcr pcrccption ol
scarcity was occurring in thc highcost rcgions, cvcn though thcrc wcrc many
morc spccialists availablc on a pcr capita basis. Sound lamiliar: As rcportcd
in Chaptcr :, thc carlicr Fowlcr intcrvicw study documcntcd much thc samc
phcnomcnon: \crmontcrs living in 8urlington, whcrc thc pcr capita numbcr
ol mcdical spccialists was high, rcportcd grcatcr di culty in gctting to scc
a physician whcn thcy wantcd to. Now, on a national basis wc scc cvidcncc
that having morc physicians docs not ncccssarily mcan grcatcr acccss to carc
or grcatcr pcrccptions on thc part ol paticnts that thcir mcdical nccds arc
bcing lulllcd. As ! will discuss in Chaptcr ., policy makcrs nccd to rcsist
thc tcmptation to trcat thc symptoms ol pscudoscarcity ol physicians by
churning out morc doctors.
Tc artmouth Atlas Projcct lookcd lurthcr into thc hypothcsis that, lrom
thc pcrspcctivc ol thc paticnt, thc Unitcd Statcs may cvcn bc on thc dcsccnd
ing arm ol thc bcnctutilization curvc. Conccntrating on thc usc ol acutc
carc hospitals, wc uscd thc HC! indcx, which rcccts both timc spcnt in thc
hospital and thc intcnsity ol physician intcrvcntion during hospitalization
lor Mcdicarc paticnts, and mcasurcs ol thc paticnts cxpcricncc ol hospital
.66 :vbic~i v~vi~)iox
carc that camc lrom a ncw databasc postcd on thc CMS wcbsitc on March
:, :cc, thc Hospital Consumcr Asscssmcnt ol Hcalthcarc Providcrs and
Systcms (HCAHPS) survcy, conductcd by thc CMS.
!4
Tc survcy, bccausc it
is dcsigncd to bc a rcport card on how adult paticnts cxpcricncc carc in thcir
own hospitals, rcquircs a vcry largc samplc ol rcccntly hospitalizcd paticnts.
Tc initial CMS study was bascd on ovcr 6cc,ccc dischargcd paticnts lrom
:,. acutc carc hospitals. Paticnts answcrcd qucstions about tcn aspccts ol
thcir cxpcricncc, onc ol which was to providc a global rating ol thcir satislac
tion with thcir inpaticnt cxpcricncc on a scalc ol c (most dissatiscd) to .c
(most satiscd), similar to thc approach ]ack Fowlcr uscd in his study. CMS
thcn calculatcd lor cach hospital thc pcrccntagc ol paticnts who gavc thc
hospital a low, intcrmcdiatc, or high rating lor cach aspcct ol carc. Vc lurthcr
aggrcgatcd thc data to thc rcgional lcvcl.
Vhat did wc nd: First, thcrc is an cightlold rangc among thc .c6
rcgions in thc pcrccntagc ol paticnts who gavc thcir hospital a low global
rating (a scorc ol 6 or lcss). !t varicd lrom ol paticnts hospitalizcd in thc
rcgion with thc lcwcst dissatiscd paticnts to .c in thc rcgion with thc
most dissatiscd paticnts. Vc thcn tcstcd thc hypothcsis that grcatcr intcn
sity ol usc ol hospitals was associatcd with grcatcr paticnt dissatislaction with
carc, bascd on thc global rating paticnts gavc. Tc association was positivc
(R
2
- c.:6, p .cc.). !ndccd, paticnts living in thc rcgions with highcst carc
intcnsity tcndcd to rank thcir hospitals lcss lavorably on all aspccts ol carc,
including thc communication bctwccn physicians, nurscs, and thc paticnt,
pain control, providing hclp whcn nccdcd, clcanlincss ol rooms and quictncss
at night, dischargc planning, and willingncss to rccommcnd thc hospital thcy
had uscd to othcrs.
Vc thcn lookcd at thc association bctwccn carc intcnsity, low ovcrall rat
ing ol hospitals, and thc objcctivc quality mcasurcs lor paticnts with hcart
attacks, congcstivc hcart lailurc, and pncumonia that CMS also posts on its
wcbsitc. ]ust as prcdictcd by Laura Yasaitis study, wc lound that rcgions with
grcatcr carc intcnsity tcndcd to havc lowcr quality. 8ut wc also noticcd a
corrclation bctwccn quality mcasurcs and paticnt ratings: rcgions with lowcr
paticnt ratings ol hospitals tcndcd to havc worsc quality, as mcasurcd by
CMS quality scorcs (R
2
- c..6, p .cc.).
Vhy should thcsc two dimcnsions ol carc quality bc corrclatcd at all,
bccausc thc cvcnts that go into thc hospitals tcchnical quality scorcs arc
gcncrally not obscrvablc by thc paticnt: Altcr all, paticnts arc not rating
thcir hospitals on thc basis ol whcthcr thcy rcccivcd a pncumonia vaccinc
on admission or antibiotics within a spccicd amount ol timc. Tc corrc
lation suggcsts thc possibility ol an ovcrlapping causal pathway: chaotic,
is :ovv nv))vv- .6
disorganizcd carc rcsults in lcss attcntion to paticnt nccds and wants along
thc scvcral dimcnsions mcasurcd by thc HCAHPS survcy. At thc samc timc,
carc that is dclivcrcd by multiplc physicians, with no onc pcrson in chargc,
also lcads to substandard carc, cxccss scrviccs, and worsc pcrlormancc on
tcchnical quality mcasurcs. rganizcd carc, by contrast, pays morc consistcnt
attcntion to paticntccntcrcd carc and is ablc to coordinatc scrviccs to bct
tcr achicvc thcrapcutic goals, including thosc that arc mcasurcd in thc CMS
quality scorcs.
Vc do indccd nd an association bctwccn organizcd carc, highcr tcchnical
quality, and lowcr carc intcnsity. Tc hcalth carc markcts in many ol thc rcgions
that rank in thc bottom :c on thc HC! indcx arc dominatcd by organizcd
systcms ol carclargc group practiccs or hospital systcms. Minncapolis,
Sacramcnto, Scattlc, Portland, rcgon, and Salt Lakc City arc cxamplcs. !n
thcsc rcgions, wcllcstablishcd organizcd systcms ol carc dominatc thc hcalth
carc landscapc. Tc group practicc modcl is also prcvalcnt in othcr rcgions
with low HC! scorcs, including thc Mayo Clinic (Rochcstcr, Minncsota, and
LaCrossc, Visconsin, rcgions), thc Gcisingcr Clinic (anvillc, Pcnnsylvania,
rcgion), thc 8illings Clinic (8illings, Montana, rcgion), thc Marshcld Clinic
(Marshcld, Visconsin, rcgion), thc uluth Clinic (uluth, Minncsota,
rcgion), thc Scott and Vhitc Clinic (Tcmplc, Tcxas, rcgion), thc artmouth
Hitchcock Clinic (Lcbanon, Ncw Hampshirc, rcgion), thc Univcrsity ol !owa
Clinic (!owa City rcgion), and thc Univcrsity ol Visconsin and thc can
Clinics (Madison, Visconsin, rcgion). Vith a lcw cxccptions, (lor cxamplc,
thc Hcnry Ford Clinic in thc ctroit rcgion and thc chsncr Clinic in thc
Ncw rlcans rcgion), largc group practiccs arc notably abscnt in rcgions with
highcr HC! scorcs.
! will rcturn in latcr chaptcrs to suggcst that organizcd carc with a low
HC! indcx should scrvc as bcst practicc bcnchmarks lor cvaluating thc c
cicncy ol hcalth carc organizations in dclivcring carc lor thosc with chronic
illncss. To givc thc rcadcr a hcadsup on whcrc thc discussion is going, how
cvcr, lct mc call attcntion to thc practicc pattcrns in rcgions in thc lowcst :c
ol thc HC! indcx, comparcd to thc rcgions in thc highcst quintilc whcn it
comcs to caring lor chronically ill paticnts during thc last two ycars ol thcir
livcs (Tablc .c..).
As thc rcadcr can scc, thc bottom :c ol rcgionsthosc oltcn dominatcd
by organizcd carc systcmsand thc top :c ol rcgions arc vcry dicrcnt in
tcrms ol thc amount ol rcsourccs thcy usc and thc carc paticnts with simi
lar typcs and scvcrity ol illncss cxpcricncc. Tc hcalth carc providcrs scrving
highintcnsity rcgions spcnd much morc moncy pcr paticnt and usc many
morc hospital bcds and many morc physiciansprimary carc physicians as
.6 :vbic~i v~vi~)iox
Tablc .c... Practicc Pattcrns in Managing Chronic !llncss in Rcgions that Rankcd in
Highcst and Lowcst uintilcs on thc Hospital Carc !ntcnsity (HC!) !ndcx
Hospital Care Intensity (HCI) Quintile
Lowest Highest (Ratio)
HC! indcx scorc c.6 ..6 (:..)
Rcsourcc inputs during thc last two ycars ol lilc
Mcdicarc spcnding pcr paticnt s.,.cc s6c,cc (..o)
Physician labor inputs pcr .,ccc paticnts
All physicians .6.6 :o. (..)
Mcdical spccialists (MS) .6 .... (:..)
Primary carc physicians (PC) . ... (..)
Ratio PC/MS ... c. (c.66)
Hospital bcd inputs pcr .,ccc paticnts c.c c. (..)
Tcrminal carc
Paticnt days pcr paticnt, last six months ol
lilc
. ..6 (...)
!npaticnt visits pcr paticnt, last six months
ol lilc
.:.o .6.. (:.:)
Pcrccnt sccing .c or morc Ms, last six
months ol lilc
:c.: .. (:..6)
Pcrccnt ol dcaths with !CU admission ... :..: (..6.)
Pcrccnt cnrollcd in hospicc .c.. .c.: (..cc)
!CU, intcnsivc carc unit, M, physician.
HC! indcx is bascd on last two ycars ol lilc, lrom :cc. to :cc, thc lowcst and highcst quintilcs
contain approximatcly cqual numbcrs ol paticnts. Ratcs arc adjustcd lor agc, scx, racc, and chronic
conditions.
Source: artmouth Atlas Projcct databasc.
wcll as mcdical spccialistsin providing carc. Mcdical spccialists tcnd to
dominatc practicc, as cvidcnccd by thc ratio ol primary carc physicians to
mcdical spccialists. Paticnts in highintcnsity rcgions spcnd much morc timc
in thc hospital and incur many morc physician visits, many morc physicians
arc involvcd in thcir carc, and thcy arc much morc likcly to cxpcricncc a stay
in thc intcnsivc carc unit at thc timc ol thcir dcaths. !n rcvicwing thcsc lacts,
it is good to kccp in mind that, on avcragc, thc outcomcs and quality ol carc
tcnd to bc bcttcr, and paticnts arc bcttcr ablc to acccss physicians and arc
morc satiscd with carc in lowintcnsity rcgions.
From work that bcgan in \crmont, Mainc, 8oston, and Ncw Havcn, and
morc rcccntly lrom our rcscarch lor thc artmouth Atlas Projcct, my
is :ovv nv))vv- .6o
collcagucs and ! havc concludcd that illncss cxplains only a small lraction
ol thc variation in thc practicc ol mcdicinc lor thc chronically ill that wc scc
in dicrcnt parts ol thc country. Acutc carc hospital usc is closcly associatcd
with acutc carc hospital capacity and physician supply. Tc amount ol supply
scnsitivc carc providcd is not govcrncd by strong mcdical thcory, much lcss
by valid mcdical cvidcncc. Physicians arc gcncrally unawarc ol whcrc thcy or
thcir hospitals stand on thc spcctrum ol carc intcnsity. !n a mcdical cnviron
mcnt whcrc both physicians and paticnts bclicvc implicitly that morc carc is
bcttcr, thc variation sccms bcst cxplaincd by thc ccct that capacity cxcrts on
thc clinical dccision making that lics bchind thc lrcqucncy ol scrviccs.
Howcvcr, lor supplyscnsitivc carc, morc is not bcttcr. !n rcgions with high
carc intcnsity, cohorts ol paticnts with hip lracturcs, colon canccr, and hcart
attacks rcccivc morc scrviccs and thcy havc highcr mortality ratcs ovcr thc
ycars lollowing thcir initial indcx cvcnt than thosc in lowintcnsity rcgions.
Paticnt satislaction with hospital carc is worsc in highintcnsity rcgions, as
is thc quality ol hospital carc, as mcasurcd by using CMS publishcd data lor
thc trcatmcnt ol hcart attacks, pncumonia, and congcstivc hcart lailurc. Tcsc
ndings arc consistcnt with Sccnario ., introduccd at thc bcginning ol this
chaptcr, thc hypothcsis that thc Unitcd Statcs is on thc wrong sidc ol thc
utilizationbcnct curvc, at lcast in tcrms ol our usc ol acutc hospital carc
lor thc chronically ill. Tcy arc also consistcnt with Sccnario , thc idca that
high spcnding lcvcls and poor outcomcs arc a conscqucncc ol a third lactor
inc cicncy rcsulting lrom poor organization and systcmatic coordination
lailurc in thc hcalth carc systcm.
.c
Finding solutions to unwarrantcd variation and ovcrusc ol carc rcquircs
lcadcrship lrom acadcmic mcdicinc, thc institutions on which thc nation
dcpcnds to cnsurc that mcdicinc is bascd on valid clinical scicncc. Yct cvcn
among thc sclcct lcw acadcmic mcdical ccntcrs that rcsidc at thc vcry top in
tcrms ol thcir national rcputation lor cxccllcncc, thcrc is littlc cvidcncc that
clinical practicc is bascd on a scicntic conscnsus on thc bcst way to practicc
mcdicinc. Acadcmic mcdical ccntcrs appcar to vary as much as othcr hospitals
in thc Unitcd Statcs in tcrms ol thc quality ol thc carc thcy dclivcr, in thc
various ways thcy spcnd Mcdicarcs moncy and usc rcsourccs, and in thc cxpc
ricnccs thcy providc thcir paticnts. Mobilizing acadcmic mcdicinc to assumc
rcsponsibility lor improving thc scicncc ol hcalth carc dclivcry is a major task
lacing thosc who want to rclorm hcalth carc in thc Unitcd Statcs.
Acadcmic mcdical ccntcrs also vary substantially in thc way thcy orga
nizc thcir hcalth carc dclivcry systcms or, in many cascs, nonsystcms. Many
appcar to sharc in thc gcncral chaos ol Amcrican mcdicinc, cxhibiting littlc
cvidcncc that thcir mcdical stas providc coordinatcd carc lor thcir chroni
cally ill paticnts. A lcw arc lormally organizcd as largc, multidisciplinary
group practiccs and, as ! show in this chaptcr, thc rcgions scrvcd by thcsc
organizcd acadcmic mcdical ccntcrs tcnd to bc rclativcly c cicnt: thcir
mcthod ol dclivcring scrviccs costs Mcdicarc lcss, uscs lcss physician labor
and rcsourccs, and subjccts chronically ill paticnts to a much lowcr intcnsity
..
Are Americas Best Hospitals
Really the Best?
~vv ~:vvic~s nvs) nosvi)~is vv~iiy )nv nvs)- ..
and morc conscrvativc pattcrn ol practicc. !l thc rcst ol thc nation wcrc to
achicvc thc bcnchmarks ol thcsc institutions, thc nation would nccd many
lcwcr hospital bcds and physicians. Tis chaptcr will cxaminc thcsc issucs,
and in doing so it will challcngc thc nations acadcmic mcdical ccntcrs to stcp
up to thc platc and takc on thc task ol improving thc c cicncy ol thcir own
carc, so that thcy might scrvc as an cxamplc to thc rcst ol thc nation.
Americas Best Hospitals?
ach ycar, many ol Amcricas acadcmic mcdical ccntcrs gurc promincntly at
or ncar thc top ol thc list in U.S. News & World Reports (USN&WRs) 8cst
Hospitals issuc. Using a mcthod that rclics to a largc cxtcnt on prolcssional
rcputation,
!
thc magazinc tclls rcadcrs which hospitals rcprcscnt a paticnts
bcst bct lor scvcral spccic chronic conditions, including hcart discasc, can
ccr, and lung discasc, and which rank bcst on ovcrall pcrlormancc. 8cing
dcsignatcd as a bcst hospital is a prizcd distinction and hospitals that attain
it proudly display thcir rank in advcrtiscmcnts and adorn thcir buildings with
banncrs proclaiming thcir cxccllcncc.
8ut what do thcsc ratings tcll us about thc rclativc c cicncy ol carc and
thc paticnt cxpcricncc: Tc artmouth Atlas Projcct mcthod lor cvaluating
pcrlormancc in caring lor thosc with chronic illncss (dcscribcd in dctail in
thc Appcndix) rcsults in thrcc rcports: thc Mcdicarc Spcnding Rcport, thc
Rcsourcc Allocation Rcport, and thc Paticnt xpcricncc Rcport. ur ratings
ocr a vcry dicrcnt picturcand onc that as yct has not motivatcd hospitals
to advcrtisc thcir ranking.
Takc thc vc hospitals at thc top ol thc USN&WR honor roll list lor
:cc: thc Univcrsity ol Calilornia, Los Angclcs Mcdical Ccntcr (UCLA),
Massachusctts Gcncral Hospital (MGH), ]ohns Hopkins Hospital, thc
Clcvcland Clinic Foundation Hospital, and St. Marys Hospital, thc prin
cipal hospital ol thc Mayo Clinic in Rochcstcr, Minncsota. Tcsc hospitals
cnjoy consistcntly stcllar rcputations, not just in thc pagcs ol USN&WR, but
also among paticnts, physicians, and policy makcrs. Yct what is rcmarkablc
about our cvaluation ol thcsc hospitals is thc cxtraordinary lack ol consis
tcncy in how thcy actually trcat paticnts.
Tcsc vc hospitals show widc variation in thc intcnsity ol thc carc thcy
givc to thc chronically ill. Tcy also vary in tcrms ol rclativc c cicncy
thc rcsourccs thcy usc to trcat similar groups ol paticnts and thc pcr capita
amount Mcdicarc spcnds on thosc paticnts (Tablc ....).
Tablc ..... Routinc Pcrlormancc Rcports lor Managing Chronic !llncss uring thc Last Two Ycars ol Lilc (caths lrom :cc.
through :cc) lor Highly Rankcd Acadcmic Mcdical Ccntcrs
Johns Hopkins
Hospital
Mayo Clinic (St.
Marys Hospital)
UCLA Medical
Center
Cleveland Clinic
Foundation
Massachusetts
General Hospital
Rank among bcst hospitals . : .
Mcdicarc spcnding pcr paticnt, last two ycars ol lilc
Total Mcdicarc spcnding s,:o s.,.: so.,: s,... s,666
!npaticnt sitc ol carc s6.,co s.,.: s6.,occ s.,. s.,c
utpaticnt sitc ol carc s..,c s, s.,.: s,oc6 s..,co
Skillcd nursing/longtcrm carc s.,: s,.. s6,o. s,.c. s.,.o
Homc hcalth carc s.,.. s66: s.,oo s:,.o s,.
Hospicc carc s:,:. s:,c s.,6o s:, s.,c.
All othcr carc s.,o:o s.,6. s.,:. s:,:.c s:,:o
Rcsourcc inputs pcr .,ccc paticnts, last two ycars ol lilc
Physician labor
All physician FT labor :. :c.. .. :6.. :o.
Mcdical spccialist FT .o .o :..: .c.6 ...
Primary carc physician FT .c.c 6. o.6 . ...
Ratio ol mcdical spccialist to
primary carc labor inputs
c.o ...c :.:c ..:c ..c:
Hospital bcds
All bcds .: .: . 6. o.:
Highintcnsity !CU/CCUs ... .6. ... ... ..c
!ntcrmcdiatcintcnsity !CUs .: :.c :.. . ..c
Mcdical and surgical bcds .: .o. . 6. 6..:
Paticnt cxpcricncc, last six months ol lilc
Hospital days pcr paticnt .6. .:.c .. .. ...
Physician visits pcr paticnt :.o :..o :. .... .o.
Pcrccnt sccing .c or morc physicians .6 ..c :.o .: ..
Tcrminal carc
Pcrccnt ol dcaths in hospital .6. .c.: ..: ..6 .
Pcrccnt ol dcaths with !CU
admission
:..: :.. ..o :... ::.
Pcrccnt cnrollcd in hospicc ..: :o.. :. .6.6 :..
Avcragc copaymcnt pcr paticnt last
two ycars ol lilc
s.,.oc s:,.o s,. s.,c s.,co
CCUs, coronary carc units, FT, lulltimc cquivalcnt, !CU, intcnsivc carc unit.
Source: artmouth Atlas Projcct databasc. Ranking ol hospitals is by U.S. News & World Report 8cst Hospitals lor :cc.
. :vbic~i v~vi~)iox
Mcdicarc Spcnding
Lcts look rst at how much Mcdicarc spcnds pcr capita on chronically ill
paticnts in thc last two ycars ol lilc at thcsc vc hospitals. Tcsc cstimatcs arc
bascd on dcaths that occurrcd lrom :cc. through :cc:
Mcdicarc spcnding lor all scrviccs was ncarly 6 morc on a pcr capita
grcatcr on a pcr capita basis lor paticnts using UCLA Mcdical Ccntcr
and ]ohns Hopkins comparcd to thc Mayo Clinics St. Marys Hospital
and thc Clcvcland Clinic Foundation Hospital.
Pcr capita spcnding in othcr scctors also shows striking variation:
Mcdicarc spcnding at UCLA Mcdical Ccntcr lor ambulatory carc
scvcn timcs grcatcr on a pcr capita basis than lor St. Marys Hospital
paticnts.
Hospicc spcnding varicd about 6, with thc highcst spcnding ratc
lor Clcvcland Clinic Foundation Hospital paticnts and thc lowcst lor
Massachusctts Gcncral Hospital.
!t is important to rcmcmbcr that most, although not all, ol this varia
tion in pcr capita spcnding is accountcd lor by dicrcnccs in thc volumc
ol scrviccsthc numbcr ol days paticnts spcnd in thc hospital or cxtcndcd
carc lacilitics, or thc numbcr ol visits that physicians makc to hospitalizcd
paticnts and o cc visits that paticnts makc to thcir providcrs. icrcnccs
in pricc pcr unit ol scrvicc havc lar lcss ccct on spcnding. For cxamplc,
comparcd to St. Marys Hospital, UCLA Mcdical Ccntcrs highcr ratc
in pcr capita Mcdicarc spcnding lor inpaticnt carc rcsultcd lrom thc lact that
UCLA Mcdical Ccntcr paticnts spcnt morc days in thc hospital pcr
capita than thc Mayo Clinics paticnts. Tc pricc ol carc, by contrast, or thc
~vv ~:vvic~s nvs) nosvi)~is vv~iiy )nv nvs)- .
avcragc rcimburscmcnt pcr day in thc hospital, was : highcr. For physi
cian visits, whcrc Mcdicarc pricc controls arc cvcn morc ccctivc in kccping
priccs consistcnt across thc country, thc .: highcr UCLA Mcdical Ccntcr
pcr capita Mcdicarc spcnding was cxplaincd mostly by thc high volumc ol
physician visits pcr capitawhich cxcccdcd thc Mayo Clinics visit ratc by
oo. Avcragc rcimburscmcnts pcr visits, on thc othcr hand, wcrc only ..
highcr.
2
Physician Labor
Tc nations vc bcst acadcmic mcdical ccntcrs dicr widcly in how thcy
usc physician labor in trcating paticnts who arc csscntially similar in thcir
nccds. Tc UCLA Mcdical Ccntcr uscd 90 morc lulltimc cquivalcnt phy
sicians pcr paticnt than thc Mayo Clinic. Massachusctts Gcncral Hospital
uscd morc, thc Clcvcland Clinic Foundation Hospital, : morc, and
]ohns Hopkins, : morc.
Tcrc arc also rcmarkablc dicrcnccs in thc mix bctwccn mcdical spccial
ists and primary carc physicians among thc dicrcnt hospitals. Tc worklorcc
managing chronically ill paticnts loyal to thc UCLA Mcdical Ccntcr is ori
cntcd toward mcdical spccialists, whilc ]ohns Hopkins tcnds to lavor primary
carc. Tc UCLA Mcdical Ccntcr uscd :. timcs morc mcdical spccialist labor
than ]ohns Hopkins. Tc ratio ol mcdical spccialist to primary carc labor was
:.: at UCLA Mcdical Ccntcr and c.o at ]ohns Hopkins.
Tis list ol statistics suggcsts that thcrc is littlc scicncc bchind thc way
acadcmic mcdical ccntcrs dcploy physicians in caring lor thcir paticnts. And
yct, thcsc institutions havc apparcntly rcachcd a conscnsus on thc nccd to
cxpand thc physician worklorcc and, in particular, thc nccd lor morc spccial
ists. 8ut our data suggcst that morc physicians, and cspccially morc mcdical
spccialists, will cxaccrbatc thc ovcrusc ol highintcnsity carc. (Scc Chaptcr .
lor lurthcr discussion.)
Hospital 8cds
Amcricas bcst hospitals also dicr widcly in how many bcds pcr .,ccc
paticnts thcy usc lor managing chronic illncss ovcr thc last two ycars ol lilc:
Tc UCLA Mcdical Ccntcr stands out lor its ovcrall high lcvcl ol bcd
inputs and its cmphasis on intcnsivc carc unit (!CU) bcds, cspccially intcr
mcdiatcintcnsity bcds. (!ronically, thc hospital rcccntly was rcconstructcd
and morc !CU bcds wcrc addcd!) Tc UCLA Mcdical Ccntcr uscd on a
.6 :vbic~i v~vi~)iox
pcr capita basis morc total bcds and twelve times morc intcrmcdiatc
stcpdown !CU bcds than thc Mayo Clinic. Tc UCLA Mcdical Ccntcr
also had :c morc mcdical and surgical unit bcds comparcd with thc
Mayo Clinic (but lcwcr highintcnsity !CU bcds). Looking at thc total bcd
inputs, thc Massachusctts Gcncral Hospital uscd .6 morc than thc Mayo
Clinic, ]ohns Hopkins uscd . morc, and thc Clcvcland Clinic Foundation
Hospital uscd .. morc, largcly bccausc ol thcir highcr usc ol mcdical and
surgical unit bcds.
Tc Paticnt xpcricncc
Amcricas bcst hospitals dicr in thc intcnsity ol carc thcy dclivcr to thcir
chronically ill Mcdicarc paticntsand thc cxpcricncc thcy providc thcir
paticnts at thc cnd ol lilc. uring thc last six months ol lilc (lor dcaths lrom
:cc. through :cc), carc intcnsity was lowcst lor paticnts loyal to thc Mayo
Clinic and highcst lor thosc using thc UCLA Mcdical Ccntcr:
Mayo Clinic paticnts avcragcd twclvc days in thc hospital and incurrcd
twclvc days in thc hospital, and six days in !CUs, and incurrcd ncarly
lortytwo physician visits pcr capita.
Phocnix Mayo Hospital paticnts spcnt ncarly tcn days in thc hospital,
skillcd nursing lacilitics (SNFs) varicd lrom lcss than s:,ccc in somc
rcgions to morc than so,ccc in othcrs. \olumc (days pcr paticnt in
SNF) varicd cvcn morc, whilc pricc (rcimburscmcnts pcr day in SNF)
varicd much lcss. Tc R
2
ol association bctwccn volumc and pcr capita
rcimburscmcnts was c.66, lor pricc, it was c.:6.
Hospicc paymcnts pcr paticnt varicd lrom lcss than s6cc to morc than
s,cc pcr paticnt with chronic illncss ovcr thc last two ycars ol lilc.
Tc numbcr ol visits pcr capita, which rangcd lrom vc to scvcnty
two among rcgions, cxplaincd ol thc variation in spcnding, pricc
dicrcnccs (paymcnt pcr visit) bctwccn rcgions wcrc rclativcly slight,
ranging lrom s. to s:c, and wcrc csscntially uncorrclatcd with total
spcnding.
Vhat this all mcans is that thc volumc, or amount ol carc dclivcrcd pcr
paticnt, is gcncrally morc important than thc pricc ol cach unit ol carc whcn
it comcs to addrcssing variations in Mcdicarc spcndingin all scctors ol
carc, not just acutc carc hospitals. Mcdicarc has rcpcatcdly tricd to rcin in
spcnding by controlling priccs. And it has bccn succcsslul up to a point: il it
had not constraincd pricc, thc dicrcnccs in priccs would no doubt contrib
utc morc to cxplaining pcr capita spcnding variation and thc variation might
bc cvcn grcatcr. 8ut in a lcclorscrvicc world, controlling priccs without
addrcssing volumc will havc only a limitcd ccct on Mcdicarcs pcr capita
spcnding or, lor that mattcr, any othcr insurcrs spcnding. Given the impor-
tance of the supply of medical resources in generating volume, reducing the overuse
of acute care hospitals will require a strategy for dealing with capacity.
Figurc .:.:. Tc rclationship bctwccn inpaticnt rcimburscmcnts and hospital days
pcr paticnt (left) and avcragc rcimburscmcnts pcr day in hospital (right) during thc last
two ycars ol lilc among hospital rclcrral rcgions (dcaths occurring :cc. through :cc).
(Sourcc: artmouth Atlas Projcct databasc.)
R
:
- o.6
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:
- o.+
+o,ooo
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4. More Skilled Nursing Facilities, Outpatient Care, and Home Health
Care Will Not Cut Inpatient Hospital Use
Mcdicarcs othcr stratcgy lor controlling hospital spcndingmaking non
hospital, lowcrcost sitcs ol carc availablchas also mct with limitcd succcss.
vcr thc ycars, policy makcrs havc argucd that thc way to rcducc unncccssary
hospitalizations is to makc carc in othcr scttings morc rcadily availablc, so
paticnts who arc no longcr acutcly ill but who still nccd carclul managcmcnt
can rcccivc thcir carc in lcss intcnsivcand lcss cxpcnsivcscttings. Tis
would not only allow carlicr dischargc lrom thc acutc carc hospital, it would
also, by lurthcr stabilizing thc coursc ol chronic illncss, rcducc thc nccd lor
rcadmission to acutc carc lacilitics. And il hospicc carc wcrc morc widc
sprcad, lcwcr paticnts would bc subjcctcd to hightcch dcaths in an intcn
sivc carc unit (!CU). r at lcast that is how thc thinking gocs. 8ascd in part
on thcsc assumptions, Mcdicarc has addcd bcncts ovcr thc ycars lor homc
hcalth carc, hospicc, and SNFs, all in an cort to rcducc thc ratcs ol hospi
talization and spcnding.
!t has not workcd out vcry wcll. !t turns out that simply making othcr
kinds ol carc morc rcadily availablc docs not ncccssarily lcad to a dcclinc in
hospitalizations or inpaticnt spcnding. arly in our rcscarch in \crmont, wc
saw no cvidcncc that grcatcr usc ol nursing homcs and physician o cc vis
its was associatcd with lowcr ratcs ol hospitalization. Today, thc artmouth
Atlas tclls a similar story. Among thc .c6 hospital rclcrral rcgions, highcr
utilization and spcnding in ambulatory scttings, SNFs, and homc hcalth carc
wcrc associatcd with higher utilization and spcnding lor inpaticnt carc. Tc
association bctwccn inpaticnt spcnding and spcnding lor SNFs and homc
hcalth agcncics is particularly strong (scc Figurc .:..).
Hospicc carc was thc only sctting that showcd an invcrsc association
with inpaticnt days in thc hospital and inpaticnt spcnding, and this ccct
ol hospicc is rcstrictcd to rcducing thc usc ol non!CU bcds. Tc sad truth
is, seeking care from a hospital that uses more hospice care does not reduce your
chances of experiencing a high-tech deathone associated with admission to
an ICU.
Vhat can account lor thcsc paradoxical ndings: Vhy do physicians not
makc usc ol thcsc altcrnativc sitcs ol carc in a way that hclps thcir chronically
ill paticnts, many ol whom arc lrail and sucring alrcady, avoid thc acutc carc
hospital: Tcrc arc scvcral rcasons.
First, paymcnt policy makcs it a rcquircmcnt that Mcdicarc paticnts bc
hospitalizcd in an acutc carc hospital bclorc bccoming cligiblc lor admission
to a skillcd nursing homc, thus, skillcd nursing homcs cannot scrvc as an
wny wv xvvb )o vvvov: )nv w~y wv :~x~cv cnvoxic iiixvss .o
altcrnativc to acutc carc hospitals, cvcn though, as ! discuss in Chaptcr .., this
might grcatly rcducc thc usc ol acutc carc hospitals.
Sccond, undcr traditional Mcdicarc, rcimburscmcnt bctwccn thc scctors
ol carc is not linkcd. Mcdicarc pays lor cach typc ol utilization (c.g., inpa
ticnt, SNF, and homc hcalth) indcpcndcntly, without rcgard lor thc lcvcl
ol spcnding in thc othcr scctors in caring lor thosc with chronic illncss. !n
thc abscncc ol an ovcrall budgct lor managing carc ovcr timc, thcrc is no
inccntivc to providcrs to work toward c cicncy. As I discuss in Chapter 15,
it may become necessary to establish such an annual budget for managing chronic
and acute illness if the nation is to deal eectively with the overuse of acute care
hospitals.
Tird, as ! argucd in prcvious chaptcrs, thc culturc ol mcdicinc itscll
cnsurcs that availablc capacity is utilizcd. Vhcn paticnts cxpcricncc an acutc
cxaccrbation ol thcir undcrlying chronic illncss(cs), most physicians continuc
to bclicvc that morc intcnsivc rcscuc carc is bcttcr. !n rcgions ol thc coun
try whcrc thc acutc carc scctor has bccn built up rclativc to thc population
scrvcd, thc rcady availability ol inpaticnt bcds makcs thc usc ol thc hospital
thc path ol lcast rcsistancc, cvcn whcn othcr sitcs ol carc arc in placc. Tus,
thc supply ol hospitalbascd rcsourccs in thc rcgion whcrc paticnts livc inu
cnccs how intcnscly thcy arc trcatcd.
Fourth, thc positivc association bctwccn thc usc ol inpaticnt lacilitics
and thc usc ol skillcd nursing homcs and homc hcalth agcncics makcs clin
ical scnsc, thcsc lacilitics arc important in planning lor thc dischargc ol
Figurc .:... Tc rclationship bctwccn rcimburscmcnts lor inpaticnt carc and skillcd
nursing lacilitics (SNFs) (left) and homc hcalth agcncics (HHA) (right) during thc
last two ycars ol lilc among hospital rclcrral rcgions (dcaths occurring :cc. through
:cc). (Sourcc: artmouth Atlas Projcct databasc.)
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!npaticnt rcimburscmcnts pcr paticnt (8) !npaticnt rcimburscmcnts pcr paticnt (8)
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chronically ill paticnts lrom acutc carc hospitals. Vhcn morc paticnts arc
hospitalizcd, morc arc dischargcd to othcr carc scctors, crcating dcmand lor
such scrviccs.
Tc tcndcncy to rcly on thc acutc carc hospital is lurthcr cxaccrbatcd by
thc lragmcntcd naturc ol much ol thc carc that is dclivcrcd to chronically ill
cldcrly paticnts. As thc !nstitutc ol Mcdicinc and othcrs havc pointcd out,
thcrc is littlc coordination bctwccn primary carc physicians and thc many
spccialists thc chronically ill oltcn nd thcmsclvcs sccing, nor is thcrc coor
dination ol carc bctwccn thc various altcrnativc sitcs whcrc scrviccs can bc
dclivcrcd. Paticnts in nursing homcs may bc admittcd lor inpaticnt carc lor
cach crisis, lcading to a hospitalizcd hightcch dcath, cvcn whcn thcy havc
cxprcsscd strong prclcrcnccs to avoid such an cnding. Carc transitions, or
handos, can bc particularly chaotic in hcalth carc markcts whcrc thcrc
is littlc coordination ol carc. Handos bctwccn primary carc and spccial
ist physicians, bctwccn nursing homcs and hospitals, bctwccn homc hcalth
carc and primary carc, and bctwccn acutc carc and hospicc and palliativc
carc arc oltcn plagucd with miscommunications about thc paticnts mcdical
nccds and carc prclcrcnccs, lcaving paticnts in thc wrong lacility or rccciv
ing highintcnsity carc that will do littlc to allcviatc sucring or improvc
outcomcs. ltcn, thc paticnts advancc dircctivcsdcsigncd to guard against
lutilc carc that thc paticnt docs not wantarc ignorcd in thc hcat ol thc
momcnt. Similarly, paticnts with chronic conditions arc routincly hospital
izcd during acutc cpisodcs ol thc undcrlying discasc, cpisodcs that oltcn
could havc bccn controllcd with bcttcr carc managcmcnt and coordination
among physicians.
Tc kcy point hcrc is that wc as a nation havc lailcd to rccognizc that
our hcalth carc systcm is not scllrcgulating. Vc havc lclt it to thc markct,
thc paticnt, and his physicians to cnsurc that this highly tcchnological and
complcx collcction ol scrviccs is dclivcrcd in a way that scrvcs thc paticnt.
Tis stratcgy is not working. Given the fragmented nature of the health care
Americans now receive, reducing the overuse of acute care hospitals will require a
strategy for coordinating the care of those with chronic illness.
5. Overuse Will Not Go Away on Its Ownand It Is Getting Worse
An important rcason lor paying attcntion to thc ovcrusc ol thc acutc carc
scctor is that it is gctting worsc. Tc volumc ol scrviccs and intcnsity ol carc
dclivcrcd to thc chronically ill arc incrcasing cvcrywhcrc but cspccially in
rcgions that alrcady cxhibit thc most aggrcssivc pattcrns ol carc.
wny wv xvvb )o vvvov: )nv w~y wv :~x~cv cnvoxic iiixvss .o
Vc havc cxamincd changcs in carc intcnsity in managing chronic illncss
ovcr thc vcycar pcriod lrom :cc. to :cc and lound somc alarming trcnds.
Nationally, thc pcr capita input pcr .,ccc paticnts ol mcdical rcsourccs (bcds,
physicians, ctc.) allocatcd to managing chronic illncss during thc last two
ycars ol lilc incrcascd stcadily cach ycar (Tablc .:..). 8y :cc, thc nations
hcalth carc providcrs wcrc using ... morc !CU bcds than thcy did in :cc.
lor trcating similar paticnts. Tc amount ol physician labor uscd to managc
chronic illncss ovcr thc last two ycars ol lilc also incrcascd by .o.o lor mcdi
cal spccialists and ...: lor primary carc physicians.
Ratcs ol utilization ol !CUs and physician visits during thc last six months
ol lilc also incrcascd rapidly, particularly among regions that at baseline (2001)
were already providing the most care. !n othcr words, thc disparity in utili
zation bctwccn high and lowratc rcgions grcw ovcr thc vcycar pcriod,
bccausc utilization ratcs arc accclcrating in thc rcgions whcrc utilization is
alrcady highcst. !n this study, rcgions wcrc aggrcgatcd into vc groups that
wcrc rankcd on total Mcdicarc spcnding pcr paticnt during thc last two ycars
ol lilc among thosc whosc dcaths occurrcd in :cc. (Tablc .:.:). ach group
had approximatcly cqual paticnt populations. Avcragc Mcdicarc spcnding lor
dcaths occurring in thc lowcstrankcd quintilc was s.c,co, in thc highcst
rankcd quintilc, it was s,. pcr paticnt, or : highcr. Growth in utiliza
tion ratcs was proportionatc to thc basclinc spcnding lcvcl, thc grcatcr thc
spcnding in :cc., thc grcatcr thc pcrccntagc ol incrcasc in utilization ovcr thc
vcycar pcriod lrom :cc. through :cc. For cxamplc, usc ol intcnsivc carc
grcw . in thc highcstspcnding rcgions, .o in thc mcdianrankcd rcgions,
and .... in thc lowcstrankcd rcgions. Tc rangc in variation in pcr paticnt
days in !CUs incrcascd lrom :..6 lor dcaths occurring in :cc. to :.:o lor
dcaths that occurrcd in :cc. Mcdical spccialist visits pcr paticnt grcw ....
in thc highspcnding rcgions and o. in thc lowspcnding rcgions, with cor
rcsponding incrcascs in thc rangc in variation. Tc growth ratc in primary
Tablc .:... Rcsourcc !nputs pcr .,ccc Chronically !ll Mcdicarc Paticnts uring thc
Last Two Ycars ol Lilc by Ycar ol cath, lrom :cc. through :cc
Resource 2001 2002 2003 2004 2005 Increase 2001
to 2005
!ntcnsivc carc bcds ...c ...6 ... .. ..c ...
Mcdical spccialists . .. . o.c o.: .o.o
Primary carc physicians . . o.c o.. o. ...:
Source: artmouth Atlas Projcct databasc.
Tablc .:.:. !ncrcasc in Utilization pcr Chronically !ll Mcdicarc Paticnt uring thc Last Six Months ol Lilc
lrom :cc. through :cc by uintilc ol Pcr Capita Spcnding in 8asclinc Ycar :cc.
Quintile Patient Days in Intensive Care Medical Specialist Visits Primary Care Visits
Increase
in 5 Years
Ratio to Q5 Increase in
5 Years
Ratio to Q5 Increase in
5 Years
Ratio to Q5
2001 2005 2001 2005 2001 2005
. (s,.) ..c :..6 :.:o .... :.o :. 6.: ... ..o
: (s.,c) .6.c ..: ..c .c ..o ..o: 6.6 ..:. ..:6
. (s.,.o) .o .. ... . ..6. .. ... .... ...:
(s.,.6) ...6 ..: ..: .. ... ...c .. ..co ....
(s.c,co) .... ..cc ..cc o. ..cc ..cc :.: ..cc ..cc
, uintilc.
Spcnding is lor thc last : ycars ol lilc.
Source: artmouth Atlas Project database.
wny wv xvvb )o vvvov: )nv w~y wv :~x~cv cnvoxic iiixvss .oo
physician carc visits pcr paticnt in thc highspcnding rcgions was 6.:, almost
thrcc timcs that ol thc lowspcnding rcgions. Tc disparity bctwccn thc high
cst and lowcstquintilc rcgions incrcascd lrom a lactor ol ... to ..o.
!n vicw ol thc cvidcncc that morc aggrcssivc usc ol inpaticnt carc
appcars to rcsult in worsc outcomcs, the fact that care intensity in managing
severe chronic illness and end of life care is growing everywhere, and is grow-
ing at a faster rate in regions that already provide the most aggressive patterns
of care, should be cause for alarm. We must focus our attention on reducing the
growth of care intensity, particularly in regions where the intensity of care is
already high.
6. It Is Not Just a Medicare Fee-for-Service Problem
Tc ovcrusc ol acutc carc hospitals is not just a problcm lor Mcdicarc, and
it is not simply a phcnomcnon ol lcclorscrvicc rcimburscmcnt. !t accts
thosc youngcr than 6 ycars ol agc, thosc in prclcrrcd providcr organizations
(PPs), thosc in managcd carc hcalth maintcnancc organizations (HMs)
(thc Mcdicarc Advantagc Program and commcrcial HMs), and thosc in
Mcdicaid. !t docs not sccm to mattcr who is paying or how.
Tc lact that variation in thc way chronic illncss is managcd is not just a
problcm lor cldcrly Amcricans, agcd 6 ycars and oldcr, was cvidcnt carly on
in our \crmont and Mainc data, which covcrcd thc cntirc population, not
just thosc in Mcdicarc. At that timc, all physicians in Ncw ngland wcrc
rcimburscd through lcclorscrvicc, and thc pattcrns ol carc lor oldcr and
youngcr paticnts wcrc strikingly similar. Tc story is thc samc today. !n a
study ol paticnts insurcd by 8luc Cross in Michigan, r. avid Vcnnbcrg
(my son) and ! documcntcd striking variation in hospital dischargc ratcs
lrom onc rcgion ol thc statc to anothcr
1
(Figurc .:.). Tc ratcs lor Michigan
8luc Cross mcmbcrs varicd morc than thrcclold and wcrc highly corrclatcd
with ratcs lor Mcdicarc cnrollccs living in thcsc rcgions, suggcsting that thc
samc lactors inucncing thc utilization ol acutc hospital carc ol thc cldcrly
arc also inucncing thc carc ol youngcr paticnts. Tc most important lactor
accting thc ratc ol hospitalization lor thc young as wcll as thc old was thc
supply ol hospital bcds.
Similar studics conductcd in Louisiana by thc company Hcalth ialog
show strong rcgional corrclations bctwccn utilization ratcs not only lor
Mcdicarc and commcrcially insurcd paticnts but also lor paticnts covcrcd
by Mcdicaid.
4
Tc similarity bctwccn thc cxpcricnccs ol thcsc thrcc dicrcnt
paticnt populations suggcsts that the national Medicare data can be used as a
:cc :vbic~i v~vi~)iox
provisional indicator of the way specic regions and hospitals treat all chronically
ill patients, not just those covered under Medicare fee-for-service.
Nor is thc ovcrusc ol acutc carc hospitals rcstrictcd to lcclorscrvicc or
PP providcrs. Tis bccamc cvidcnt in a rcccnt study hcadcd by Laurcncc
8akcr, a Stanlord cconomist, who cxamincd Calilornia hospitalization
ratcs lor paticnts cnrollcd in lour dicrcnt insurancc plans: thc Mcdicarc
Advantagc Program (Mcdicarcs capitatcd HM plan), commcrcial HMs
(capitatcd plans, including Kaiscr Pcrmancntc, availablc to thosc undcr 6
ycars ol agc), traditional lcclorscrvicc Mcdicarc, and PP plans lrom pri
vatc insurcrs. Tc study comparcd hospitalization ratcs on a hospitalspccic
basis lor carc providcd to thc chronically ill ovcr thc last two ycars ol lilc,
using thc artmouth Atlas Projcct mcthodology.
Tc volumc ol hospital
carcmcasurcd as days in hospitalshowcd cxtcnsivc variation, cvcn among
paticnts in commcrcial HMs. Morcovcr, hospitals with high discharge rates
for Medicare also had high discharge rates for the other three insured groups, and
vice versa. !n othcr words, thc likclihood ol bcing admittcd to thc hospital
varicd in a similar way, indcpcndcnt ol dicring cconomic inccntivcs cmbod
icd in thcsc dicrcnt insurancc plans. Howcvcr, thc lcngth ol stay in thc hos
pital was lower lor paticnts cnrollcd in Mcdicarc Advantagc and commcrcial
HMs, suggcsting that oncc hospitalizcd, HMs work to gct paticnts out
ol thc hospital as soon as possiblcan intcrprctation that is in linc with thc
Figurc .:.. Tc association bctwccn mcdical dischargcs lor adult 8luc Cross/8luc
Shicld ol Michigan (8C8SM) cnrollccs (.oo) and Mcdicarc mcdical dischargcs
(.oo6) (left) and acutc carc hospital bcds (.oo6) (right) among Michigan hospital
scrvicc arcas with .cc,ccc or morc rcsidcnts. (Sourcc: Vcnnbcrg, ]ohn ., and avid
. Vcnnbcrg, cds., Te Dartmouth Atlas of Health Care in Michigan, Hanovcr, NH: Tc
Ccntcr lor thc valuativc Clinical Scicnccs, artmouth Mcdical School, :ccc).
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cconomic inccntivcs providcrs lacc whcn caring lor paticnts insurcd undcr a
capitatcd rcimburscmcnt plan.
Te overuse of supply-sensitive care and unwarranted variation in rates of
surgical procedures is a problem aecting all payers and all patients, indepen-
dent of economic incentives now built into standard reimbursement practices,
including capitation. As I discuss in Chapter 15, developing regional or statewide
all-payer databases to make variation transparent should become a goal of health
care reform.
7. Organized Systems of Care Do Not Have All the Answers (Yet)
Many policy makcrs bclicvc that organizcd carc systcms hold thc kcy to
hcalth carc rclorm and point to such largc group practiccs as thc Mayo
Clinic and Kaiscr Pcrmancntc or to hospital nctworks such as !ntcrmountain
Hcalthcarc as bcst practicc cxamplcs ol carc that should bc cmulatcd clsc
whcrc. Tc artmouth Atlas Projcct providcs cvidcncc that group practiccs
and organizcd hospital nctworks do indccd tcnd to usc lcwcr rcsourccs, havc
lowcr spcnding, and ocr highcrquality carc, at lcast comparcd to thc rcst
ol thc systcm, which is lar lcss organizcd. As shown in Chaptcr .., bcnch
marks lrom thcsc organizcd group practiccs suggcst largc savings could bc
glcancd il high cost, poorly organizcd hospitals and hcalth carc markcts
wcrc to achicvc thc c cicncy ol organizcd group practiccs. Howcvcr, thc
carc ol thc chronically ill in organizcd group practiccs docs not as yct lollow
a dcncd and rcplicablc modcl ol carc managcmcnt.
! rcvicwcd thc data showing variation within thc Mayo Clinic sitcs in
Chaptcr ... Hcrc wc rcvicw how hospital carc intcnsity varics among popula
tions cnrollcd in thc Kaiscr Pcrmancntc systcm. Rcccntly, Mark Sticlcl and
Paul Fcigcnbaum ol Kaiscr workcd with lliott Fishcr to cxaminc hospital
ization ratcs among thirtycight Kaiscr rcgions, ol which twcnty wcrc locatcd
in northcrn Calilornia, twclvc wcrc in southcrn Calilornia, and six wcrc in
othcr statcs.
6
Tcy lound a morc than twolold variation in days in thc hos
pital and a lourlold variation in days spcnt in intcnsivc carc units (!CUs)
during thc last six months ol lilc lor Mcdicarc Advantagc paticnts. Although
Kaiscr ratcs tcndcd to bc lowcr than thosc lor thc lcclorscrvicc Mcdicarc
population in thc corrcsponding mcdical communitics, thc Mcdicarc lcc
lorscrvicc and thc Kaiscr ratcs wcrc highly corrclatcd, with R
2
- c.. lor
paticnt day ratcs and R
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- c.6. lor !CU usc.
uitc lrankly, ! was surpriscd by this rcsult. ! had long subscribcd to
cconomist Alain nthovcns point ol vicw that thc supcrior c cicncy ol
:c: :vbic~i v~vi~)iox
Kaiscr dcrivcd lrom its commitmcnt to what Alan callcd privatc scctor
hcalth planning. Kaiscr, unlikc lcclorscrvicc organizations, knows prc
ciscly thc numbcr ol Kaiscr mcmbcrs in cach ol its gcographic rcgions and
thus knows its dcnominatorthc sizc ol thc population it scrvcs. ! had
assumcd that Kaiscr would thcrclorc bc ablc to managc hospital capacity
throughout its various gcographic locations, sccking to achicvc morc or lcss
cqual numbcrs ol hospital bcds pcr capita in cach rcgion (with somc adjust
mcnts lor lcvcls ol illncss in thc local population) and thus cnsurc that thc
utilization ratcs lor paticnts with chronic illncss would bc about thc samc
cvcrywhcrc. Tis study makcs clcar that this is not thc casc: cvcn in thc
Kaiscr systcm, thcrc is littlc consistcncy in thc way capacity is distributcd
among dicrcnt locations. Tc corrclations bctwccn thc ratcs ol acutc carc
utilization sccn in thc artmouth Atlas Mcdicarc lcclorscrvicc data and
thc Kaiscr ratcs suggcst that rcgional capacity accts thc bchavior ol Kaiscr
physicians in a manncr that is similar to how it accts providcrs rcimburscd
undcr lcclorscrvicc Mcdicarc.
Variation in the use of acute care hospitals is a problem aecting organized as
well as disorganized systems of care. Tat said, organized systems of care like Mayo
and Kaiser are still more e cient than most other providers. Developing replicable,
evidence-based models of care management and resource allocation must become a
goal of health care reform; as I discuss in the next chapter, organized systems must
play a central role in achieving this goal.
8. It Isnt Fair: Reason No. 1
Tc ovcrusc ol acutc carc hospitals and thc way Mcdicarc is nanccd
togcthcr crcatc a problcm ol gcographic incquity, in which taxpaycrs in
lowspcnding statcs arc subsidizing thc carc ol citizcns in highspcnding
statcs and paticnts (and cmploycrs) who buy hcalth insurancc in low
spcnding rcgions within statcs arc subsidizing thc pricc ol insurancc lor
thosc in highspcnding rcgions in othcr parts ol thcir statcs. Tcsc cross
markct subsidics arc somctimcs vcry largc. For cxamplc, assuming that
Mcdicarc spcnding continucs to risc at a pcr capita inationadjustcd ratc
ol .., a typical 6ycarold in Los Angclcs, Calilornia will rcccivc ovcr
s:,ccc morc in Mcdicarcnanccd hcalth carc than a typical 6ycarold
in Minncapolis, Minncsota, or about thc pricc ol a ncw 8MV Scrics .
7
8ut thc moncy docs not purchasc a sports car, which lor Los Angclcs rcsi
dcnts would yicld rcal plcasurc. Nor, as wc havc shown, docs it purchasc
clcctivc surgcry, including intcrvcntions that might improvc thc quality
wny wv xvvb )o vvvov: )nv w~y wv :~x~cv cnvoxic iiixvss :c.
ol lilc, such as kncc rcplaccmcnts or thc rcmoval ol cataracts.
8
n avcr
agc, clcctivc surgcry ratcs arc just about thc samc in lowcost Minncapolis,
Portland, rcgon, and Salt Lakc City, as thcy arc in highcost Manhattan,
Los Angclcs, and Miami. Tc translcr paymcnts principally purchasc morc
hospitalizations, morc stays in !CUs, and morc physician visits lor thosc
with chronic discascs.
Tis crossmarkct subsidization is thc rcsult ol lcdcral taxcs and insur
ancc prcmiums that arc not adjustcd lor local spcnding pattcrns.
9
And
local hcalth carc spcnding pattcrns arc dctcrmincd in largc mcasurc by
capacity. Tc most important systcm lactor (as opposcd to a lactor having
to do with paticnts, such as thc prcvalcncc ol illncss) dctcrmining whcthcr
a community is a nct importcr or cxportcr ol Mcdicarc dollars is thc sizc
ol its acutc carc hospital scctor rclativc to thc numbcr ol chronically ill
paticnts who nccd trcatmcnt. Miami, Manhattan, and Los Angclcs havc
ovcrbuilt thcir hospitals, Minncapolis, Portland, rcgon, Sacramcnto, and
Salt Lakc City havc bccn morc lrugal, using lcwcr hospital bcds, lcss phy
sician labor, and lcss cxpcnsivc tcchnologics such as !CU bcds and mcdical
imaging dcviccs. !t sccms ironic that taxpaycrs in thosc rcgions arc pun
ishcd lor thc lrugality ol thcir hcalth carc providcrs by having to subsidizc
thc carc ol Mcdicarc rccipicnts in rcgions likc Los Angclcs, Miami, and
Manhattan.
Tc problcm is only gctting worsc, bccausc, as wc havc sccn, carc intcnsity
lor managing chronic illncss is growing lastcr in rcgions that historically havc
bccn nct importcrs ol Mcdicarc dollars. Financial disparity among rcgions,
at lcast in tcrms ol Mcdicarc spcnding, thus can bc cxpcctcd to incrcasc.
!ronically, lrom thc pcrspcctivc ol clinical cquity, rcgions with lcss dcpcn
dcncy on acutc carc hospitals appcar to bc bcttcr o, thcy tcnd to havc bcttcr
outcomcs and lcss ovcrusc ol scrviccs.
Another reason for reducing the overuse of acute care hospitals is that it would
substantially improve geographic equity in Medicare.
9. It Isnt Fair: Reason No. 2
vcrusc imposcs a sccond cconomic pcnalty, onc that is unlair to paticnts
who livc in highspcnding, highusc rcgions. !n lcclorscrvicc Mcdicarc,
paticnts arc rcsponsiblc lor :c ol thc cost lor physician scrviccs and lor
mcdical cquipmcnt such as whcclchairs and oxygcn trcatmcnts. Vhilc pro
vidcrs in highcost rcgions arc winncrs bccausc thc subsidics hclp pay lor
thcir ovcrusc ol carc, thc paticnts in thcsc rcgions losc on two accounts. First,
:c :vbic~i v~vi~)iox
bccausc pcr capita spcnding is grcatcr, thcy lacc highcr copaymcnts, which
thcy must pay out ol pockct unlcss thcy havc supplcmcntal insurancc. For
cxamplc, thc avcragc copaymcnt ovcr thc last two ycars ol lilc lor paticnts
living in Miami is s,ccc, and in Los Angclcs, it is s,cc, lor thosc living
in Minncapolis, it is s.,occ, and in Portland, rcgon, it is s:,.cc. 8ut Los
Angclcs and Miami rcsidcnts losc on yct a sccond account, thc incrcascd
paymcnts arc dircctly associatcd with thc ovcrusc ol acutc carc hospitals, as
is cvidcnt in thc closc association among thc .c6 hospital rclcrral rcgions
bctwccn thc HC! indcx and copaymcnts lor which paticnts arc rcsponsiblc
(Figurc .:.). Tc additional carc thcy arc rccciving and paying lor has no nct
marginal bcnct. Reducing the overuse of acute care hospitals will reduce economic
costs to patients and would probably improve their outcomes , as long as providers
also make the move from disorganized to organized care,
10. Overuse Alters the Life Experience of the Patient for the Worse
Pcrhaps thc most important rcason lor rcducing thc ovcrusc ol acutc carc
hospitals is thc pcnalty that it imposcs on thc livcs ol paticnts and thcir lami
lics. !t is not just a mattcr ol wastcd rcsourccs, it is a mattcr ol how Amcricans
cxpcricncc thc incvitablc dcclinc in thcir hcalth that cnds in dcath. At thc
Figurc .:.. Tc association bctwccn hospital carc intcnsity (HC!) indcx and avcragc
copaymcnts pcr paticnt during thc last two ycars ol lilc among hospital rclcrral rcgions
(dcaths occurring :cc. through :cc). (Sourcc: artmouth Atlas Projcct databasc.)
R
:
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Hospital carc intcnsity indcx
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(
8
)
wny wv xvvb )o vvvov: )nv w~y wv :~x~cv cnvoxic iiixvss :c
samc timc, it is cqually important to rcmcmbcr that thc ovcrusc ol carc is
not just a phcnomcnon at thc cnd ol lilc. Carc intcnsity during tcrminal carc
and during thc last six months ol lilc is only part ol a pattcrn, rcgions and
hospitals that providc aggrcssivc rcscuc carc at this stagc in thc progrcssion
ol illncss also do so at carlicr stagcs. !l a hightcch dcath in thc hospital
wcrc thc pricc thc dying must pay to makc surc that thosc with progrcssing
chronic illncss cnjoycd a longcr lilc and a highcr quality ol lilc, thcn it might
bc vicwcd as thc cost ol mcdical progrcss. 8ut thc cvidcncc indicatcs that this
is not thc casc. vcrusc involvcs thc mcdicalization ol dcath in an apparcntly
lutilc cort to cxtcnd lilc cxpcctancy.
Tc impact on Amcricans can bc sccn in thc artmouth Atlas Projcct
statistics: most Amcricans will dic lrom chronic illncss, but thcir cxpcricncc
ol dcath will vary according to whcrc thcy livc. Among Mcdicarc paticnts
who dic lrom chronic illncss, .c ol thosc living in Los Angclcs and :o
ol thosc in Miami will cxpcricncc a stay in an !CU at thc timc ol dcath, in
Minncapolis and in Portland, rcgon, only . will. Tc ovcrusc ol acutc
carc hospitals imposcs a burdcn on paticnts, which hcrctolorc has occurrcd
largcly with littlc or no awarcncss on thc part ol paticnts, lamilics, or thcir
physicians.
Awareness on the part of patients and their families, and their physicians, of
the pattern of practice in their own community and at their own hospital is an
important step in the process of change. !n subscqucnt chaptcrs, ! will discuss
how paticnts, thcir lamilics, and thcir physicians might usc artmouth Atlas
Projcct inlormation to hclp paticnts rcccivc thc kind ol carc that most closcly
ts thcir prclcrcncc.
Tcrc arc compclling rcasons lor thc nation to dcal with thc ovcrusc ol mcdi
cal carc, particularly thc acutc carc hospital scctor. 8ut to takc action, wc nccd
to idcntily inc cicncy, cstimatc wastc, mcasurc thc paticnt cxpcricncc, and
thcn rclorm thc dclivcry systcm, so that it is morc c cicnt and morc locuscd
on thc nccds and wishcs ol paticnts and dclivcrs highcr quality carc and bct
tcr outcomcs.
This page intentionally left blank
:c
My undcrstanding ol thc sourccs ol unwarrantcd variation and undisciplincd
growth in hcalth carc points to thc importancc ol rcplacing disorganizcd,
chaotic systcms ol carc with organizcd systcms, rcplacing dclcgatcd dcci
sion making and thc doctrinc ol inlormcd conscnt with sharcd dccision mak
ing and thc standard ol inlormcd paticnt choicc, improving thc scicncc ol
hcalth carc dclivcry, and constraining undisciplincd growth in hcalth carc
capacity and spcnding.
Tc nal scction ol my book scts lorth somc idcas and stratcgics lor how
thcsc goals might bc accomplishcd. Tc locus lor Chaptcr .. is on promoting
thc growth ol organizcd carc by providing cconomic inccntivcs to providcrs
who acccpt rcsponsibility lor caring lor thcir population ol loyal paticnts
not just in thc acutc phasc but throughout thc coursc ol thcir illncss, a strat
cgy that sccms particularly suitcd lor chronically ill paticnts. Tc cconomic
inccntivc is sharcd savingsthc opportunity lor providcrs who bccomc morc
c cicnt to rctain part ol thc savings to rcinvcst in carc and rcduction ol
dcbt. Tc sharcd savings stratcgy could rcsult in largc rcwards lor providcrs
in highcost rcgions who rcducc thcir inpaticnt spcnding to thc pcr capita
lcvcls ol providcrs in lowcost rcgions. Acadcmic mcdical ccntcrs arc callcd
on to undcrtakc thc ncccssary rcscarch to rationalizc thc clinical pathways
lor managing chronic illncssand to adjust thcir rcsourcc inputs toward thc
v~v) iv
Pathways to Reform
:c v~)nw~ys )o vvvov:
c cicncy bcnchmarks that cmcrgc lrom thcir rcscarch. Sharcd savings would
bc kcy to thc complction ol this mission.
Chaptcr . considcrs scvcral approachcs to promoting sharcd dccision
making and cstablishing inlormcd paticnt choicc, including changcs in statc
laws govcrning malpracticc to providc grcatcr immunity to physicians who
providc highquality sharcd dccision making, dcmonstration projccts, cco
nomic inccntivcs, and thc assumption by primary carc physicians ol advo
cacy and prolcssional accountability lor cnsuring inlormcd paticnt choicc
as a standard ol practicc. Comparativc ccctivcncss rcscarch along thc lincs
discusscd in Chaptcr would makc it lcasiblc lor primary carc physicians to
assumc this rolc.
Vhilc thc nation dcspcratcly nccds to rccnginccr clinical practicc, it can
not dcpcnd on rclorm ol thc dclivcry systcm as thc primary mcans lor con
trolling capacity and spcnding. !n this upsidcdown cconomy, rclorm rcquircs
working lrom thc top down as wcll as lrom thc bottom up. !n Chaptcr ., !
outlinc six stcps that can bc takcn to placc limits on capacity and spcnding
and buy timc lor rclorm ol thc dclivcry systcm to takc hold.
Tc nal chaptcr summarizcs thc challcngc ol practicc variation.
:co
Motivating providcrs to coordinatc carc and achicving savings lrom rcduc
tions in ovcrusc will rcquirc ncw policics and ncw ways ol thinking about
chronic illncss and how to organizc and nancc hcalth carc. Tc lions sharc
ol Mcdicarc spcnding gocs toward caring lor thc chronically ill, paticnts who
arc trcatcd as il thcy havc acutc (c.g., tcmporary) conditions. 8ut chronic
illncss docs not go away. No mattcr how succcsslul sccondary prcvcntion
may bc, barring major brcakthroughs in mcdical scicncc, most paticnts with
chronic illncss arc on a trajcctory that usually lasts until dcath, with symp
toms and lunctional dcclinc bccoming progrcssivcly morc dcbilitating lor
thc paticnt and morc costly lor lamilics and lor Mcdicarc. For this paticnt
populationthc nations most costlyMcdicarc is not an insurancc plan
intcndcd to covcr unlorcsccn risks, it is thc paycr lor carc ovcr an cxtcndcd
pcriod ol timc involving an incvitablc dcclinc in hcalth and risc in costs. Tc
rclcvant cpisodc ol illncss is thus mcasurcd in months and ycars, and stratc
gics to managc thc paticnts carc must havc a similar longrangc locus.
Tc way chronic illncss is managcd dicrs markcdly lrom rcgion to rcgion
and lrom providcr to providcr within rcgions. A providcrs pattcrn ol practicc
in trcating chronic discasc cxtcnds throughout thc coursc ol thc paticnts
illncss, not just during its tcrminal phasc. Hospitals that arc ovcrtrcating in
thc last six months ol paticnts livcs arc ovcrtrcating thcm long bclorc that.
Morcovcr, ovcrusc is drivcn in largc mcasurc by thc inucncc that capacity
..
Promoting Organized Care
and Reducing Overuse
:.c v~)nw~ys )o vvvov:
(worklorcc and lacilitics) cxcrts on physician dccisions madc in thc abscncc
ol mcdical cvidcncc. Tus, thc rcmcdy lor ovcrusc and unwarrantcd variation
must simultancously locus on scvcral variablcs at multiplc lcvclsadjusting
rcsourcc capacity rclativc to thc sizc ol thc population ol paticnts scrvcd,
coordinating carc c cicntly across multiplc carcgivcrs and multiplc scttings
ovcr timc, and cnsuring thc timcly usc ol spccic intcrvcntions as callcd lor
by thc dictatcs ol cvidcnccbascd mcdicinc, all ol which rcquircs an orga
nizcd systcm ol carc accountablc to a dcncd paticnt population.
Tc currcnt rcimburscmcnt systcm makcs such rclorms cxcccdingly
di cult, il not impossiblc. !t rcimburscs lor utilization, not carc managc
mcnt ovcr timc, rcwards highintcnsity inpaticnt carc handsomcly, pays
rclativcly littlc lor primary carc and othcr componcnts ol carc csscntial lor
populationbascd, communitywidc managcmcnt ol chronic illncss, rcwards
rathcr than punishcs unncccssary duplication ol scrviccs, docs not compcn
satc hospitals lor losscs associatcd with rcduction in acutc carc capacity, and
lails, lor thc most part, to makc distinctions bctwccn high and lowquality
pcrlormancc.
!ronically, a Madc in thc USA modcl lor organizing carc that is account
ablc to a dcncd paticnt populationand how to pay lor italrcady cxists
in thc lorm ol prcpaid group practiccs such as Kaiscr Pcrmancntc and Group
Hcalth Coopcrativc. So why has thc modcl not sprcad: nc rcason is that
it is cxtrcmcly di cult to organizc providcrs to bccomc tcam mcmbcrs and
coordinatc carc. 8ut cvcn whcn providcrs want to bccomc organizcd, cco
nomic inccntivcs work against thcm. Pcoplc havc bccn working on this prob
lcm lor a long timc. !n thc ycars lcading up to thc Clinton hcalth rclorm
proposal, ! attcndcd scvcral mcctings ol thc ]ackson Holc Group, organizcd
by Paul llwood and Alain nthovcn. Much ol thc discussion locuscd on
how to crcatc markct inccntivcs to drivc providcrs into compcting orga
nizcd systcms whcrc hcalth carc workcrs and administrators work as a uni
cd tcam to coordinatc carc across scctors, including hospitals, cxtcndcd carc
lacilitics, nursing homcs, and othcr communitybascd hcalth lacilitics, and
whcrc carc takcs placc within thc constraints ol an annual budgct.
Tc plan lor managcd compctition bascd on nthovcns conccpts wcnt
down with thc Clinton hcalth carc plan. !t bccamc a targct ol proponcnts
ol a singlcpaycr systcm who vicwcd it as a last ditch cort to prcscrvc
thc insurancc industry. Skcptics also cmcrgcd who did not bclicvc that thc
markct would adcquatcly control priccs. 8ut it also dicd bccausc ol lack
ol rclcvancc and appcal to Amcricans who did not livc in urban scttings. !n
many parts ol thc country, it is not lcasiblc to dividc providcrs into compcting
groups. !ndccd, to sustain a lully compctitivc modcl along thc lincs proposcd
vvo:o)ixc ovc~xizvb c~vv ~xb vvbicixc ovvvisv :..
undcr thc managcd carc initiativc, wc havc cstimatcd that a rcgion would
nccd a minimum ol ..: million pcoplc.
!
!n .ooc, only : ol thc U.S. popu
lation livcd in such rcgions. !n lcsspopulatcd rcgions, compctition among
providcrs makcs lcss scnsc, and in rural, small town Amcrica, it makcs no
scnsc at all.
Shared Savings as an Incentive to Promote Organized Care
Prcpaid group practiccs such as Kaiscr Pcrmancntc or Group Hcalth
Coopcrativc rcmain a compclling Amcrican succcss story, and it is ol intcr
cst that thcy did not gct thcir start bccausc ol markct compctition. Somc
bcgan primarily in rural rcgions to providc carc whcrc nonc cxistcd, in small
towns that cxpandcd dramatically during Vorld Var !! to providc carc
to shipyard workcrs, or, as in thc casc ol Group Hcalth Coopcrativc, as a
consumcrowncd coopcrativc to scrvc thc nccds ol Scattlc. Soon altcr thc
lailurc ol thc Clinton plan, my collcagucs and ! bcgan thinking about how
paymcnt rclorm could bc dcsigncd to givc hcalth carc providcrs in \crmont
and Ncw Hampshircwhcrc thc population basc ol local mcdical markcts
lalls way bclow thc rcquircd population basc lor compctition bctwccn intc
gratcd hcalth carc systcmsthc cxibility thcy nccd to addrcss unwarrantcd
variation. From my \crmont days, ! was awarc ol thc pattcrn ol ovcrusc in
Randolph, a small town in thc middlc ol thc statc. !n thc latc .o6cs, Randolph
stood at or ncar thc top ol thc distribution in pcr capita spcnding and utiliza
tion, primarily bccausc ol its high ratc ol admission to thc towns onc hospital
lor mcdical conditions. As artmouth Atlas Projcct data bccamc availablc in
thc mid.oocs, Randolph continucd to stand out as a high utilizcr, and wc
thought it might bc possiblc to dcvisc a plan that would hclp thc providcrs ol
Randolph bccomc morc c cicnt.
A lcw things had changcd sincc Randolph rst camc to our attcntion.
Many ol thc primary physicians living in thc community had joincd thc
sta ol thc local hospital, Giord Mcmorial, as lulltimc, salaricd cmploy
ccs. Salaricd physicians cmploycd by thc artmouthHitchcock Mcdical
Ccntcrliving cithcr on sitc in Randolph, or in Hanovcrwcrc now provid
ing most ol thc spccialty carc. Tosc two changcs mcant that Randolph had
alrcady comc part ol thc way toward bccoming an organizcd group practicc.
Vc suggcstcd a plan to thc providcr community to pay lor carc on a pcr cap
ita basis. vcryonc, administrators and physicians alikc, sccmcd to agrcc that
this would hclp thcm dclivcr highcrquality carc and providc bcttcr stcward
ship in managing costs and rcsourccs.
:.: v~)nw~ys )o vvvov:
Vc workcd with thc providcrs to dcvclop a proposal lor a dcmonstra
tion projcct to cstablish a budgct lor managing carc lor thc population ol
Randolph, bascd on what wc callcd virtual capitation.
2
Tis was tcchnically
lcasiblc bccausc thc claims data allowcd us to associatc thc providcrs ol carc
thc physician sta ol thc Giord Mcmorial Hospital and thc artmouth
Hitchcock Mcdical Ccntcrwith thc population thcy scrvcd. Vc could thcn
calculatc how much moncy was spcnt lor this population on an annual basis
and usc this to cstablish a prospcctivc budgct lor thc cnsuing ycar. Paymcnts
would bc madc on a rcgular monthly basis. Savings obtaincdlor cxamplc,
by rcducing thc capacity ol thc acutc carc hospital, which our data showcd
lar cxcccdcd thc bcnchmark ol othcr hospitals in thc rcgioncould thus bc
capturcd by thc providcrs and rcinvcstcd in ncw scrviccs, including thosc
not covcrcd undcr lcclorscrvicc at that timc, such as anticholcstcrol statin
drugs lor highrisk paticnts, discasc managcmcnt programs, and commu
nitybascd prcvcntion programs. ur paymcnt modcl was dcsigncd to givc
thc Randolph hcalth carc providcrs thc cxibility thcy nccdcd to rcallocatc
rcsourccs to morc c cicnt purposcs and to givc Mcdicarc (and othcr insurcrs,
wcrc thcy to join) thc assurancc that global (total pcr capita) spcnding could
bc controllcd.
Vhcn wc proposcd a projcct bascd on thcsc idcas to Mcdicarc, wc rcccivcd
only a lukcwarm rcsponsc, and altcr scvcral ycars ol going back and lorth, thc
idca dicd ol attrition (and cxhaustion). 8ut thc conccpts ol sharcd savings,
global budgcts, and virtual capitation that did not rcquirc thc lormal cnroll
mcnt ol paticnts into a hcalth maintcnancc organization (HM) havc livcd
on. !n thc carly :cccs, Scnator ]amcs ]cords introduccd lcgislation modclcd
altcr our lailcd corts to rccnginccr hcalth carc in Randolph, which bccamc
law undcr Scction 66 ol thc Mcdicarc Prcscription rug !mprovcmcnt
and Modcrnization Act ol :cc. (Pub. L. .c..), as thc Mcdicarc Hcalth
uality cmonstration Program.
1
Tc law allows providcrs to cstablish pro
spcctivc budgcts lor managing carc, lrccing thcm to allocatc rcsourccs toward
caring lor paticnts ovcr timc, rathcr than invcsting in whatcvcr scrvicc linc
is supportcd by thc lcc schcdulc. Tc law allows thc Sccrctary ol Hcalth and
Human Scrviccs to waivc rcgulatory provisions, including thc Stark anti
kickback statutcs, so that providcrs can participatc in a sharc ol thc savings
obtaincd by improving c cicncy and quality ol carc.
Morc rcccntly, my collcagucs r. lliott Fishcr and ]onathan Skinncr,
togcthcr with r. Mark McClcllan and othcrs at thc 8rookings !nstitution,
havc proposcd a national sharcd savings program.
4
Tcir proposal would
cncouragc providcrs in virtually cvcry mcdical community to takc stcps to
bccomc accountablc carc organizations (ACs), intcgratcd hcalth carc
vvo:o)ixc ovc~xizvb c~vv ~xb vvbicixc ovvvisv :..
systcms capablc ol mccting ccrtain quality standards and improving thc coor
dination ol carc. !l thcy accomplish this, Mcdicarc would thcn sharc part ol
thc savings lrom improvcmcnts in c cicncy with thc providcr. !l succcsslully
implcmcntcd, thc AC modcl could grcatly lacilitatc thc transition lrom
disorganizcd to organizcd carc throughout thc Unitcd Statcs.
!t is important to cmphasizc that thc cort to promotc organizcd and
accountablc carc through sharcd savings programs is quitc dicrcnt lrom
thc cort in thc .oocs to lorcc paticnts into managcd carc. First, thcsc proj
ccts locus on maintaining and improving quality, using acccptcd, objcctivc
mcasurcs, many morc ol which arc availablc today than in thc past. Sccond,
thc Ccntcrs lor Mcdicarc & Mcdicaid Scrviccs (CMS) is dcaling dircctly
with providcrs, not insurancc companics motivatcd to capturc thcir sharc
ol thc rcvcnuc strcam. Tird, thc paticnts lrccdom to choosc thcir providcr
is thc samc as undcr traditional Mcdicarc. Tcy arc not lockcd into using
a providcr lor a ycar or longcr, as thcy wcrc undcr managcd carc. Tcy
can lcavc and go clscwhcrc lor carc at any timc thcy want il thcy bccomc
dissatiscd.
!n this chaptcr, ! discuss how providcrs might rcspond to sharcd savings
inccntivcs to organizc and coordinatc carc, strivc to achicvc thc c cicncics
dcmonstratcd by organizcd group practiccs and intcgratcd hospital systcms,
and, in thc casc ol acadcmic mcdical ccntcrs, undcrtakc thc ncccssary rcscarch
to rationalizc thc black box ol supplyscnsitivc carc.
rganizcd Systcms ol Carc
Multispccialty group practiccs and intcgratcd hospital systcms, bccausc thcy
arc shovcl rcady systcms, would bc thc most obvious candidatcs to bccomc
ACs. Tcy havc alrcady accomplishcd what lor most providcrs will bc thc
most di cult task: thcy arc organizcd and thcir physicians arc practiccd in
carc coordination and tcam mcdicinc. vcn so, thcrc is considcrablc room
lor improvcmcnt in thcsc organizcd systcms. As discusscd in prcvious chap
tcrs, chronic carc managcmcnt among wcllorganizcd, largc multispccialty
groups docs not as yct lollow a wclldcncd and rcplicablc modcl that could
bc cxportcd as a bcst practicc stratcgy, or modcl. To undcrtakc thc ncccssary
rcstructuring ol capacity and thc rcdcsign ol thc clinical pathways lor man
aging carc, organizcd systcms, likc all providcrs, nccd a rcimburscmcnt plan
that crcatcs a targct budgct lor managing thcir paticnt population ovcr timc
and pays in rcal timc a sharc ol thc savings in lcclorscrvicc spcnding madc
possiblc by rcducing utilization.
:. v~)nw~ys )o vvvov:
rganizcd practiccs arc pcrhaps idcally situatcd to takc advantagc ol sharcd
savings as a stratcgy lor capitalizing growth into othcr gcographic arcas, or
within thcir own markcts. Tcy could acquirc inc cicnt hospitals or physician
practiccs, rcducc thc acquircd practiccs ovcrusc ol carc, particularly acutc carc
hospitals, and invcst thc savings to build a communitybascd, and primary
carcbascd, systcm lor managing chronic illncsscs. Tc savings lrom improv
ing thc c cicncy ol acutc carc hospitals arc potcntially quitc largc, as illus
tratcd by thc rcccnt acquisition and subscqucnt rcduction in capacity ol South
Vilkcs8arrc Hospital by thc Gcisingcr Clinic. According to thc artmouth
Atlas, thc Vilkcs8arrc, Pcnnsylvania, rcgion has only thrcc hospitals. 8ut
comparcd to thc anvillc rcgion, thc homc basc ol thc Gcisingcr Clinic, hos
pital utilization ratcs lor acutc and chronic illncsscs in Vilkcs8arrc wcrc
much highcr. ur data indicatc that Gcisingcr Clinics dccision to rcducc
acutc carc hospital capacity will rcsult in largc savings in hcalth carc spcnd
ingas much as s... million pcr ycar lor Mcdicarc lcclorscrvicc mcdicinc
alonc. Systcmwidc savings ol this magnitudc, rcturncd to group practiccs that
participatc in sharcd savings program, could providc a major sourcc ol capital
lor constructing thc inlrastructurc ol communitywidc managcmcnt ol hcalth
carc and a strong inccntivc lor group practiccs to cxpand into ncw markcts.
rganizcd group practiccs may also cxtcnd thcir rcach into ncw rcgions
through growth in primary carc and thc usc ol physician cxtcndcrsnursc
practitioncrs, physicians assistants, and casc managcrs. Tc Kaiscr Pcrmancntc
hcalth carc systcm has shown how this can bc donc in Gcorgia, whcrc Kaiscr
Pcrmancntc has cxpandcd into ncw mcdical communitics by dcploying pri
mary carc physicians who arc backcd up by nursc coachcs and sclcctcd mcdi
cal spccialist consultants.
Finally, individual hospitals and thcir associatcd physician stas may bccomc
motivatcd to scck partncrships with largc group practiccs or intcgratcd hospi
tal systcms that alrcady havc thc inlrastructurc and cxpcricncc to hclp thcm
through thc transition lrom disorganizcd to organizcd systcms ol carc.
Multihospital Nctworks
Hospital nctworks could conccivably scrvc as thc nuclcus lor thc rapid
growth ol organizcd carc. Tc Suttcr Hcalth Systcm in Sacramcnto and
!ntcrmountain Hcalthcarc in Salt Lakc City arc modcls lor how hospi
tal nctworks can dcvclop into coordinatcd carc systcms. vcr thc past lcw
dccadcs, a numbcr ol hospital systcms havc ariscn around thc country
somc notlorprot, somc lorprot, somc associatcd with acadcmic mcdical
vvo:o)ixc ovc~xizvb c~vv ~xb vvbicixc ovvvisv :.
ccntcrs, and othcrs not. 8y :cc, lully .c ol traditional Mcdicarc paticnts
hospitalizcd lor chronic illncss during thc last two ycars ol lilc wcrc trcatcd
primarily in hospitals bclonging to nctworks with tcn or morc mcmbcr lacil
itics. Tcrc arc striking variations among thc hospitals bclonging to thcsc
nctworks, suggcsting that thcrc is plcnty ol room lor bcttcr managcmcnt
that would rcsult in sharcd savings (Figurc ....). For cxamplc, among thc ..o
Hospital Corporation ol Amcrican (HCA) hospitals, Mcdicarc rcimbursc
mcnts varicd by a lactor ol :., lrom about s.,cc pcr paticnt ovcr thc last
two ycars ol lilc to morc than so,ccc. Tcrc was cvcn morc variation among
thc hospitals bclonging to thc Tcnct Hcalthcarc Corporation (indccd, thc
highcst pcr paticnt spcnding among all hospitals bclonging to a nctwork was
sccn at Tcnct hospitals). Among laithbascd nctworks, Catholic Hcalthcarc
Vcst and Catholic Hcalth ast showcd grcat variation.
Tc opportunity lor signicant savings is particularly high lor providcrs
in highcost rcgions (Los Angclcs, Ncw ]crscy, Miami, and downstatc Ncw
York, lor instancc). Tis might motivatc thc managcmcnt tcams at hospital
nctworks with lacilitics in both high and lowcost rcgions to takc aggrcssivc
stcps to improvc c cicncy. Considcr thc opportunitics lor nancial gain that
would bc availablc to Catholic Hcalthcarc Vcst, which in :cc was compriscd
ol thirtythrcc hospitals, ol which vc wcrc locatcd in thc highcost Los
Angclcs rcgion and six in lowcost Sacramcnto. According to thc artmouth
Atlas routinc rcports, ovcr thc last two ycars ol thcir chronically ill paticnts
livcs, pcr capita Mcdicarc spcnding lor all scctors ol carc (not just inpaticnt
carc) was soc,66: lor thc vc Los Angclcs hospitals, whcrcas spcnding lor
similar paticnts trcatcd in thc six Catholic Hcalthcarc Vcst hospitals scrv
ing Sacramcnto was just ovcr hall ol that, so,. pcr paticnt. 8ccausc thcy
achicvc bcttcr quality using lcwcr rcsourccs, thc Catholic Hcalthcarc Vcst
hospitals in Sacramcnto should scrvc as a rclativc c cicncy bcnchmark lor
thc systcms hospitals in Los Angclcs.
Hcrc is an idca ol thc potcntial savings. Had thc vc Los Angclcs hos
pitals and associatcd physicians lcarncd to providc carc at thc Sacramcnto
ratc ovcr thc vcycar pcriod lrom :cc. through :cc, thc cost ol carc lor
Catholic Hcalthcarc Vcsts paticnts in Los Angclcs would havc amountcd
to only s:6c million in Mcdicarc dollars. !nstcad, actual spcnding was sc
million. Tc dicrcncc bctwccn actual and prcdictcd spcnding undcr thc
Sacramcnto bcnchmarkalmost s::c million ovcr vc ycarsindicatcs thc
approximatc amount that could bccomc availablc il Catholic Hcalthcarc
Vcst hospitals in Los Angclcs wcrc to succcsslully rcach thc Sacramcnto
bcnchmark lor rclativc c cicncy in managing chronic illncss. Notc that thcsc
savings arc only lor carc in thc last two ycars ol lilc and just lor chronically
Figurc ..... Mcdicarc spcnding pcr paticnt during thc last two ycars ol lilc lor paticnts with common chronic
illncsscs rccciving most ol thcir carc lrom a hospital bclonging to onc ol twclvc hospital systcms (dcaths
occurring :cc. through :cc). ach dot rcprcscnts a hospital. (Sourcc: artmouth Atlas Projcct databasc.)
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Health
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Ascension
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Catholic
Health
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Catholic
Healthcare
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Trinity
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Catholic
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Adventist
Health
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Sunbelt
Catholic
Healthcare
Partners
Most costly
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vvo:o)ixc ovc~xizvb c~vv ~xb vvbicixc ovvvisv :.
ill paticnts, and thus this amount undcrcstimatcs thc total savings il Los
Angclcs Catholic Hcalthcarc Vcst providcrs wcrc to rcach thc Sacramcnto
Catholic Hcalthcarc Vcst lcvcl ol intcnsity ol carc.
Physician Practicc Nctworks
Vhat about thc prospccts lor a physician nctworkthc socallcd !ndcpcndcnt
Physician Associations (!PAs), which arc particularly prcvalcnt in Calilornia:
r a primary carc nctwork organizcd as a mcdical homc that qualics as
an AC: n thc surlacc, thc prospccts sccm quitc good. As wc havc sccn,
cvcn within a rcgion such as Los Angclcs, thcrc is rcmarkablc variation in
Mcdicarc spcnding lor thc chronically ill among paticnts loyal to a givcn hos
pital, mostly bccausc ol dicrcnccs in intcnsity ol inpaticnt carc and thc asso
ciatcd usc ol skillcd nursing homcs and longtcrm carc hospitals. Assuming
that thc nctworks physicians arc lrcc to scnd paticnts to any hospital locatcd
within thcir community, thc artmouth Atlas rcports can point such organi
zations as !PAs toward thc hospitals that havc thc lowcst pcr capita spcnding
lor Mcdicarc paticnts with progrcssivc chronic illncss. 8y mcrcly translcrring
paticnts to thc morc c cicnt hospital, thc physician nctwork would likcly
rcalizc a largc rcward lor incrcascd c cicncy, without any apparcnt loss in
thc quality ol carc (8ox ....).
From thc point ol vicw ol Mcdicarc and othcr paycrs, thc ovcrall impact
may not bc so lavorablc, unlcss stratcgics to rcducc thc ovcrusc ol acutc carc
hospitals acct thc capacity ol thc inpaticnt scctor in a givcn community. Tus,
incrcasing thc c cicncy ol onc hospital may turn out to bc just anothcr lorm
ol cost shilting, as thc pcr paticnt intcnsity ol carc riscs in thc hospital that
is losing paticnts. Tis is onc rcason why a sharcd saving stratcgy may nccd a
big stick to kccp ovcrall spcnding undcr control on a hospitalspccic as wcll
as a rcgional basis. For cxamplc, artmouth routinc rcports would rccord any
incrcascs in pcr capita spcnding at St. Mary Mcdical Ccntcr abovc, say, thc
national avcragc cxpcctcd incrcasc as dctcrmincd by Mcdicarc. Tis inlorma
tion could bc uscd to tailor an ovcrusc pcnalty (discusscd in Chaptcr .) to
prcvcnt any compcnsatory risc in ovcrutilization that might occur as rcsult ol
a dcclinc in thcir paticnt population.
Acadcmic Mcdical Ccntcrs
Acadcmic mcdical ccntcrs, as shown in Chaptcr .., cxhibit striking variation
in thc intcnsity ol carc and thc usc ol rcsourccs. As part ol thcir rcsponsibility
:. v~)nw~ys )o vvvov:
lor thc intcrlacc bctwccn clinical scicncc and clinical practicc, acadcmic mcd
ical ccntcrs must bc challcngcd to undcrtakc thc studics nccdcd to cstablish
a morc scicntic basis lor managing acutc and chronic illncss ovcr timc. !n
addition to conducting comparativc ccctivcncss rcscarch to tcst thc c cacy
ol individual trcatmcnts and tcsts, making mcdicinc morc scicntic rcquircs
thc rcdcsign and tcsting, and still lurthcr rcdcsign and rctcsting, ol carc pro
ccsscs. !l, as may wcll happcn, acadcmic mcdical ccntcrs cnd up providing
lcwcr scrviccs in rcsponsc to bcttcr cvidcncc, thc outcomc will bc a loss in
rcvcnuc. Tus, a sharcd savings program may bc an csscntial componcnt
ol thc inccntivc packagc acadcmic mcdical ccntcrs will nccd to participatc
aggrcssivcly in thc rcdcsign ol clinical practicc. !n othcr words, it will not bc
su cicnt simply to pay thcm to conduct comparativc ccctivcncss rcscarch.
Mcdicarc (and othcr insurcrs) must also ocr thc acadcmic mcdical ccntcrs a
nancial bridgc to grcatcr c cicncy.
For supplyscnsitivc carc, carc proccsscs arc prctty much a black boxthc
ratc ol scrviccs is drivcn primarily by availablc rcsourccs and a pcrvcrsc pay
mcnt systcm, unconstraincd by mcdical thcory and mcdical cvidcncc. \cry
lcw hcalth carc organizations havc a track rccord ol accomplishmcnts that
8ox ..... How Physician Networks Might Benet from a Shared
Savings Program: Te Long Beach, California, Example
Tcrc arc thrcc hospitals in Long 8cach, all within thrcc milcs ol cach
othcr. 8ctwccn :cc. and :cc, rcimburscmcnts to St. Mary Mcdical
Ccntcr totalcd so,ccc pcr capita ovcr thc last two ycars ol lilc::
morc than thc s.,ccc that Mcdicarc spcnt on similar paticnts using
Long 8cach Mcmorial Hospital. Tc third hospital in thc commu
nityPacic Mcdical Ccntcrspcnt soc,ccc pcr capita, .. morc
than Long 8cach Mcmorial Hospital. 8y changing rclcrral pattcrns
to cnsurc that its paticnts with chronic illncss arc managcd in con
junction with inpaticnt scrviccs providcd by Long 8cach Mcmorial
Hospital, a physician nctwork locatcd in that community would rcal
izc a rcduction in cxpcctcd costs lor managing chronic illncss ovcr thc
last two ycars ol lilc ol about s.,ccc lor paticnts translcrrcd lrom St.
Mary Mcdical Ccntcr and so,ccc lor paticnts lrom Pacic Mcdical
Ccntcr. !n :cc, thc quality ol carc compositc scorcs lor Long 8cach
Hospital wcrc slightly bcttcr than thosc lor St. Marys, Pacic Mcdical
Ccntcr did not rcport its quality rcsults.
vvo:o)ixc ovc~xizvb c~vv ~xb vvbicixc ovvvisv :.o
providc a modcl ol how this rcscarch and dcvclopmcnt might bc conductcd.
!ntcrmountain Hcalthcarc, an intcgratcd hospital nctwork ol ltccn hospi
tals locatcd in wcstcrn Utah and southcastcrn !daho, is onc ol thc lcw, and
thc rcscarch bcing conductcd thcrc scrvcs as a window on thc potcntial and
pitlalls ol rccnginccring thc carc ol thc chronically ill.
!nspircd by thc work ol V. . cming, a guru ol continuous quality
improvcmcnt, r. 8rcnt ]amcs and his collcagucs at !ntcrmountain cmbarkcd
about ltccn ycars ago on a program to rationalizc thc way mcdicinc was
practiccd across thc !ntcrmountain Hcalthcarc systcm. Today, !ntcrmountain
is an imprcssivc cxamplc ol how comparativc ccctivcncss rcscarch can
rcducc variation, improvc carc outcomcs, and contributc to thc scicncc ol
clinical dccision making. Tc clinical program lor diabctcs providcs an cxam
plc. !ntcrmountain supports thc carc ol morc than :c,ccc diabctic paticnts,
dclivcrcd by morc than lty providcr tcams across thc cntirc systcm. A kcy
lcaturc is thc rationalization ol thc rclationships bctwccn primary carc and
spccialty carc. Tc primary carc physicians providc almost oc ol thc carc.
ndocrinologiststhc diabctcs knowlcdgc cxpcrtswork primarily in a
consultativc rolc to primary carc, dircctly managing only thc most di cult
cascs. A sct ol routinc pcrlormancc rcports guidc carc managcmcnt. Tc
rcports includc a iabctcs Action Lista summary lor cach paticnt that
a givcn tcam is managingol crucial quality mcasurcs such as glycosylatcd
hcmoglobin, lowdcnsity lipids, rctinal cyc cxams, and blood prcssurc. Tc
rcport ags paticnts with unlavorablc prolcs. n thc basis ol thcsc rcports,
spccic stcps arc takcn to addrcss problcms.
Vhilc usclul in motivating mcmbcrs ol thc tcam to pay attcntion to out
licrs, thc rcports on comparativc pcrlormancc arc primarily vicwcd as an
opportunity to lurthcr cxaminc thc carc pathways ol high pcrlorming prac
ticcs to lcarn why thcy arc comparatively more eective than othcrs. Vhat is
it that thcy arc doing that othcrs arc not doing: !n othcr words, thc strat
cgy is built around thc principlc that progrcss rcquircs an organization that
can lcarn lrom cxpcricncc. Undcr thc !ntcrmountain approach, comparativc
ccctivcncss rcscarch is thus playing an important rolc in an itcrativc stratcgy
to improvc thc scicntic basis ol clinical dccision making.
Tc commitmcnt to scicncc and improvcmcnt in thc scicntic basis ol
clinical dccision making undcrscorcs thc !ntcrmountain approach. Tc samc
inlrastructurc that rcsults in thc cxplication ol clinical proccsscs, tracking ol
outcomcs, and linking togcthcr ol carc proccsscs has positioncd !ntcrmountain
Hcalthcarc to undcrtakc morc traditional mcdical ccctivcncss rcscarch to
cvaluatc clinical hypothcscs using clinical trials or cohort studics that havc
bccn publishcd in pccrrcvicwcd journals.
::c v~)nw~ys )o vvvov:
Vhcn it comcs to managing supplyscnsitivc carc lor chronically ill
paticnts, thc Salt Lakc City rcgion, whcrc carc is dominatcd by !ntcrmountain
Hcalthcarc, is among thc nations most rclativcly c cicnt (scc Chaptcr ..).
For a numbcr ol conditions, !ntcrmountain is moving bcyond rclativc c
cicncy as a critcrion lor cvaluating pcrlormancc to cvaluating hcalth carc
dclivcry according to its costccctivcncsson bcst practiccs bcnchmarks
that arc bascd on rcal knowlcdgc ol thc rclationship bctwccn rcsourcc inputs
and hcalth outcomcs. Tus, thc rcsourcc input bcnchmarks and carc proccsscs
documcntcd in thc casc ol diabctcs rcprcscnt a morc rcliablc basis lor undcr
standing thc contcnt ol high valuc carc, or carc that dclivcrs rcal outcomcs,
and how much it actually costs to dclivcr it.
Such inlormation is critical lor thc longtcrm goal ol basing rcimburscmcnt
policy on thc costs ol dclivcring costccctivc carc. To bc surc, !ntcrmountain
has yct to complctc thc rationalization ol black box carc into clinical pro
grams lor a numbcr ol important chronic illncss, and dicrcnccs rcmain in
thc way mcdical rcsourccs arc uscd in managing chronic illncss lrom placc to
placc within thc !ntcrmountain systcm. Howcvcr, it has thc inlrastructurc in
placc to turn its attcntion to thcsc problcms.
utsidc ol a lcw othcr organizations that havc bccn willing, likc
!ntcrmountain, to sclllund this rcscarchthc Gcisingcr, Marshcld, and
Mayo Clinics comc to mindprogrcss has bccn quitc limitcd, cvcn among
organizcd practiccs that havc thc clcctronic mcdical rccord systcms and inlra
structurc in position to carry out such rcscarch. An obvious rcason is thc lack
ol lunding. Sincc thc mid.oocs downgradc ol thc Agcncy lor Hcalth Carc
Policy and Rcscarch (and its mctamorphosis into thc Agcncy lor Hcalthcarc
Rcscarch and uality), lcdcral lunding lor ccctivcncss rcscarch has dcclincd
to a lcw hundrcd million dollars annually, hardly cnough to support a sus
taincd assault on thc lack ol mcdical cvidcncc.
8ut lack ol rcscarch support is just onc ol thc hurdlcs. Tc morc signicant
constraint on conducting rcscarch that can lundamcntally altcr thc pattcrn
ol practicc is thc thrcat that it may bring to thc nancial stability ol thc
organization itscll. Pcrhaps thc most startling rcvclation yct to cmcrgc is that
cvcn though !ntcrmountain Hcalthcarc is among thc nations most c cicnt
hcalth carc organization in managing chronic illncss, thc rationalization ol
its carc proccsscs is lcading to still grcatcr c cicncics and rccovcrics ol wastc.
As 8rcnt ]amcs has discovcrcd, no good dccd gocs unpunishcd, bccausc
strcamlining !ntcrmountains dclivcry systcm and bccoming morc c cicnt
is nancially dcstabilizing. As thcir practicc pattcrns bccamc morc c cicnt,
lcwcr spccialty scrviccs wcrc nccdcd, as carc improvcd, hospitalization ratcs
lcll. Vhilc !ntcrmountain was ablc to ncgotiatc sharcd savings arrangcmcnts
vvo:o)ixc ovc~xizvb c~vv ~xb vvbicixc ovvvisv ::.
with somc ol its insurancc companics, thc nct ccct was a squcczc on rcv
cnuc, a situation that naturally lcads to troubling qucstions about how lar
improvcmcnt can bc allowcd to outpacc thc nccd lor rcvcnuc.
!mproving thc scicntic basis lor managing chronic illncss is critical to
thc rclorm ol hcalth carc. To do it right, lcading hcalth carc organizations
lrom dicrcnt parts ol thc country nccd to bc rccruitcd to this mission.
Largc group practiccs and intcgratcd hospital nctworks arc uniqucly quali
cd to conduct rcscarch that dcpcnds on organizcd dclivcry systcms, and
rcscarch grants undcr thc comparativc ccctivcncss rcscarch agcnda nccd to
bc targctcd to bring such organizations on board. Tcaching hospitals, partic
ularly thosc likc thc Univcrsity ol Calilornia hospitals that cxhibit strikingly
dicrcnt pattcrns ol carc, cvcn whilc thcy bclong to thc samc systcm ol
carc, must also bc rccruitcd. Yct rcscarch grants will not bc cnough to cnsurc
rapid implcmcntation ol this practiccchanging rcscarch agcnda. Tc rcdc
sign ol carc lor thc acutcly and chronically ill, gcarcd to improvc c cicncy
and clinical outcomcs, may lundamcntally altcr thc rcsourcc rcquircmcnts,
changing thc nccd lor bcds, physician worklorcc, and cquipmcntand dis
rupting thc ow ol volumc ol carcgcncratcd dollars csscntial lor shorttcrm
nancial stability. Progrcss in cstablishing costccctivc carc as thc standard
ol practicc will occur at a snails pacc unlcss thcsc organizations arc at lcast
partially shicldcd lrom major nancial impacts associatcd with dcclining
utilization ratcs. Tis is why thc comparativc ccctivcncss rcscarch agcnda
nccds to bc ticd to a sharcd savings program such as Mcdicarcs Scction
66 dcmonstration projcct.
Opportunities for Radical Redesign of Care for Aging America
A distinguishing charactcristic ol thc Amcrican culturc is its willingncss to
cxpcrimcnt to adapt to ncw challcngcs by guring out what works, cvcn whcn
this mcans a radical dcparturc lrom tradition. vcr thc past ltccn ycars, right
hcrc in Hanovcr, practically in thc backyard ol thc artmouthHitchcock
Mcdical Ccntcr, an cxamplc ol radical rcdcsign has takcn placc, but thc impli
cations lor both thc paticnt cxpcricncc and hcalth carc costs havc only rcccntly
bccomc apparcnt. Tc cxpcrimcnt involvcs thc cvolution ol a primary carc
bascd approach to providing continuous mcdical carc to thc rcsidcnts ol a
rctircmcnt community, locatcd in Hanovcr, Ncw Hampshirc. Most ol thc
c mcmbcrs ol thc community comc lrom prolcssional and busincss back
grounds, with many holding advanccd dcgrccs. As with most scnior living
communitics, thc mcmbcrs arc su cicntly a ucnt to bc ablc to purchasc thcir
::: v~)nw~ys )o vvvov:
homc and also pay monthly lccs. Tc sccurity thcy purchasc is lilctimc carc in
thc community. ncc mcmbcrs, virtually all rcmain until dcath.
According to r. cnnis McCullough, thc communitys lounding mcdi
cal dircctor, thc approach to hcalth carc is bascd in a comprchcnsivc dis
cussion among carcgivcrs and community mcmbcrs around mcdical carc
issucs, including prclcrcnccs lor carc at thc cnd ol lilc. vcr timc, a closc
collaboration bctwccn community mcmbcrs and carc providcrs has crcatcd
a mcdical subculturc that cmbraccs a rcmarkably conscrvativc stratcgy lor
managing acutc and chronic illncsscs and carc at thc cnd ol lilc. !n addition
to community participation and rcgularly rcpcatcd cducation on how thc
carc systcm works, ccntral clcmcnts includc carly lamily involvcmcnt in all
rccognizcd mcdical problcms, promotion ol a slowcd pacc lor carclul dcci
sion making lor all chronic problcms, and mcdical consultations as advicc
consultations (as opposcd to translcr ol paticnt managcmcnt). Tcsc impor
tant clcmcnts wcrc idcnticd and implcmcntcd jointly with thc community
ol cldcrs. Many rctircd rcsidcnt mcdical and nursing prolcssionals (a numbcr
ol whom had workcd at thc artmouthHitchcock Mcdical Ccntcr) wcrc
vital to thc initial planning ol thc communitys approach to hcalth carc. Tc
approach to carc dcvclopcd by and lor thc community bccamc thc basis lor
Slow Mcdicinc, a philosophy and sct ol practiccs dcscribcd in a book by thc
samc namc by r. McCullough.
6
Tc carc modcl is primary carcbascd, involving onc lulltimc cquivalcnt
primary carc physician and two nursc practitioncrs. As with many scnior
rctircmcnt communitics, thcrc arc onsitc lacilitics lor dcaling with progrcss
ing chronic illncss, including a skillcd nursing lacility (SNF) that is qualicd
lor Mcdicarc rcimburscmcnt. Tc primary carc tcam, composcd ol thrcc or
lour pcoplc, is accountablc lor continuous carc, on call :/, so usc ol thc
cmcrgcncy dcpartmcnt is gcncrally avoidcd. Tc carc tcam managcs rclcr
rals to spccialists and coordinatcs all admissions to thc ncarby artmouth
Hitchcock Mcdical Ccntcr. Tc usc ol thc onsitc SNF as a substitutc lor acutc
carc hospitalization provcd to bc an important assct lor accomplishing thc
goal ol avoiding hospitalization. vcn though Mcdicarc docs not rcimbursc
thc SNF lor carc unlcss thc stay lollows an acutc carc hospital admission, thc
mcmbcrs ol thc community and thcir providcrs arc dcdicatcd to avoiding
acutc carc hospitalization, il at all possiblc. For cxamplc, paticnts who cxpcri
cncc an acutc problcm, such as pncumonia or rccurrcncc ol congcstivc hcart
lailurc, arc routincly monitorcd and trcatcd in thc SNF rathcr than bcing scnt
to thc hospital. Physician and nursc practitioncr lccs arc billcd on a lcclor
scrvicc basis through Mcdicarc. Carc at thc cnd ol lilc, with rarc cxccptions,
takcs placc within thc community.
vvo:o)ixc ovc~xizvb c~vv ~xb vvbicixc ovvvisv ::.
Tc succcss ol thc communitys rcdcsign ol clinical practicc in mccting
thc goals ol thc community lor conscrvativc managcmcnt ol chronic illncss
and supportivc carc at thc cnd ol lilc is rccctcd in thc artmouth Atlas
statistics. Mcasurcd ovcr a tcnycar pcriod (.oo through :cc6), thc hospital
ization ratcs wcrc cxtrcmcly low comparcd to thc ratcs lor thc ncighboring
townspcoplc: only ol dcaths occurrcd in thc hospital comparcd to ::
ol rcsidcnts ol similar agcs living clscwhcrc in Hanovcr. (Nationally, about
.: ol thc dcaths in thc Mcdicarc population occur in hospital, in somc
rcgions, such as McAllcn, Tcxas, as many as ol paticnts dic in hospital.)
Community rcsidcnts wcrc hospitalizcd lor surgical proccdurcs at about thc
samc ratc as othcr citizcns ol Hanovcr, thc grcatcst dicrcncc bcing in thc
usc ol hospitals lor acutc and chronic mcdical conditions. Tc admission ratc
lor paticnts ycars ol agc and oldcr was only about oncthird ol that ol oth
crs living in Hanovcr6 admissions pcr .,ccc, comparcd to :.c pcr .,ccc.
mcrgcncy dcpartmcnt usc was similarly lowcr.
Tc potcntial lor thc radical translormation ol thc hcalth carc cconomy rcsts
in communitics and individuals coming to tcrms with prclcrcnccs rcgarding
thc managcmcnt ol chronic illncss and carc at thc cnd ol lilc. Primary carc is
crucial to hclping paticnts to both dcnc and achicvc thcir goals and support
altcrnativcs to acutc carc hospitalization. Tc story ol what has happcncd at
thc Hanovcr rctircmcnt community providcs an cxccllcnt cxamplc ol what
an AC might look likc: a dcncd systcm accountablc lor thc continuous
carc ol a population ol paticnts, in a way that is rcsponsivc to thcir nccds
and thcir wishcs. !t is also an cxamplc ol what is today widcly advocatcd as
thc primary carc mcdical homca paticntccntcrcd or communityccntcrcd
collaborativc modcl lor carc, organizcd around a primary carc tcam. !t points
to kcy lcaturcs that should bc supportcd undcr a sharcd savings program,
including thc organization ol primary carc as a lulltimc salaricd tcam with
:/ covcragc and dircct admission to an SNF without rcquiring a prior stay
in an acutc carc hospital.
As thc nation movcs lorward with hcalth carc rclorm, wc must acknowl
cdgc thc harms, both nancial and physical, that ovcrusc imposcs on paticnts,
cspccially thc cldcrly. Tc goal ol any hcalth carc systcm should bc to promotc
hcalth and to casc thc sucring that comcs with scrious illncss and dying.
Much ol our socallcd systcm docs ncithcr. Yct thcrc arc modcls out thcrc,
cxamplcs ol highquality, highvaluc carc and c cicncy, that can and should
lcad thc way toward a bcttcr, morc just, morc compassionatc, and paticnt
ccntcrcd way ol doing busincss. Tis mcans that wc havc somc, although
:: v~)nw~ys )o vvvov:
not all, ol thc answcrs to thc qucstion ol how to rccnginccr, strcamlinc, and
rclorm thc way wc managc chronic illncss and carc at thc cnd ol lilc. Vhat
rcmains to bc sccn is whcthcr thc nation has thc will to cxpcrimcnt with dil
lcrcnt approachcs and ncw ways ol both rcimbursing and organizing hcalth
carc until wc gct it right.
::
Tc dcmocratization ol thc doctorpaticnt rclationshipthc rcplaccmcnt
ol dclcgatcd dccision making by sharcd dccision making and thc doctrinc
ol inlormcd conscnt by a standard ol practicc bascd on inlormcd paticnt
choiccrcprcscnts a translormation in thc culturc ol mcdicinc that will not
bc casy to achicvc. Tat proccss was sct back by thc loss ol lunding lor thc
Paticnt utcomcs Rcscarch Tcams (PRTs) and thc grcatly diminishcd rolc
ol thc Agcncy lor Hcalthcarc Rcscarch and uality (lormcrly thc Agcncy
lor Hcalth Carc Policy and Rcscarch). Noncthclcss, sharcd dccision making
appcars to bc on rmcr ground than cvcr bclorc.
!
Paticnt dccision aids havc
bccomc availablc lor an incrcasing numbcr ol clinical conditions, and thcir
ccctivcncss has bccn cstablishcd by morc than lty clinical trialscnough
so that thcy havc bccn subjcctcd to rcvicw by thc Cochranc Collaboration,
an intcrnational nctwork ol rcscarchcrs dcvotcd to synthcsizing and apprais
ing mcdical knowlcdgc through a systcmatic rcvicw ol clinical data.
2
Tc
rcvicw conrms that dccision aids lacilitatc sharcd dccision making, incrcasc
paticnts knowlcdgc ol what is at stakc, promotc activc cngagcmcnt in dcci
sion making, rcducc unccrtainty on thc part ol thc paticnt about which trcat
mcnt to choosc, and improvc thc agrccmcnt bctwccn thc paticnts valucs or
prclcrcnccs and thc trcatmcnt option that is actually choscn.
1
Tc availability ol a growing library ol paticnt dccision aids makcs lcasiblc
thc broad implcmcntation ol sharcd dccision making into cvcryday practicc.
.
Establishing Shared Decision Making
and Informed Patient Choice
::6 v~)nw~ys )o vvvov:
Morc and morc providcrs arc committcd to cnsuring that paticnts lacing clcc
tivc surgcry havc an opportunity to bc lully inlormcd and to sharc thc trcat
mcnt dccision with thcir physicians, and dccision aids arc bcing intcgratcd
into cvcryday practicc with incrcasing sophistication and c cacy. Lcgislators
in scvcral statcs appcar to bc on thc vcrgc ol changing thc lcgal standard lor
dctcrmining mcdical ncccssity, lrom inlormcd conscnt to inlormcd paticnt
choicc. And thc nation, oncc again, may do somcthing signicant to improvc
cconomic inccntivcs lor thc rclorm ol thc hcalth carc dclivcry systcms.
Howcvcr, wc still lacc signicant barricrs.
Getting to Shared Decision Making
Lct mc bcgin with a bricl rcvicw ol thc history ol thc implcmcntation ol
sharcd dccision making at thc artmouthHitchcock Mcdical Ccntcr,
which illustratcs somc ol thc di cultics, as wcll as thc succcsscs, in bring
ing about cultural changc. Tc rst mcdical ccntcr to bcgin using dccision
aids in cvcryday practicc was thc \ctcrans Administration (\A) Hospital,
which is in Vhitc Rivcr ]unction, \crmont, just ovcr thc rivcr lrom thc
artmouthHitchcock Mcdical Ccntcr in Lcbanon, Ncw Hampshirc, and
onc ol thc tcaching hospitals lor thc artmouth Mcdical School. !n .o,
Mary La8rccquc, a rcspcctcd nursc practitioncr at thc \A Hospital, tcamcd
up with our rcscarch group to conduct thc initial study ol thc bcnign pros
tatic hypcrplasia (8PH) dccision aid. Shc rst uscd it as a kind ol virtual
sccond opinion, showing it to about twcntyvc paticnts who wcrc on thc
waiting list lor surgcry lor 8PH. To cvcryoncs surprisc, ncarly hall ol thc
paticnts who wcrc waiting lor surgcry dccidcd that thcy rcally did not want
thc surgcry altcr all. Subscqucntly, Mary hclpcd thc \A to implcmcnt thc
usc ol thc dccision aid as part ol a routinc proccss lor diagnosing paticnt
prclcrcnccs lor 8PH surgcry. 8y all accounts thc projcct was quitc succcss
lul, paticnts wcrc satiscd and physicians wcrc adaptcd to incrcascd paticnt
participation in choicc ol trcatmcnt. And thc projcct had a rcal ccct on
paticnt dcmand, rcsulting in signicant savings to thc \A as thc ratc ol sur
gcry droppcd, just as it had in thc HM cxpcrimcnt discusscd in Chaptcr 6.
8ut dcspitc (or rathcr bccausc ol ) this succcss, thc projcct was quitc sud
dcnly intcrruptcd by thc mcdical schools dcpartmcnt ol urology. !t turncd
out that undcr sharcd dccision making, thc numbcr ol surgical proccdurcs in
thc \A hospital dippcd wcll bclow thc lcvcl nccdcd to cnsurc that urology
rcsidcnts pcrlormcd cnough 8PH opcrations to mcct thc minimum rcquircd
to qualily lor board ccrtication. Faccd with this crisis, thc nccds ol mcdical
vs)~niisnixc sn~vvb bvcisiox :~xixc ::
cducators trumpcd paticnt prclcrcnccs and thc dccision was madc to cnd thc
\A cxpcrimcnt.
Sharcd dccision making thcn lound a ncw champion in .oo6 in r. ]amcs
Vcinstcin, who was rccruitcd lrom thc Univcrsity ol !owa. A conscrvativc sur
gcon by naturc, ]im has long bclicvcd that paticnts nccd to bc lully cngagcd in
thc dccision about somcthing as potcntially lilc changing as surgcry. ]im had
alrcady rccognizcd thc valuc ol dccision aids whilc hc was at thc Univcrsity
ol !owa, whcrc hc scrvcd as a mcmbcr ol thc back pain paticnt outcomcs
rcscarch tcam lundcd by thc Agcncy ol Hcalth Carc Policy and Rcscarch.
Soon altcr ]im camc to artmouth, Hcalth ialog and thc Foundation lor
!nlormcd Mcdical ccision Making bcgan thc proccss ol cxpanding thc
library ol dccision aids, and ]im saw to it that inlormcd paticnt choicc lor
orthopcdic conditions bccamc thc standard ol practicc in his dcpartmcnt. !n
.ooo, ]im loundcd thc Ccntcr lor Sharcd ccision Making to coordinatc thc
dclivcry ol dccision aids throughout thc mcdical ccntcr, and shortly altcr that
hc rccruitcd Katc Clay, a nursc and biocthicist, who still scrvcs as program
dircctor. Anncttc Connor, a rcscarchcr lrom thc Univcrsity ol Toronto and
an cxpcrt in sharcd dccision making, hclpcd train Katc to support paticnts as
thcy makc dccisions, a proccss that rcquircs considcrablc clinical skill. Vith
Katc as dircctor, incrcasingly morc paticnts havc gonc through thc sharcd
dccisionmaking proccss, and shc and ]im havc bccn ablc to pcrsuadc morc
and morc physicians at artmouthHitchcock to participatc.
8rcast rcconstruction surgcon r. . alc Collins was onc ol thc carli
cst convcrts, and shc has hclpcd to build a program that allows cvcry brcast
canccr paticnt a chancc to bccomc lully cngagcd in thc dccisions that must
bc madc about hcr trcatmcnt. As part ol thc sharcd dccisionmaking proccss,
cach woman with carlystagc brcast canccr lollows a dcncd clinical path
way, or scqucncc ol visits with particular physicians and nurscs, that bcgins
with hcr initial diagnosis and cnds with hcr trcatmcnt choicc. Shortly altcr
thc diagnosis is madc, shc vicws a vidcobascd paticnt dccision aid, which
cxplains thc pros and cons ol cach trcatmcnt option. Shc thcn complctcs an
onlinc qucstionnairc aimcd at probing thc quality ol hcr dccision. id shc
undcrstand thc vidco, and has shc thought about how shc lccls about thc
altcrnativcs: Finally, shc discusscs hcr options with alc or onc ol thc othcr
surgcons, who uscs thc dccision quality qucstionnairc as a rclcrcncc point.
Lct mc illustratc how thc sharcd dccisionmaking proccss works with
a rcal cxamplc. As an carlystagc brcast canccr paticnt, Mary Smith (not
hcr rcal namc) laccd a choicc. Shc had to dccidc bctwccn complctc rcmoval
ol hcr brcast and lumpcctomy, which involvcs local cxcision ol hcr tumor,
lollowcd by radiation. vcr thc ycars, surgcons at artmouthHitchcock and
:: v~)nw~ys )o vvvov:
rcscarchcrs who study sharcd dccision making havc lound that thcy can prc
dict with somc accuracy which choicc a woman will makc, dcpcnding on how
shc lccls about thc tradcos bctwccn losing a brcast vcrsus having to worry
about a local rccurrcncc ol hcr tumor. Somc womcn arc vcry conccrncd about
loss ol thcir brcast and prclcr lumpcctomy and radiation, othcrs wish to min
imizc thc possibility ol local rccurrcncc, and thc nccd lor ongoing survcil
lancc as wcll as radiation, and thcrclorc prclcr mastcctomy. Smith watchcd
thc paticnt dccision aid, which dcscribcd both proccdurcs, thc sidc cccts ol
cach, and thc lact that thc two arc cqually ccctivc in tcrms ol rcducing hcr
risk ol dying ol brcast canccr. Shc also llcd out a qucstionnairc dcsigncd to
tcst hcr knowlcdgc ol thc proccdurcs and thcir dicrcnt conscqucnccs, and
hcr own valucs rcgarding kccping hcr brcast vcrsus not having to worry about
a rccurrcncc ol hcr tumor. Smith dccidcd on mastcctomy.
Tc ncxt stcp lor Smith was an appointmcnt with alc, who is part ol
thc multidisciplinary brcast oncology program at artmouthHitchcock,
a tcam that includcs brcast surgcons, oncologists, nurscs, radiologists, and
surgcons who spccializc in rcconstructivc surgcry. 8clorc thc appointmcnt,
alc lookcd ovcr thc qucstionnairc that Smith had llcd out and lound that
somcthing was not quitc right. Tc paticnt undcrstood thc tradcos bctwccn
mastcctomy vcrsus lumpcctomy, but shc had indicatcd that shc valucd kccp
ing hcr brcast morc highly than thc pcacc ol mind that shc might gain by
choosing mastcctomy. Tat suggcstcd to alc that hcr paticnt should havc
choscn lumpcctomy.
uring thc appointmcnt, alc discovcrcd that hcr paticnt may not havc
undcrstood hcr choicc as wcll as shc should havc. alc askcd Smith to look
at thc paticnt dccision aid again and think through hcr choicc. Altcr going
through thc proccss again, Smith told alc that shc had originally choscn
mastcctomy bccausc that is what shc thought hcr brcast surgcon bclicvcd was
bcst. Altcr having hcr appointmcnt with alc and looking at thc dccision
aid again, shc rcalizcd that shc rcally prclcrrcd lumpcctomy. Shc undcrstood
that cithcr surgcry ocrcd hcr an cxccllcnt shot at a curc, and pcrhaps most
important ol all, thc choicc was hcrs to makc.
Tis paticnts cxpcricncc cxcmplics cvcrything that is right with sharcd
dccision making. Shc incorrcctly intuitcd hcr surgcons prclcrcncc and would
havc undcrgonc a major surgcry, thc loss ol a brcast, which shc rcally did not
want. alc was ablc to probc Smiths dccision with thc hclp ol thc qucstion
nairc and a lacctolacc intcrvicw. Vhcn shc saw that thc quality ol Smiths
dccision was poorit did not jibc with hcr valucsthc surgcon scnt thc
paticnt back to thc dccision aid. Togcthcr, thcy wcrc ablc to avoid a major
vs)~niisnixc sn~vvb bvcisiox :~xixc ::o
mcdical crror, a surgical proccdurc with lasting conscqucnccs that thc paticnt
did not want.
Tc qucstionnairc that mcasurcs dccision quality is a kcy componcnt ol
thc proccss, cnsuring that paticnts arc making good choiccs lor thcmsclvcs,
as thc casc ol Mary Smith makcs clcar. Tcsc qucstionnaircs arc also impor
tant lor auditing thc ovcrall pcrlormancc ol thc brcast canccr ccntcr. Rcports
arc gcncratcd on a pcriodic basis to mcasurc how wcll womcn scorc on thc
knowlcdgc qucstions conccrning risks and bcncts, and thc dcgrcc ol agrcc
mcnt bctwccn thc paticnts own valucs and thc trcatmcnt that was choscn. As
! discuss latcr, high scorcs on dccision quality mcasurcs could also bc uscd to
rcward hospitals and clinics lor doing wcll in implcmcnting inlormcd paticnt
choicc.
Gctting to thc point whcrc sharcd dccision making is widcly practiccd
at artmouthHitchcock has takcn a tcnycar cort lcd by champions likc
alc Collins, ]im Vcinstcin, and Katc Clay. !t has bccn hampcrcd by rcim
burscmcnt systcms that rcward physicians handsomcly lor pcrlorming an
opcration but poorly lor taking thc timc to lcarn what paticnts want. Tc cul
turc ol mcdicinc has also bccn slow to changc, physicians traincd undcr thc
assumptions that it is thc doctors job to prcscribc carc and thc paticnts job to
comply with mcdical advicc nccd to lcarn and bccomc comlortablc with ncw
rolcs, whilc paticnts havc to comc to undcrstand that thcy lacc choiccs, and
thosc choiccs involvc tradcos on which only thcy can placc valuc.
Tis chaptcr suggcsts thrcc stratcgics lor accclcrating thc cultural changcs
rcquircd to dcmocratizc thc doctorpaticnt rclationship. Tc rst locuscs
on statc lcgislators and statc govcrnmcnts, and what thcy can do to changc
inlormcd conscnt laws and othcrwisc promotc thc transition to inlormcd
paticnt choicc as thc standard ol practicc. Tc sccond involvcs paycrs, who can
drivc rclorm in parallcl with thc cvolving lcgal cnvironmcnt, through changcs
in rcimburscmcnt policics. Tc third is lor primary carc physicians to bccomc
champions lor sharcd dccision making and inlormcd paticnt choicc.
Adopting Informed Patient Choice as the Legal Standard
Undcr currcnt law, physicians who cngagc in sharcd dccision making may
cxposc thcmsclvcs to malpracticc suits. !n a now lamous casc, at lcast among
lamily practicc physicians, a young rcsidcnt namcd anicl Mcrcnstcin hclpcd
a middlcagcd paticnt dccidc whcthcr hc wantcd to undcrgo a PSA tcst. Tc
paticnt dccidcd against thc tcst, but whcn hc subscqucntly wcnt to anothcr
physician, hc was givcn onc without his knowlcdgc. Tc tcst showcd his PSA
:.c v~)nw~ys )o vvvov:
was high, and a subscqucnt biopsy lound advanccd prostatc canccr. Tc paticnt
succcsslully sucd thc largc lamily practicc whcrc Mcrcnstcin was training,
dcspitc cxtcnsivc documcntation by Mcrcnstcin that thc paticnt was lully
inlormcd ol thc tradcos whcn hc madc his initial choicc not to gct tcstcd.
Tc outcomc ol such cascs rcsts in part on thc dcnition ol informed con-
sent, thc lcgal standard lor cnsuring that paticnts undcrstand what thcy arc
gctting into whcn thcy agrcc to tcsts, such as thc PSA, as wcll as clcctivc
surgcry and othcr invasivc proccdurcs. ach statc adhcrcs to onc ol two dc
nitions ol inlormcd conscnt, and both arc an impcdimcnt to sharcd dccision
making. !n a larrcaching articlc publishcd in :cc6 in thc American Journal
of Law & Medicine, 8cnjamin Moulton, who is thc cxccutivc dircctor ol thc
Amcrican Socicty ol Law, Mcdicinc and thics, and ]aimc Staplcs King,
now a mcmbcr ol thc laculty at Hastings School ol Law, rcvicwcd inlormcd
conscnt law in light ol thc unwarrantcd variation in prclcrcnccscnsitivc
trcatmcnts.
4
Tcy rcachcd a startling conclusion: currcnt lcgal conccpts
ol inlormcd conscnt arc at odds with not only modcrn mcdical practicc, but
also individual autonomy rights . !ronically, altcr placing autonomy at thc
ccntcr ol inlormcd conscnt, wc havc crcatcd a lcgal lramcwork that lails to
promotc thc pcrsonal valucs ol individual paticnts (scc 8ox ...).
8oth standards ol inlormcd conscnt assumc that physicians undcrstand
what paticnts want and what thcy nccd to know in ordcr to givc conscnt. Tc
rcality, as ! discuss in Chaptcrs . through , is that physicians arc not vcry
good at diagnosing paticnt prclcrcnccs or cxplaining thc tradcos involvcd in
mcdical dccisions. ]aimc and 8cn rccommcndcd a substantial ovcrhaul ol thc
currcnt inlormcd conscnt systcm to balancc paticnt autonomy with physician
cxpcrtisc and bcncccncc.
Tc KingMoulton articlc would soon contributc in a substantial way to
thc rst lcgislativc succcss story lor sharcd dccision making. !n :cc, a 8luc
Ribbon Commission on Hcalth Carc Costs and Acccss, which includcd
Vashington statc lcgislators and mcmbcrs ol thc community, issucd a rcport
on thc statcs hcalth carc systcm, rclying in part on artmouth Atlas practicc
variations data. !n Novcmbcr, ! was invitcd by thc \irginia Mason Mcdical
Ccntcr, a largc, multispccialty group practicc in Scattlc, Vashington, to givc
a talk to which mcmbcrs ol thc statc lcgislaturc wcrc invitcd. Statc Scnator
Pug and a scnatc stacr, ]onncl Andcrson, hcard my prcscntation on sharcd
dccision making and thc articlc by 8cn and ]aimc. Scnator Pug thcn got in
touch with thcm. Two months latcr, shc introduccd lcgislation to substan
tially rcvisc thc statcs inlormcd conscnt laws and promotc sharcd dccision
making. ]aimc, 8cn, and ! wcrc subscqucntly invitcd to tcstily bclorc thc
lcgislaturc in lavor ol thc lcgislation.
vs)~niisnixc sn~vvb bvcisiox :~xixc :..
8ox .... Informed Consent Laws Fail to Promote Personal
Values of Individual Patients
A ccntral nding ol thc KingMoulton analysis is that inlormcd con
scnt laws lail to promotc thc pcrsonal valucs ol individual paticnts.
Vhat cxplains this paradoxical outcomc:
Tc laws ol inlormcd conscnt in thc Unitcd Statcs lollow two
lincs ol lcgal thinking: in about hall ol thc statcs, thc laws lollow a
physicianbascd standard, and in thc othcr hall, a paticntbascd stan
dard is lollowcd. Tc physicianbascd standard rcquircs physicians to
inlorm paticnts, as a rcasonably prudcnt practitioncr would do. Tc
lundamcntal assumption is that physicians agrcc on thc bcst trcatmcnt
option and agrcc as wcll on what inlormation paticnts nccd to achicvc
inlormcd conscnt. !n othcr words, thc physician standard codics thc
agcncy rolc ol thc physician (discusscd in Chaptcr :) and lails to pro
motc thc standard ol inlormcd paticnt choicc lor thc many rcasons
outlincd in this book.
Tc paticntbascd standard rcquircs that physicians providc all
inlormation that a rcasonablc paticnt would want to know. Tc lun
damcntal assumption bchind this standard is that rcasonablc paticnts
valuc inlormation on risks and bcncts similarly and that physicians
know what rcasonablc paticnts nccd and thcy can diagnosc thcir
prclcrcnccs. Tc aws in this standard arc cvidcnccd by thc practicc
variation phcnomcnon, particularly thc randomizcd trials ol sharcd
dccision making that show that paticnts who rcccivc thcir carc as part
ol usual practicc, cvcn whcn conductcd in practiccs govcrncd by thc
paticntbascd standard lor inlormcd conscnt, arc at risk lor rccciving
surgcry thcy do not want.
8oth standards lail bccausc ncithcr providcs physicians with a clcar
cxplanation ol thcir lcgal disclosurc obligations, nor paticnts with a
valid undcrstanding ol what inlormation thcy havc a right to posscss.
Again, it was thc data on practicc variations that sccmcd to gain thc lcg
islators attcntion. Tcy wcrc lascinatcd, and ! bclicvc disturbcd, by thc grcat
dicrcnccs in thc usc ol surgcry among thc communitics thcy rcprcscnt as
clcctcd o cials. Tc malc mcmbcrs ol thc lcgislaturc sccmcd particularly sur
priscd by thc striking dicrcnccs in surgcry lor 8PH surgcry (Figurc ...).
:.: v~)nw~ys )o vvvov:
A mcmbcr ol thc lcgislaturc lrom Port Angclcs could scc that thc ratc lor
8PH surgcry thcrc was about ninc proccdurcs pcr .,ccc mcn, .. timcs grcatcr
than that ol Mcdicarc mcn living in Yakima. Ratcs in Spokanc wcrc twicc
thosc ol Scattlc. 8y comparing thc ratcs in Vashington communitics to thc
.c6 rcgions across thc Unitcd Statcs, ! was ablc to makc thc point that whilc
practicc variations wcrc a national problcm, it was onc that nccdcd a local
solutiona changc in thc doctorpaticnt rclationship to cnsurc that dcmand
lor prclcrcnccscnsitivc carc is bascd on inlormcd paticnt choicc.
Tc bill, which was signcd into law on May :, :cc, rcprcscnts thc rst
timc sharcd dccision making and thc normativc importancc ol inlormcd
paticnt choicc havc bccn lormally acknowlcdgcd by a statc lcgislaturc
(8ox
..:). Tc bcnct ol using dccision aids was also rccognizcd in thc law, as was
thc nccd lor a proccss ol ccrtication to cnsurc thcir high quality. Tc bill
providcs supcrior lcgal protcction lrom lailurc to inlorm malpracticc suits
against physicians who cngagc in sharcd dccision making. Tc lcgislation
also says that paticnts who agrcc to trcatmcnt as a rcsult ol sharcd dccision
making havc givcn inlormcd conscnt that can only bc rcbuttcd by clcar and
convincing cvidcncc, a highcr standard ol dclcnsc than that govcrning tra
ditional inlormcd conscnt, whcrc rcbuttal is bascd on prcpondcrancc ol cvi
dcncc. (Tc lattcr standard rcquircs a paticnt to dcmonstratc that it is morc
Figurc .... Ratcs ol transurcthral prostatcctomy (TURP) lor bcnign prostatic
hypcrplasia among hospital rclcrral rcgions (shaded circles) and sclcctcd hospital
scrvicc arcas (lled circles) locatcd in Vashington Statc (:cc: through :cc.).
(Source: artmouth Atlas Projcct databasc.)
+
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+:
Port Angclcs o.+
Spokanc .:
vcrctt .+
Tacoma .o
Scattlc :.
lympia :.+
Yakima :.6
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8ox ..:. What Is in Washington States Blue Ribbon
Commission Health Bill (ESSB 5930)?
An cndorscmcnt ol sharcd dccision making:
Te legislature nds that there is growing evidence that, for preference-
sensitive care involving elective surgery, patient-practitioner commu-
nication is improved through the use of high-quality decision aids that
detail the benets, harms, and uncertainty of available treatment options.
Improved communication leads to more fully informed patient decisions.
Te legislature intends to increase the extent to which patients make
genuinely informed, preference-based treatment decisions, by promoting
public/private collaborative eorts to broaden the development, certica-
tion, use, and evaluation of eective decision aids and by recognition of
shared decision making and patient decision aids in the states laws on
informed consent.
A dcnition ol sharcd dccision making:
a process in which the physician or other health care practitioner discusses
high quality, up-to-date information about the condition, including risks
and benets of available options and, if appropriate, the limits of scientic
knowledge about outcomes; values clarication to help patients sort out their
values and preferences; and guidance or coaching in deliberation, designed to
improve the patients involvement in the decision process.
A dcnition ol paticnt dccision aids (lor purposcs ol this lcgislation):
a written, audio-visual, or online tool that provides a balanced presenta-
tion of the condition and treatment options, benets, and harms, including, if
appropriate, a discussion of the limits of scientic knowledge about outcomes,
and that is certied by one or more national certifying organizations.
A strong grant ol immunity lor physicians who usc sharcd dccision
making and ccrticd dccision aids:
If a patient signs an acknowledgement of shared decision making [this]
shall constitute prima facie evidence that the patient gave his or her
informed consent to the treatment administered and the patient has the
burden of rebutting this by clear and convincing evidence.
:..
:. v~)nw~ys )o vvvov:
probablc than not |i.c., a c.. chancc| that thc physician lailcd to providc
all matcrial inlormation.)
!n passing thc bill, thc lcgislaturc took an additional stcp to cncouragc
Vashington statc physicians to adopt inlormcd paticnt choicc as thc stan
dard ol practicc. !t callcd lor thc Vashington Statc Hcalth Carc Authority
thc agcncy ovcrsccing all statc agcncics involvcd in hcalth carc, including
statc cmploycc insurancc plans and Mcdicaidto conduct a sharcd dccision
making dcmonstration projcct at onc or morc group practicc sitcs that pro
vidc hcalth carc purchascd by thc statc. Sincc thcn, thanks in largc part to
an cducational program run by thc Milbank Foundation, a numbcr ol statc
lcgislators havc attcndcd scminars on thc issuc ol sharcd dccision making,
and scvcral havc passcd, or arc contcmplating, similar lcgislation.
Tc call ol thc Vashington statc lcgislators lor dcmonstration projccts
appcars to bc paying o. At thc timc ol this writing, lour projccts havc bccn
organizcd, including onc undcrtakcn by Group Hcalth Coopcrativc, a largc
group practicc that dcpcnds primarily on capitation as its paymcnt modcl.
Group Hcalth is now dcvcloping clinical pathways to cnsurc thc implcmcn
tation ol sharcd dccision making lor most common surgical proccdurcs, and
lor carc at thc cnd ol lilc, and intcgrating dccision aids and dccision quality
rcports into its clcctronic mcdical rccord systcm. Longtcrm lollowup ol
paticnts will soon bc possiblc, just as was donc in thc original carly .oocs col
laboration bctwccn Group Hcalth and thc 8PH and low back pain PRTs
! rcportcd on in prcvious chaptcrs.
vcr thc ycars sincc thcn, ! havc kcpt in touch with thc lcadcrs ol thosc
carly studics and sharcd thcir lrustration that oncc thc studics wcrc n
ishcd, Group Hcalth did not adopt (or champion) sharcd dccision making
as its modcl lor managing prclcrcnccscnsitivc trcatmcnt dccisions. !t just
sccmcd to makc so much scnsc that it should do this, as Group Hcalth phy
sicians arc primarily salaricd and havc no dircct cconomic gain lrom doing
surgcry. Most Group Hcalth mcmbcrs arc capitatcd, so lcclorscrvicc
inccntivcs do not drivc physician practicc pattcrns. Morcovcr, as Group
Hcalth providcrs had lcarncd lrom thc PRT studics, undcr sharcd dcci
sion making thcir paticnts wcrc making morc knowlcdgcablc dccisions, and
dccisions morc in linc with thcir prclcrcnccs. And thc usc ol sharcd dcci
sion making rcduccd thc ratc ol surgcry at Group Hcalth, saving moncy
without introducing lcar among its mcmbcrs that thcy wcrc bcing dcnicd
carc thcy truly wantcd.
So why did sharcd dccision making not bccomc thc way mcdicinc was
practiccd at Group Hcalth: A considcrcd answcr would rcquirc cxtcnsivc
rcscarch and intcrvicws with kcy pcrsonncl. Howcvcr, thc lacts scrvc to
vs)~niisnixc sn~vvb bvcisiox :~xixc :.
illustratc just how di cult it is to changc thc culturc ol mcdicinc whcn only
a lcw sccm to carc. mploycrs, paycrs, and policy makcrs paid only pass
ing attcntion to what was going on. At thc timc, inlormation on practicc
variation was not gcncrally availablc. Tc champions within Group Hcalth
rcmaincd a vocal minority without pcrsuasivc powcr.
8y thc mid:cccs, howcvcr, thcrc was an awakcning. Tc Govcrnors 8luc
Ribbon Commission on Hcalth Carc Costs and Acccss raiscd thc qucstion
ol sharcd dccision making and prcscntcd data showing that mcdical practicc
varics substantially lrom placc to placc. Group Hcalth lcadcrship was part ol
that proccss and cmcrgcd as strong proponcnts ol thc lcgislativc changcs in
support ol inlormcd paticnt choicc. And oncc thc bill was passcd, thc organi
zation committcd itscll to changc. According to Karcn Mcrrikin, who scrvcs
as Group Hcalths cxccutivc dircctor lor public policy, practicc variation data
playcd an important rolc in gaining thc attcntion ol physicians throughout
thc Group Hcalth organization and gctting thcir commitmcnt. Using its own
claims data, Group Hcalth analysts dcmonstratcd variations among its own
providcrs in tcrms ol how Group Hcalth mcmbcrs wcrc trcatcd, dcpcnding
on thc clinic thcy uscd.
Regulatory and Financial Incentives to Promote
a Transition to Informed Patient Choice
conomic and rcgulatory inccntivcs will bc nccdcd to push thc transi
tion lrom dclcgatcd dccision making to sharcd dccision making. Undcr
thc inlormcd paticnt choicc standard, clinical appropriateness would still bc
dcncd by mcdical cxpcrts (bascd to thc lullcst cxtcnt possiblc on cvidcncc
garncrcd lrom mcdical ccctivcncss rcscarch), and covcragc dccisions that
cstablish thc contcnt ol thc bcnct packagc would still bc madc by thc paycr.
Howcvcr, thc ncccssity ol carc in thc spccic casc would bc dctcrmincd by thc
paticnt, through participation in a highquality sharcd dccisionmaking pro
ccss. Vhy thc distinction bctwccn appropriatcncss and ncccssity: 8ccausc an
individual paticnt can bc an appropriatc candidatc lor surgcry bascd on clini
cal critcria, yct that paticnt may want an altcrnativc (also appropriatc) option.
For this paticnt, surgcry is unncccssary. As wc lound in our 8PH work, and
Canadian rcscarchcr Gillian Hawkcr and hcr collcagucs lound in thc casc ol
joint rcplaccmcnt, thc numbcr ol paticnts who arc appropriatc candidatcs lor
surgcry (as judgcd by cvidcnccbascd clinical critcria) lar cxcccds thc numbcr
who actually want to havc surgcry.
6
Clinical trials ol dccision making also
suggcst that thc numbcr ol paticnts who arc appropriatc candidatcs lor many
:.6 v~)nw~ys )o vvvov:
othcr surgcrics and tcsts is largcr than thc numbcr ol paticnts who bclicvc
that thc intcrvcntion is ncccssary, oncc thcy havc undcrgonc sharcd dccision
making.
7
Vhat arc thc rcgulatory and cconomic inccntivcs that can promotc sharcd
dccision making: !n a rcccnt papcr in Health Aairs, my collcagucs and ! pro
poscd a stratcgy lor thc Ccntcrs lor Mcdicarc & Mcdicaid Scrviccs (CMS)
to addrcss thc cconomic barricrs.
8
ur proposal initially targcts clcvcn com
mon conditions that account lor about c ol Mcdicarcs spcnding lor inpa
ticnt surgcry. (Scc Tablc ... lor a list ol thcsc conditions and thc primary
trcatmcnt options.) !l sharcd dccision making can bc implcmcntcd lor thcsc
highprolc conditions, cxtcnding it to othcr conditions should bc rclativcly
casy. And thcrc is all thc morc rcason to implcmcnt sharcd dccision making
lor othcr conditions lor which thc clinical cvidcncc lor c cacy is lcss clcar,
bccausc paticnts dcscrvc to know whcn thc proccdurc bcing ocrcd has not
bccn shown to bc ccctivc.
Tc longtcrm goal ol paycrs (not just Mcdicarc) should bc to cnsurc that
all paticnts havc acccss to sharcd dccision making. ur Health Aairs pro
posal is a thrccphasc stratcgy intcndcd to lcad progrcssivcly ovcr a dccadc
to thc point whcrc dclcgatcd dccision is rcplaccd by highquality sharcd
dccision making, and inlormcd paticnt choicc is cstablishcd as thc national
standard ol practicc. Hcrc is a bricl summary. A pilot projcct phasc ol vc
or so ycars would givc spccial attcntion to dcvcloping modcls that intc
gratc sharcd dccision making into cvcryday practicc, including hospitals and
thc primary carc mcdical homc. uring this phasc, thc lcdcral govcrnmcnt
would support two kcy rcscarch and dcvclopmcnt tasks that arc csscntial lor
thc transition to inlormcd paticnt choicc. nc is an analysis ol thc costs ol
supporting sharcd dccision making in thc various clinical scttings, so that
providcrs can bc compcnsatcd lairly lor providing sharcd dccision making.
Tc othcr is a proccss lor ccrtication. Tc rcimburscmcnt and lcgal rclorms
discusscd in this chaptcr rcquirc thc availability ol paticnt dccision aids that
havc bccn ccrticd to mcct ccrtain quality standards. Although cxpcrts havc
rcachcd conscnsus on what should bc thc standards lor dcvclopmcnt and
cvaluation,
9
a lormal ccrtication proccss has not as yct bccn cstablishcd.
Tc cpartmcnt ol Hcalth and Human Scrviccs should work with national
accrcditing organizations to dcvclop this proccss. !t should also dcvclop a
proccss lor ccrtilying that a givcn providcr has put into placc thc kcy com
poncnts lor supporting highquality sharcd dccision making, including
rcporting on paticnt dccision quality mcasurcs that would dctcrminc pay lor
pcrlormancc inccntivc rcwards.
vs)~niisnixc sn~vvb bvcisiox :~xixc :.
Altcr lour or vc ycars, building on thc accomplishmcnts ol thc pilot
projccts, paycrs would undcrtakc a national cort to changc thc standard
lor dcning mcdical ncccssity. Group practiccs, hospitals, ambulatory sur
gcry ccntcrs, and primary carc physicians practicing in organizcd mcdical
homcs would bc cncouragcd to implcmcnt ccrticd sharcd dccisionmaking
proccsscs and participatc in a paylorpcrlormancc program. vcntually (wc
suggcst thc targct datc bc within tcn ycars), paycrs would no longcr rcimbursc
providcrs lor surgcry il thcy lail to comply with thc ncw standard lor dcning
mcdical ncccssity. Compliancc would bc dcncd by thc prcscncc ol a ccrticd
sharcd dccisionmaking proccss and satislactory scorcs on (auditcd) dccision
quality mcasurcs.
Tablc .... Trcatmcnt ptions lor Sclcctcd Conditions
Clinical Condition Treatment Options
Chronic cholccystitis and silcnt
gallstoncs
Vatchlul waiting
Cholccystcctomy (usually laparoscopic
rathcr than opcn surgcry)
Chronic stablc angina (chcst pain or
othcr symptoms lrom coronary
artcry discasc)
Mcdical trcatmcnt
Angioplasty
8ypass surgcry
Hip and kncc ostcoarthritis Mcdical trcatmcnt
Hip rcplaccmcnt
Claudication (cxcrtional lcg pain
lrom pcriphcral vascular discasc)
Mcdical trcatmcnt, cxcrcisc
Angioplasty
8ypass surgcry
Carotid stcnosis (strokc risk lrom
narrowing ol carotid artcry)
Aspirin
Carotid cndartcrcctomy
Hcrniatcd disc or spinal stcnosis
(causing back pain or othcr
symptoms)
Mcdical trcatmcnt
Chiropractic and othcr
8ack surgcry
arlystagc prostatc canccr Vatchlul waiting
Radiation (convcntional or implant sccds)
Radical prostatcctomy
arlystagc brcast canccr Lumpcctomy
Mastcctomy
nlargcd prostatc (bcnign prostatic
hypcrplasia)
Surgical trcatmcnt (scvcral mcthods)
rug trcatmcnt
Vatchlul waiting
:. v~)nw~ys )o vvvov:
Primary Care as Professional Advocates for Informed Patient Choice
xpcricncc shows that without strong prolcssional advocacy, thc transition
to inlormcd paticnt choicc will takc ycars, il it occurs at all. ! am imprcsscd
by thc lcrvor ol thc commitmcnt to paticntccntcrcd carc on thc part ol
advocatcs lor tcambascd primary carc mcdicinc. Paticntccntcrcdncss lorms
onc ol its ccntral tcncts: cvcry Amcrican nccds a longtcrm prolcssional
rclationship with a pcrsonal physician who hclps paticnts navigatc thc com
plcxitics ol thc hcath carc systcm and lcads a tcam ol hcalth carc workcrs,
who collcctivcly takc rcsponsibility lor thc paticnts carc. Tc job dcscription
calls lor a comprchcnsivc rolc ol thc pcrsonal physician to providc all thc
paticnts hcalth carc nccds at all stagcs ol lilc, including bcing rcsponsiblc
lor arranging rclcrrals to mcdical and surgical spccialists.
!0
How this assump
tion ol rcsponsibility unlolds could bc kcy lor thc prospccts ol implcmcnting
inlormcd paticnt choicc. !l thc mcmbcrs ol thc mcdical homc wcrc to assumc
prolcssional rcsponsibility lor shcphcrding paticnt prclcrcnccs lor trcatmcnt
options, particularly thosc involving clcctivc surgcry and cnd ol lilc carc, a
critical structural barricr to cstablishing inlormcd paticnt choicc would bc
ovcrcomc.
Traditionally, thc rclcrrals that primary carc physicians makc to surgi
cal spccialists havc had two goals: onc is to obtain an cxpcrts diagnosis ol
thc paticnts condition, and thc othcr to obtain a trcatmcnt rccommcnda
tion. Not surprisingly, surgcons commonly diagnosc a nccd lor surgcry, and
rccommcnd thcmsclvcs to pcrlorm it. Progrcss in comparativc ccctivcncss
rcscarch, howcvcr, will changc thc primary carc physicians dcpcndcncy on
spccialist opinion. For a numbcr ol common proccdurcs, including most ol
thosc listcd in Tablc ..., cvidcnccbascd practicc guidclincs now makc it
possiblc lor primary carc physicians to diagnosc conditions lor which sur
gcry is an option, and to dctcrminc which paticnts arc clinically appropriatc
candidatcs. !mplcmcnting sharcd dccision making would allow thc primary
carc physician to dctcrminc il thc paticnt also wants surgcry. For cxamplc,
our carly work with 8PH cstablishcd thc practicc guidclincs lor diagnos
ing thc condition and dctcrmining thc paticnts prclcrcnccs. Tis could all
bc managcd by thc primary carc physician. !ndccd, most common surgical
proccdurcs can bc similarly managcd.
Structurally, primary carc physicians and thcir tcam mcmbcrs sccm thc
idcal prolcssional advocatcs lor inlormcd paticnt choicc and thc appro
priatc guarantors ol thc intcgrity ol thc sharcd dccisionmaking proccss.
Unlikc spccialists who pcrlorm spccic proccdurcs or lavor ccrtain clinical
options, primary carc physicians, at lcast in thcory, havc no horsc in thc
vs)~niisnixc sn~vvb bvcisiox :~xixc :.o
racc, no nancial intcrcst in onc trcatmcnt option ovcr anothcr. Vith thc
dcvclopmcnt ol clinical ccctivcncss rcscarch along thc lincs ol thc PRT
tcams, primary carc physicians can havc acccss to uptodatc inlormation
on thc outcomcs ol various trcatmcnt options. Vith thc dcvclopmcnt ol
paticnt dccision aids and othcr mcans ol inlorming paticnts about trcat
mcnt options, thc primary carc tcam has acccss to tools that lacilitatc thc
sharcd dccisionmaking proccss. Tc physicians pcrlormancc in achicving
inlormcd paticnt choicc can bc cvaluatcd using paticnt dccision quality
instrumcnts.
Tus, lor a numbcr ol common conditions that involvc clcctivc surgcry
and tcsts, thc mcdical homc tcam can bccomc accountablc lor managing thc
clinical problcm, using practicc guidclincs to sort out which paticnts would
qualily as clinically appropriatc candidatcs and hclping paticnts makc thc
critical choiccs bctwccn thc trcatmcnt options. At this juncturc in thc dcci
sion scqucncc, thc primary carc physician should bc in a position to rclcr
thc paticnt who wants surgcry to thc spccialist bcst qualicd to pcrlorm thc
opcration (8ox ...). Tc proccss, idcally, would thus cnsurc that only paticnts
who truly wantcd a proccdurc would bc rclcrrcd to a surgcon, prclcrably onc
who scorcs wcll on tcchnical compctcncc. Naturally, not all conditions can
bc accuratcly diagnoscd by thc primary carc physician, and in thosc cascs thc
physician would nccd to rclcr thc paticnt to thc spccialist bclorc thc paticnt
has had acccss to a paticnt dccision aid and undcrgonc sharcd dccision mak
ing. !n such cascs, thc paticnt could sharc thc trcatmcnt dccision with thc
spccialist, or rcturn to his or hcr primary carc physician bclorc coming to a
dccision.
Paycrs should givc spccial priority to a pilot projcct to tcst thc mcdi
cal homc modcl lor implcmcnting sharcd dccision making and cstimating
paticntdrivcn dcmand lor clcctivc surgcry. Using cvidcnccbascd guidc
lincs, thc primary carc tcam can idcntily paticnts who mcct uptodatc
cvidcnccbascd guidclincs lor clinical appropriatcncss and thcn, through
sharcd dccision making, hclp paticnts dccidc il thcy want surgcry or
anothcr trcatmcnt. Tus, primary carc, bccausc it scrvcs a dcncd paticnt
population, is wcll situatcd to hclp policy makcrs lcarn which ratc is right:
which utilization ratcs lor prclcrcnccscnsitivc trcatmcnts approximatc
truc dcmand.
Prolcssional advocacy on thc part ol primary carc physicians should also
accclcratc thc cstablishmcnt ol inlormcd paticnt choicc as thc standard ol
practicc. !t would incrcasc thc intcrcst ol othcr stakcholdcrs in promoting
sharcd dccision making. Primary carc advocacy in thc statc ol Vashington
inucnccd lcgislators to takc action, and primary carc physicians could
8ox .... Another Mission for the Science of Health Care
Delivery
!nlormation on thc outcomcs ol surgcry according to thc condition
ol thc paticnt and thc placc whcrc surgcry is pcrlormcd is csscntial
in making a dccision to undcrgo surgcry and whcrc to havc it. Yct
such inlormation is rarcly availablc in cvcryday practicc, providing thc
inlrastructurc lor achicving transparcncy should bc a goal ol com
parativc ccctivcncss rcscarch. \alid inlormation dcpcnds on skill in
accomplishing onc ol thc most di cult tasks lacing thc cpidcmiolo
gistmaking inlcrcnccs lrom obscrvational data about thc outcomcs
ol carc. !n addition to skillcd cpidcmiologists, it rcquircs thc data
inlrastructurc to cnsurc thc systcmatic lollowup ol all paticnts trcatcd
at a givcn institution and thc ability to analyzc thc data. For rcasons
ol cconomy ol scalc, and lor lccdback and intcrprctation, thc proccss
is bcst organizcd with multiplc institutions participating in a nctwork
dcsigncd around thc principlcs ol continuous quality improvcmcnt.
Tc Northcrn Ncw ngland Cardiovascular iscasc Study Group
(NNCSG) providcs an cxamplc ol how thc scicncc ol hcalth carc
dclivcry contributcs to rationalizing surgical carc lor coronary artcry
discasc. rganizcd in .o undcr thc lcadcrship ol artmouth cpidc
miologist Gcrald Connor, thc NNCSG maintains rcgistrics ol
all paticnts opcratcd on in hospitals in Mainc, Ncw Hampshirc, and
\crmont who rcccivc coronary artcry bypass gralting, pcrcutancous
coronary intcrvcntion, or hcart valvc rcplaccmcnt surgcry. uring thc
last scvcntccn ycars, inlormation on .c,ccc paticnts has bccn accu
mulatcd in thc rcgistrics.
Tc databasc tracks clinical outcomcs ol all rcvascularization pro
ccdurcs, and outcomc data lor coronary artcry bypass gralting arc
availablc on a ccntcrspccic basis on thc wcbsitc. Studics undcrtakcn
by thc NNCSG havc rcsultcd in morc than cighty pccrrcvicwcd
articlcs in mcdical journals. ata lccdback has luclcd a numbcr ol
intcrvcntions to improvc quality. Using thc rcgistry data, Connor
and his collcagucs havc dcvclopcd riskadjustcd modcls ol outcomcs.
ccisionmaking tools havc bccn dcvclopcd to hclp clinicians, paticnts,
and lamilics undcrstand thc likcly outcomcs ol carc according to thc
risk status ol thc individual paticnt. Tcsc tools arc availablc on thc
NNCSG wcbsitc (http://www.nnccdsg.org).
:c
vs)~niisnixc sn~vvb bvcisiox :~xixc :.
also push CMS and privatc paycrs to providc thc rcgulatory and cconomic
inccntivcs to makc sharcd dccision making part ol cvcryday practicc.
Rcplacing dclcgatcd dccision making and inlormcd conscnt with sharcd
dccision making and inlormcd paticnt choicc will not bc casy. !t rcquircs
a translormation in thc culturc ol mcdicinc. Tis chaptcr has suggcstcd a
stratcgy lor achicving this translormation, bascd on changcs in lcgal, cco
nomic, and rcgulatory inccntivcs, improvcmcnts in clinical scicncc, and a
ncw rolc lor primary carc physicians as advocatcs and guarantors ol thc
sharcd dccisionmaking proccss. ! bclicvc thcsc rclorms hold promisc lor
achicving a markct lor prclcrcnccscnsitivc carc, a markct in which thc
utilization ol surgcry and othcr costly prclcrcnccscnsitivc trcatmcnts is
dctcrmincd by paticnt dcmand. Availablc cvidcncc suggcsts that this would
lcad to lowcr uptakc ol clcctivc surgcry and a rcduction in Mcdicarc spcnd
ing. Morc important, paticnts would bc lcss likcly to undcrgo surgcry that
thcy do not want.
::
So lar, this book has conccntratcd on thrcc ol thc lour goals lor hcalth carc
rclorm: cstablishing inlormcd paticnt choicc, promoting organizcd systcms
ol carc, and improving thc scicncc ol hcalth carc dclivcry. Tis chaptcr dcals
with thc lourth goalconstraining undisciplincd growth in capacity and
spcnding. Vhilc thc rclorms discusscd thus lar should rcsult in cost sav
ings, counting on changcs in thc dclivcry systcm as thc principal wcapon lor
containing unwarrantcd growth in spcnding is cxtrcmcly risky. How long it
will takc lor dclivcry systcm rclorms to takc hold, and how ccctivcly thcy
will modcratc rising hcalth carc costs, is lar lrom clcar. Lclt unchcckcd, thc
dynamics ol growth that lcad to ovcrutilization and cscalating costs will likcly
continuc wcll into thc luturc, bccoming incrcasingly intolcrablc, and dcstroy
ing our compctitivcncss in thc world cconomy.
An undcrstanding ol practicc variation, particularly thc rolc that supply
plays in inucncing mcdical dcmand, suggcsts scvcral concrctc stcps to chcck
undisciplincd growth and rcducc unwarrantcd variation. Tc idcas discusscd
in this chaptcr could stabilizc thc hcalth carc cconomy and buy timc, and
cvcn accclcratc thc transition lrom disorganizcd to organizcd carc, and lrom
dclcgatcd dccision making to inlormcd paticnt choicc.
Tc rst componcnt ol a costcontrol plan is to put into placc a salcty
valvc, a rcgulatory stratcgy to constrain spcnding lor supplyscnsitivc carc.
Tc sccond is to imposc obligatory copaymcnts to addrcss variation and
.
Five Ways to Control Costs and
Accelerate Health Care Reform
nv~i)n c~vv vvvov: :.
growth in thc usc ol discrctionary surgcry and othcr cxpcnsivc prclcrcncc
scnsitivc trcatmcnts. Tc third is to inucncc thc sizc and spccialty composi
tion ol thc physician worklorcc as a mcans lor rcducing growth in spcnding
and cnsuring that tomorrows physicians arc skillcd in coordinating carc and
supporting inlormcd paticnt choicc. Tc lourth stcp is to rcducc translcr pay
mcnts among rcgions by adjusting thc cost ol insurancc prcmiums to rccct
rcgional pcr capita spcnding, thus improving cquity and crcating awarcncss ol
thc rclationship bctwccn capacity and pcr capita costs. Tc lth is to cstablish
rcaltimc lccdback ol inlormation on pcrlormancc ol thc dclivcry systcm,
using routinc claims data lrom privatc as wcll as public paycrs.
Constraining Spending for Supply-Sensitive Care
ur studics ol practicc variation havc pinpointcd thc clinical conditions
that arc rcsponsiblc lor most ol thc variation in Mcdicarc pcr capita pay
mcnts among rcgions or statcs. !t is not surgcrysurgcry ratcs and Mcdicarc
spcnding on surgcry arc about thc samc in rcgions with high and low ovcrall
Mcdicarc spcnding pcr capita. !t is thc ratc ol thc usc ol hospitals and post
acutc carc lor managing acutc and chronic illncss that makc up thc bulk ol
thc ovcrusc problcm in rcgions with high Mcdicarc spcnding. Tis is thc
primary drivcr ol variation in total Mcdicarc spcnding among rcgions, and it
is rcimburscmcnts lor inpaticnt carc that account lor most ol thc spcnding.
And, as discusscd in Chaptcr .:, it is thc highspcnding rcgions that tcnd to
grow lastcst.
Tc Ccntcrs lor Mcdicarc & Mcdicaid Scrviccs (CMS) and othcr paycrs
would nd signicant savings il thcy wcrc to lollow thc moncy trail and limit
rcimburscmcnt in rcgions and among providcrs that ovcrusc carc thc most.
nc way to do that would bc to imposc an ovcrusc pcnalty: sctting an uppcr
limit on thc amount paid to hospitals and physicians lor thc inpaticnt carc
ol paticnts with acutc or chronic mcdical conditionsthc causcs ol hospital
ization that contributc most to ovcrusc. !nitially, thc pcnalty could bc quitc
modcst. For cxamplc, paycrs could dctcrminc that hospitals with agc, scx,
racc, and illncssadjustcd utilization ratcs that cxcccd thc oth pcrccntilc on
thc hospital carc intcnsity (HC!) indcx should bc rcimburscd only at thc lcvcl
ol thc oth pcrccntilc. Tc dicrcncc bctwccn thc actual amount Mcdicarc
spcnt lor managing chronic illncss in thcsc hospitals and thc targct budgct
sct lor thc oth pcrccntilc would bc thc amount an outlicr hospital would
lorgo. 8ascd on this bcnchmark lor thc volumc ol paticnt days and inpaticnt
: v~)nw~ys )o vvvov:
physician scrviccs, Mcdicarc would havc savcd about s.c millions.:.
million in rcimburscmcnts to hospitals (Part A) and s::. million lor prolcs
sional scrviccs (Part 8)in :cc.
!
Rcducing paymcnts to thc most highly inc cicnt providcrs by s.c million
would not by itscll achicvc costcontainmcnt goals, nor would it substantially
rcducc thc rcgional translcr paymcnts and disparitics in paticnt copaymcnts
discusscd in prcvious chaptcrs. 8ut it would bc a powcrlul signal that thc
rulcs ol gamc arc changing. Tc cccts on thc hcalth carc cconomy would
likcly bc prolound, particularly il an ovcrusc pcnalty wcrc implcmcntcd in
parallcl with thc sharcd savings programs discusscd in Chaptcr ., and il it
wcrc clcar to providcrs that thc Sccrctary ol Hcalth and Human Scrviccs (and
privatc paycrs) rcscrvcd thc option to usc thc targct budgct morc aggrcssivcly
il providcrs lailcd to limit growth and rccovcr wastc. !t would signal a signil
icant shilt in Mcdicarc policy away lrom lostcring undisciplincd growth and
unwarrantcd variation, as it currcntly docs, to a policy that rcwards valuc and
c cicncy in managing acutc and chronic illncss.
nc likcly rcsult ol such a stratcgy would bc that providcrs cvcrywhcrc
would bccomc vcry intcrcstcd in comparing thcir own pcrlormancc to that
ol othcrs, as mcasurcd by routinc rcports such as thc artmouth Atlas
rcports discusscd in Chaptcr ... Physicians, boards ol trustccs ol hospitals,
and administrators would want to undcrstand why ovcrusc is such a problcm
and to considcr options lor thcir hospitals to avoid thc pcnalty. Tc impact ol
imposing an ovcrusc pcnalty and crcating strong inccntivcs to rcducc cxccss
acutc carc capacity would likcly cxtcnd bcyond thc providcr community. At
thc vcry lcast, such a movc has thc potcntial to disrupt thc casy moncy tra
ditionally aordcd to hospitals by thc bond and cquity markcts, putting a
brakc on lurthcr hospital cxpansion in highusc rcgions. For cxamplc, thc
lrcnzy ol construction projccts undcr way in Los Angclcs is lundcd in largc
part by invcstors who assumc that hospitals arc lowrisk borrowcrs. Howcvcr,
il unccrtainty wcrc to arisc ovcr thc longtcrm commitmcnt ol Mcdicarc to
pay lor utilization no mattcr how proigatc, analysts rating hospital bonds
or cvaluating hospital stocks would bc much morc intcrcstcd in looking at
thc artmouth Atlas utilization rcports lor thc hospitals thcy arc cvaluating.
!t would also strcngthcn thc hand ol consumcr organizations (such as thc
Consumcrs Union) that arc sccking to draw thc attcntion ol thcir mcmbcrs
to thc dangcrs and nancial costs ol ovcrusc.
Undcr this sccnario, morc aggrcssivc usc ol thc targct budgct option might
not bc nccdcd. 8ut il thcsc corts lail and costs continuc to risc in an uncon
trollcd way, il Mcdicarc spcnding grows to thc point somc now projcct and
thc conscqucnccs ol inc cicncy and wastc bccomc ovcrwhclming, thcn a
nv~i)n c~vv vvvov: :
paymcnt mcthod that providcs CMS with thc mcans lor limiting spcnding
in a prcdictablc way may bccomc attractivc, cvcn incvitablc. A simplc way
lor CMS (and othcr paycrs) to obtain lcvcragc ovcr inpaticnt spcnding lor
supplyscnsitivc carc would bc to adjust thc bcnchmark uscd to calculatc thc
targct budgct to a pcrccntilc on thc HC! indcx that mccts policy objcctivcs.
Sctting hospitalspccic targct budgcts lor supplyscnsitivc carc, particularly
il a similar policy wcrc adoptcd by othcr paycrs, would lorcc a rcduction in
ovcrusc. !t would also motivatc providcrs to scck opportunitics to gain con
trol ovcr thcir own budgcts by taking advantagc ol sharcd savings programs,
as discusscd in Chaptcr ..
Constraining Preference-Sensitive Surgery
Corralling hcalth carc cost growth can also bc achicvcd by limiting spcnd
ing lor clcctivc surgcry. As discusscd in Chaptcr , thc pattcrn ol rcgional
variation in thc usc ol surgcry is rcmarkably consistcnt lrom ycar to ycar,
without cvidcncc ol any signicant rcgrcssion to thc mcan, cvcn though thc
pcr capita ratc ol surgcry is growing rapidly lor many opcrations. Tis con
sistcncy has bccn traccd to thc practicc stylc ol local physicians. 8rcaking thc
cyclc ol supplicr inucncc on thc utilization ol surgcry rcquircs rclorm ol
thc doctorpaticnt rclationship, by rcplacing dclcgatcd dccision making with
sharcd dccision making. Chaptcr . containcd scvcral suggcstions ol ways
to achicvc this goal, including changcs in lcgal, cconomic, and rcgulatory
inccntivcs, improvcmcnts in clinical scicncc, and a ncw rolc lor primary carc
as advocatcs and guarantors ol a sharcd dccisionmaking proccss. ! bclicvc
thcsc rclorms hold promisc lor crcating a rcal markct lor prclcrcnccscnsitivc
carc, onc in which thc utilization ol surgcry and othcr cxpcnsivc prclcrcncc
scnsitivc trcatmcnts arc dctcrmincd by inlormcd paticnt choicc.
Tc transition to inlormcd paticnt choicc as thc standard ol practicc is lully
justicd on cthical grounds alonc. !t is not a good idca to opcratc on paticnts
who would not want surgcry wcrc thcy truly inlormcd. Howcvcr, cvidcncc
that thc implcmcntation ol sharcd dccision making oltcn lcads to lowcr
uptakc ol surgcry and substantial savings, at lcast in thc short tcrm, should
ccrtainly cnhancc thc attractivcncss to policy makcrs and paycrs ol lostcring
thc transition to inlormcd paticnt choicc. ur study ol 8PH surgcry among
paticnts cnrollcd in Group Hcalth Coopcrativc and Kaiscr Pcrmancntc (scc
Figurc 6.., pp. ) rcgistcrcd a c drop in populationbascd ratcs ol sur
gcry lollowing introduction ol thc sharcd dccisionmaking dccision aid.
(Tis dcclinc in utilization lollowing thc shilt lrom supplicrinucnccd to
:6 v~)nw~ys )o vvvov:
paticntinduccd dcmand is all thc morc imprcssivc lor thc lact that Group
Hcalths ratcs wcrc alrcady in thc bottom quartilc ol thc ratcs lor thc coun
try.) A rcccnt Cochranc rcvicw ol randomizcd clinical trials comparing
sharcd dccision making supportcd by dccision aids to obtaining inlormcd
conscnt through usual carc showcd an avcragc : dcclinc in dcmand lor a
widc rangc ol clcctivc surgcrics and tcsts.
2
Tcrc will bc cxccptions, ol coursc,
and sharcd dccision making will lcad to an incrcasc in dcmand lor at lcast a
lcw proccdurcs. 8ut lrom a nancial standpoint, an cxpcctcd nct rcduction
in utilization in thc rangc ol : would rcsult in annual Mcdicarc savings
ol s billion or morc (in :cc6 dollars) lor thc proccdurcs listcd in Tablc ...
(pp. :.). A morc modcst dcclinc ol in dcmand would still rcsult in sub
stantial savingsabout scc millionand thc amount would bc s:. billion
il thc dcclinc is ..
8ut changing thc culturc ol mcdicincand this is what shilting to sharcd
dccision making cntailswill not happcn ovcrnight. !n thc mcantimc,
Mcdicarc could pursuc a rcgulatory approach to signal its intcntion to work
toward inlormcd paticnt choicc as thc standard ol carc. !mmcdiatc savings
would bc availablc il CMS wcrc to, in ccct, sct a quota and stop rcimbursing
providcrs in a rcgion lor ccrtain proccdurcs whcn thc ratcs risc abovc a ccrtain
pcrccntilc rank in pcr capita incidcncc ol surgcry. 8ut quotasrcmcmbcr thc
hystcrcctomy story in Lcwiston, Mainc, lrom Chaptcr lail to achicvc thc
objcctivc ol inlormcd paticnt choicc and punish all surgcons in a rcgion, not
just thosc who lail to hclp thcir paticnts bccomc lully inlormcd.
Anothcr approach would bc to imposc obligatory cost sharing lor paticnts
who choosc cxpcnsivc trcatmcnt options lor sclcctcd conditions whcrc thc
bcnct ol trcatmcnt is to incrcasc thc quality ol lilc. !mposing dicrcntial cost
sharing in situations whcrc choicc cvolvcs around considcrations ol quality ol
lilc docs not mcan thc abandonmcnt ol Mcdicarcs commitmcnt to pay lor
ncccssary carc. As \ictor Fuchs, thc Stanlord cconomist has argucd, Vhcn
quality ol lilc is thc objcct ol highintcnsity carc, thc cgalitarian impcra
tivc lor collcctivcly lunding such carc loscs much ol its lorcc.
1
For cxamplc,
Mcdicarc could rcquirc that most paticnts with kncc arthritis who clcct thc
morc cxpcnsivc trcatmcnt option, joint rcplaccmcnt, arc thcmsclvcs rcspon
siblc lor at lcast part ol thc copaymcnt lor thc opcration, cvcn whcn thcy
havc supplcmcntal insurancc. (Cost sharing lor lowincomc paticnts could
bc waivcd.) Cost sharing would likcly motivatc paticnts to scck inlormation
on trcatmcnt options and thus accclcratc thc transition to inlormcd paticnt
choicc. Although thc cvidcncc so lar prcdicts that cvcn in thc abscncc ol cost
sharing, wcllinlormcd paticnts choosc invasivc, highcost trcatmcnts lcss
oltcn, it is di cult to prcdict thc long-term impact on utilization il inlormcd
nv~i)n c~vv vvvov: :
paticnt choicc wcrc to bccomc thc standard ol practicc. !n a markct whcrc
dcmand lor prclcrcnccscnsitivc carc is bascd on inlormcd paticnts, cost shar
ing lor morc cxpcnsivc options would providc policy makcrs with a powcrlul
mcans lor kccping thc ovcrall utilization lor prclcrcnccscnsitivc trcatmcnts
within acccptablc limits.
Inuencing the Numbers, Specialty Composition,
and Training of Physicians
!n a hcalth carc cconomy pronc to supplicrinduccd dcmand, thc sizc and
spccialty composition ol thc physician worklorcc arc kcy lactors dctcrmining
thc lcvcl ol utilization and thus hcalth carc spcnding. Having morc physicians
pcr capita mcans grcatcr spcnding pcr capita. And thc spcnding ! am talk
ing about is not just lor thc carc thc physicians thcmsclvcs providc. !t is all
thc othcr scrviccs thcy prcscribcthc hospitalizations, stays in intcnsivc carc
units, cxtcndcd carc, rclcrrals to homc hcalth agcncics, and drugs and mcdical
dcviccsthat account lor thc majority ol physicianinucnccd hcalth carc
spcnding. Tc artmouth Atlas providcs an cstimatc ol how much such costs
incrcasc along with an incrcasc in physician inputs. For Mcdicarc, incrcasing
thc lulltimc cquivalcnt labor input ol physicians by onc physician pcr .,ccc
cnrollccs is associatcd with about a s.,ccc pcr cnrollcc incrcasc in spcnding
lor thc othcr scrviccs that physicians prcscribcand this amount docs not
includc spcnding lor drugs
4
(Figurc ...).
Tc lcdcral govcrnmcnt plays a pivotal rolc in subsidizing postgraduatc
mcdical cducation lor physicians, and thus a pivotal rolc in dctcrmining how
many physicians thcrc arc in thc Unitcd Statcs. !n :cc, Mcdicarc paid tcach
ing hospitals morc than s.6 billion to train somc o,ccc rcsidcnts, about
so6,ccc pcr physician.
)
:: v~)nw~ys )o vvvov:
substantial cvcn among hospital rclcrral rcgions locatcd within thc samc statc.
!n Sarasota, thc lowcstspcnding rcgion in Florida, Mcdicarc spcnt s6,oc
pcr cnrollcc, lcss than hall thc amount spcnt in Miami. !n Ncw York, spcnd
ing in thc highcstspcnding rcgion, Manhattan (s.:,.:c pcr cnrollcc) was
ncarly twicc as high as spcnding in thc lowcst rcgion, 8inghamton (s6,.cc).
Among thc ninc statcs containing at lcast tcn hospital rclcrral rcgions, ratcs
varicd morc than 6c lrom highcst to lowcst in six ol thc ninc statcs.
As discusscd in Chaptcr .:, thc cost ol hcalth insurancc is not adjustcd to
closcly rccct rcgional variation in pcr capita spcnding and utilization. Tis
lack ol markctbascd pricing rcsults in unjusticd translcr paymcnts lrom
markcts in which providcrs arc morc c cicnt to markcts whcrc thcy arc lcss
c cicnt. !t is not that thosc living in highcost arcas arc sickcr or that thcy
rcccivc bcttcr carc. Tcy simply rcccivc morc carc. Tis is so both lor paticnts
with privatc insurancc plans and lor Mcdicarc paticnts, and judging lrom
thc cxpcricncc ol Mcdicarc, wc should cxpcct at lcast a twolold variation in
privatc scctor utilization and spcnding across rcgions.
Tc lull impact ol thcsc dicrcnccs in spcnding can bc apprcciatcd by
looking at thc cstimatcd cumulativc spcnding ovcr thc lilctimc ol a 6ycar
old ncwly cnrollcd in Mcdicarcwhat cconomists call thc prcscnt valuc ol
thc Mcdicarc bcnct. For rcsidcnts ol Miami, thc cstimatcd prcscnt valuc
in :cc was s:.,.., lor Sarasota, it was s.:,., and thc avcragc lor thc
nation as a wholc was s..,cc. Assuming that thc rcsidcnts ol Miami arc
slightly abovc avcragc with rcgard to thcir Mcdicarc and incomc taxcs, thc
nct translcr ol tax dollars lrom lowspcnding rcgions likc Sarasota to Miami
is morc than s.cc,ccc pcr rcsidcnt ol Miami (and much morc pcr Miami
physician).
!t is not only bccausc thcy arc unlair that policy makcrs should pay attcn
tion to translcr paymcnts. !t is also bccausc thcy distort markct signals rclat
ing to thc costs ol carc in a givcn rcgion. For cxamplc, il thc cost ol hcalth
carc insurancc in Miami was dircctly dctcrmincd by thc ratc ol pcr capita
spcnding in Miami, a dccision to incrcasc thc capacity ol thc Miami dcliv
cry systcm would not bc unilormly vicwcd as good lor Miami. For ycars, !
havc argucd lor adjusting hcalth insurancc prcmiums and rclatcd taxation to
rccct rcgional spcnding lcvcls. Tis lairly simplc changc could sct thc stagc
lor thc cmcrgcncc ol public and privatc scctor rcsolvc to rcducc unwarrantcd
variation and growth in hcalth carc dclivcry. !t would makc transparcnt to
paticnts, providcrs, cmploycrs, hospital boards, politicians, rcgulators, and
othcrs just how much thc cost ol carc is in thcir own arca and in othcr loca
tions. !t should crcatc a broad inccntivc lor paycrs, providcrs, and paticnts
to pay attcntion to rcgional variation, in particular thc ovcrusc ol acutc carc
nv~i)n c~vv vvvov: :.
hospitals and thc lack ol community rcsourccs in caring lor thc chronically
ill. !t should also draw attcntion to thc idiosyncratic and challcnging pattcrns
ol surgical practicc lrom onc community to anothcr.
Vhilc thc rcsponsc would likcly dicr lrom rcgion to rcgion and lrom
statc to statcwith somc locations and jurisdictions sccking compctitivc
markct solutions and othcrs sccking rcgulationthc nct ccct should bc
incrcascd awarcncss that todays hcalth carc markct is not scllrcgulating and
that stcps nccd to bc takcn to movc bcyond thc status quo. !n ordcr to sct
this dynamic into motion, thc U.S. Congrcss should carclully considcr thc
option to rcquirc thc rating ol hcalth insurancc prcmiums to rccct rcgional
markcts.
Establish Feedback of Information on Practice Variation
Anothcr way to incrcasc awarcncss about practicc variation and lostcr rclorm
is to makc routinc rcports about practicc variations availablc to paycrs, pro
vidcrs, rcgulators, and paticnts and thcir lamilics on a continuing basis. Tis
book providcs a numbcr ol cxamplcs ol how inlormation lccdback changcd
clinical practicc in \crmont and Mainc. Practicc variation data playcd a
major rolc in stimulating providcrs to rcducc thc ovcrusc ol tonsillccto
mics in Morrisvillc, to participatc in our comparativc ccctivcncss studics
ol prostatc surgcry in Mainc, to organizc thc Mainc Mcdical Asscssmcnt
Foundation, and lor thc lcadcrship ol thc Amcrican Urological Association
to join in a national cort to rcducc variation in urological practicc. Practicc
variation data should play a similar rolc il this rcscarch agcnda comcs again
into lashion. Tc artmouth Atlas Projcct providcs cxamplcs ol how such
inlormation can lcad dircctly to hcalth carc rclorm, as illustratcd by thc rolc
it playcd in stimulating thc Vashington Statc Lcgislaturc to changc thc law
to lavor inlormcd paticnt choicc. Tc dccision on thc part ol Scattlcbascd
Group Hcalth Coopcrativc to undcrtakc a largcscalc projcct to implc
mcnt sharcd dccision making was motivatcd in part by thc awarcncss ol
thc variation that cxistcd among its clinics in dicrcnt parts ol thc statc ol
Vashington. Morc rcccntly, Atlas data havc bccomc a vital and oltcn quotcd
sourcc ol inlormation in Vashington, . C., in thc dcbatc ovcr hcalth carc
rclorm.
Practicc variation data can bc uscd ccctivcly by thc prcss to writc storics
that challcngc thc convcntional wisdom that hcalth carc is bascd on sound
scicncc and paticnt dcmand. Tc Ncw York Timcs covcragc ol thc cpidcmic
: v~)nw~ys )o vvvov:
ol pcrcutancous coronary intcrvcntion surgcry in lyria, hio, is a casc in
point, as is Te New Yorker articlc contrasting thc pattcrns ol carc in McAllcn
and l Paso, Tcxas, and Grand ]unction, Colorado. Tcsc articlcs, particu
larly Te New Yorker rcport, coming as it did in thc middlc ol thc dcbatc ovcr
hcalth carc rclorm, havc widcncd thc discussion ovcr whcthcr morc carc is
bcttcr. ! bclicvc such a dcbatc is csscntial to pavc thc way lor thc cultural
changcs that nccd to occur il wc arc to succcsslully rclorm hcalth carc.
Transparcncy about thc rclativc c cicncy ol providcrs in managing chronic
illncss can opcn up ncw opportunitics lor rcal choicc. Hcalth carc providcrs
scrving any individual rcgion arc not all alikc. Tc conscqucnccs ol choicc
in tcrms ol cost will dicr according to hospital, bccausc Mcdicarc spcnd
ing and rcsourcc inputs pcr capita can vary widcly lrom hospital to hospital,
cvcn within thc samc community. artmouth Atlas routinc rcports providc
this inlormation. !t is not just that Mcdicarc spcnding varics substantially
among rcgions, cvcn in thc samc statc. !t is that pcr capita spcnding varics
about as much among thc individual hospitals locatcd in a givcn rcgion (scc
Figurc ...). For cxamplc, during thc last two ycars ol lilc, spcnding among
thc hospitals locatcd in Miami (thc most costly rcgion on a pcr capita basis
in Florida) varicd ..lold lrom thc lcast to thc most costly hospital, among
Manhattan (thc most costly rcgion in Ncw York) hospitals, spcnding varicd
..lold, and among Los Angclcs hospitals, it varicd :..lold. Tc idcntitics
and locations ol thcsc hospitals, along with othcr inlormation on rcsourcc
inputs, utilization, and quality ol carc, arc availablc on thc artmouth Atlas
Projcct wcbsitc.
Knowlcdgc ol which hospital is which should bc ol grcat importancc
to insurcrs in contracting with hospitals to carc lor thcir paticnts and lor
cmploycrs trying to cncouragc thcir cmployccs to scck an c cicnt providcr.
!nlormation on capacity should bc important to hospital administrators and
trustccs in making dccisions to hirc physicians or build bcds (particularly il
CMS wcrc to imposc an outlicr pcnalty on highratc hospitals, as ! suggcst
thcy should).
Statc govcrnmcnts, particularly statcs that rcgulatc thc construction ol
hospitals or thc purchasc ol capital cquipmcnt through Ccrticatc ol Nccd
(CN) laws, should bc vitally intcrcstcd in populationbascd, hospital
spccic inlormation on rcsourcc inputs. !n thcory, CN laws should bc a
kcy stratcgy in stabilizing thc hcalth carc cconomy bccausc ol thc impor
tancc ol thc rolc that thc supply ol rcsourccs plays in inucncing dcmand: a
bcd not built or a magnctic rcsonancc imaging machinc not purchascd is a
surcrc way to constrain rcsourcc inputs and thcrclorc rcducc costs. 8ut as
wc showcd in \crmont, whcn rcgulators do not havc thc right inlormation,
nv~i)n c~vv vvvov: :
thcy can mistakcnly dctcrminc that thc hospitals with thc most bcds pcr
capita nccd still morc bcds, simply bccausc thc bcds thcy havc arc lully occu
picd.
!!
artmouth Atlas routinc rcports providc thc intclligcncc rcquircd
to avoid such rcgulatory crrors. Tcy prolc rcsourcc inputs on a pcr capita
basis among rcgions, as wcll as a hospitalspccic basis. Populationbascd
inlormation bascd on claims data (or othcr largc databascs such as Ncw
Yorks and Calilornias hospital dischargc data scts) can support a rational
approach to thc administration ol CN laws that, il ccctivcly cnlorccd,
would rcducc ovcrusc and unwarrantcd variation.
Pcrhaps most important, providcrspccic inlormation hclps paticnts
and lamilics and thcir physicians makc an inlormcd choicc about whcrc to
scck carc. Particularly lor paticnts with chronic illncss, thc choicc should
involvc nding a providcr whosc pattcrns ol mcdical practicc ts thcir prcl
crcnccs lor carc, including thc intcnsity ol acutc carc hospital usc and cnd
ol lilc carc. Hcrc is a prolc ol thc paticnt cxpcricncc bctwccn two hospitals
locatcd in thc San GabriclArcadia scction ol Los Angclcs, as rcportcd in thc
:cc artmouth Atlas.
!2
Paticnts living thcrc havc a rcal choicc. Alhambra
Figurc .... Mcdicarc spcnding pcr paticnt during thc last two ycars ol lilc lor
paticnts with chronic illncss rccciving most ol thcir carc lrom a hospital locatcd within
sclcctcd rcgions. (Sourcc: artmouth Atlas Projcct databasc.)
:o,ooo
o,ooo
o,ooo
6o,ooo
o,ooo
8o,ooo
oo,ooo
+oo,ooo
++o,ooo
+:o,ooo
+:o,ooo
+o,ooo
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)
Miami Houston Manhattan Los Angeles New Orleans Detroit Cleveland Philadelphia Chicago
Most costly hospital ++o,86o ++o:,6:o ++:+,o+o ++:o,ooo +8,86o +,6:o +:,6oo +++8,ooo +o+,+:o
HRR avcragc +8o,o:o +6,o +o,68o +8,::o +68,66o +6o,oo +:,::o +66,o+o +:,o:o
Lcast costly hospital +6:,:o +:,6:o +66,o +6+,:o +6,6o +,o +6,+o +o,oo +o,+oo
:6 v~)nw~ys )o vvvov:
Hospital providcs thc morc aggrcssivc pattcrn ol practicc: during thc last six
months ol lilc, paticnts using thc Alhambra hospital can cxpcct to spcnd an
avcragc ol .c days in hospital and incur .: physician visits, c ol paticnts
using this hospital cxpcricnccd a stay in a intcnsivc carc unit at thc timc ol
dcath, and only .. ol its paticnts wcrc cnrollcd in hospicc carc. Mcthodist
Hospital carc is morc conscrvativc: its paticnts avcragcd . days in hospital
and o physician visits, .. ol its paticnts cxpcricnccd a intcnsivc carc unit
stay at timc ol dcath, and : wcrc cnrollcd in hospicc.
Los Angclcs is not uniquc. Figurc .. prolcs thc variation in thc usc
ol thc intcnsivc carc unit at thc timc ol dcath among hospitals locatcd in
sclcctcd urban rcgions. Tc pcrccntagc ol dcaths involving a stay in an intcn
sivc carc unit varics by a lactor ol : or grcatcr in cvcry rcgion cxccpt Ncw
rlcans and Chicago.
Finally, ! suggcst that routinc lccdback rcports bc bascd on mcrgcd data
lrom all paycrs and bc availablc in as closc to rcal timc as possiblc. Tc
artmouth Atlas Projcct databasc has important limitations as an c cicnt
Figurc ... Pcrccnt ol dcaths associatcd with a stay in an !CU lor hospitals in
sclcctcd rcgions lor dcath occurring :cc. through :cc. (Sourcc: artmouth Atlas
Projcct databasc.)
+o
+
:o
:
:o
:
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Miami Houston Manhattan Los
Angeles
New
Orleans
Detroit Cleveland Philadelphia Chicago
Highcst pcrccnt + : o :6 :+ : :8 ::
HRR avcragc :: :: : :: :o :+ +o :6 :
Lowcst pcrccnt :: +: :o :o + + +: + :+
nv~i)n c~vv vvvov: :
sourcc ol inlormation lor gcncrating routinc rcports. First, it is availablc only
altcr considcrablc dclay bccausc it is bascd on rcscarch lcs and cannot pro
vidc inlormation on a rcaltimc basis. To bc maximally usclul, lccdback
should bc availablc as closc as possiblc to thc timc ol thc actual cvcnt. Tis is
particularly important il thc data arc to bc uscd in sharcd savings programs,
as advocatcd in Chaptcr ... Sccond, it is limitcd to claims gcncratcd undcr
traditional Mcdicarc. vcn though Mcdicarc utilization ratcs appcar to bc
highly corrclatcd with thc ratcs lor populations undcr 6 ycars ol agc (scc
Figurc .:., pp. :cc), it can only tcll part ol thc story and is silcnt about
matcrnal and child hcalth carc and dicrcnccs in priccs ncgotiatcd with
providcrs by commcrcial insurcrs. Tc missing inlormation is hiddcn in thc
claims lcs ol othcr paycrs, both public and privatc. Tc timcly availability
ol an allpaycr databasc, bascd on thc mcrging ol thcsc disparatc systcms,
would crcatc an important tool lor monitoring hcalth carc dclivcry, no mattcr
whcrc hcalth carc rclorm may lcad.
vcr thc ycars, thcrc havc bccn a numbcr ol corts to cstablish allpaycr
systcms on a voluntary basis, but only rcccntly havc thcy mct with somc suc
ccss, as in Mainc, Ncw Hampshirc, and Minncsota. ! bclicvc that thc U.S.
Congrcssor il not Congrcss, thcn thc statcsshould takc stcps to cnsurc
that thcsc sourccs ol data bccomc availablc and arc uscd to gcncratc pcrlor
mancc rcports at thc rcgional and individual providcr lcvcls ol aggrcgation.
Rclorm ol thc hcalth carc dclivcry systcm rcquircs major changcs in thc
doctorpaticnt rclationship, a transition lrom dclcgatcd dccision making to
sharcd dccision making and inlormcd paticnt choicc. !t also rcquircs a transi
tion lrom disorganizcd to organizcd carc that can mcct thc nccds ol paticnts
ovcr thc coursc ol thcir illncsscs. Tcsc changcs will takc timc and cxpcri
mcntation bclorc wc gct it right. !n thc mcantimc, thc incxorablc incrcascs
in hcalth carc costs must bc hcld in chcck. Tis chaptcr suggcsts vc stratc
gics that lcdcral and statc govcrnmcnts could pursuc to rcducc thc growth
in spcnding, rcducc variation, and sct thc stagc lor thc ncccssary rclorms. !t
rcmains to bc sccn how long it will takc lcgislators and policy makcrs, provid
crs, and paycrs to bcgin to movc down thc path ol putting thcm into action.
:
!t is thc thcsis ol this book that an undcrstanding ol unwarrantcd varia
tion in hcalth carc dclivcryvariation that cannot bc cxplaincd on thc basis
ol prcvalcncc ol illncss, mcdical cvidcncc, or paticnt prclcrcnccprovidcs
a lramcwork lor intcrprcting thc crisis in costs and thc chaos that plagucs
hcalth carc in thc Unitcd Statcs. Tc chaotic pattcrns ol practicc, rst uncov
crcd in \crmont and Ncw ngland, and now documcntcd by thc artmouth
Atlas Projcct across thc nation, arc incompatiblc with thc assumption that
clinical scicncc and mcdical cthics govcrn thc utilization ol carc. Vhilc pol
icy makcrs rccognizc that dclcgating choicc to thc scllcr ol scrviccs scts up
thc possibility lor abusc, most havc assumcd that unduc inucncc on utiliza
tion by physicians was rarc, thc rcsult ol thc action ol an unscrupulous lcw
who transgrcsscd thc dictatcs ol clinical scicncc or thc standards ol mcdical
cthics. 8ut supplicr inucncc on utilization is not rcstrictcd to just a lcw
bad applcsa handlul ol grccdy physicians. !t is a ubiquitous phcnomcnon,
a ccntral tcndcncy ol thc markct lor hcalth carc scrviccs. !t accts paticnts
cvcrywhcrc, including thosc carcd lor by thc nations most lamous acadcmic
mcdical ccntcrs, and by thc most caring and carclul ol physicians.
Tc mcchanisms bchind thc inucncc that physicians cxcrcisc on utili
zation dcpcnd on thc catcgory ol carc. For prclcrcnccscnsitivc carc, cpito
mizcd by clcctivc surgcry, thc most important lactor is thc physicians opinion
about thc outcomcs ol various trcatmcnt options and thc physicians bclicl
.6
Te Challenge of Practice Variations
)nv cn~iivxcv ov vv~c)icv v~vi~)ioxs :o
about thc paticnts prclcrcncc. Vhcn clinical scicncc is wcak, mcdical opin
ion is only looscly constraincd by mcdical cvidcncc, as wc saw in thc casc ol
surgcry lor an cnlargcd prostatc. Tcrc, an crroncous assumption about thc
lilccxtcnding powcr ol surgcry lcd to as many as 6c ol mcn having thcir
prostatcs rcmovcd in somc arcas ol Mainc. 8ut cvcn whcn thc dccision is
cvidcnccbascd, whcn outcomcs arc prcdictablc and risks arc wcll charac
tcrizcd, thc trcatmcnt thc physician rccommcnds may not bc thc trcatmcnt
an inlormcd paticnt would prclcr. Among Group Hcalth Coopcrativc and
Kaiscr Pcrmancntc paticnts, only :: ol mcn who wcrc scvcrcly symptom
atic lrom thcir cnlargcd prostatc gland chosc surgcry altcr bcing inlormcd
ol thc potcntial bcncts and harms ol thcir trcatmcnt options. !n ntario,
only . ol paticnts who mct cvidcnccbascd appropriatcncss guidclincs lor
kncc and hip rcplaccmcnt actually wantcd surgcry whcn thcy wcrc askcd
about thcir prclcrcncc. Unlcss thc dccision proccss that lcads to surgcry is
dcsigncd to untanglc thc paticnts prclcrcncc lrom thc physicians opinion,
thc outcomc ol thc dccision proccss can all too oltcn bc thc prcscription lor
a trcatmcnt that thc paticnt rcally docs not want.
Vc now know cnough to rcmcdy unwarrantcd variation in prclcrcncc
scnsitivc carcto complctc thc unprcccdcntcd and historic transition lrom a
passivc paticnt and a patcrnalistic physician to a doctorpaticnt rclationship
groundcd in sharcd dccision making and inlormcd paticnt choicc. Vhcn
! bcgan my studics in \crmont morc than lorty ycars ago, most paticnts
playcd a passivc rolc in thc choicc ol thcir trcatmcnts, gladly dclcgating thc
dccision to thc physician undcr thc assumption that only physicians know
what paticnts truly nccd. Today thc agcncy modcl is vicwcd with incrcasing
skcpticism, and thc path lorward has bccn blazcd: thc scicncc ol hcalth carc
dclivcry can clarily what is at stakc lor paticnts dcpcnding upon thcir choicc
among trcatmcnt options, sharcd dccision making, augmcntcd by dccision
aids, rcsults in bcttcr dccisions that arc morc in kccping with paticnt val
ucs, and a hcalth carc dclivcry systcm bascd on inlormcd paticnt choicc that
would cstablish paticntinduccd rathcr than supplicrinduccd dcmand as thc
most important dctcrminant ol utilization. !l thc Unitcd Statcs can makc
this transition to a dcmocratizcd doctorpaticnt rclationship, it will bc thc
rst nation in thc world to do so.
Tc inucncc ol physicians on thc utilization ol what wc call supply
scnsitivc carc lollows a dicrcnt bchavioral modcl. Tc primary issuc is thc
lrcqucncy, or thc intcnsity ol usc, ol routinc carcscrviccs likc physician
visits, rclcrrals to spccialists, imaging cxams, hospitalizations, and stays in thc
intcnsivc carc unit. Tc lrcqucncy ol thcsc scrviccs varics rcmarkably lrom
onc clinical sctting to anothcr, and it is thc primary rcason lor thc morc than
:6c v~)nw~ys )o vvvov:
:.lold variation in Mcdicarc spcnding among rcgions. Yct dcspitc its impor
tancc in tcrms ol ovcrall costs, thc qucstion ol appropriatc usc ol supplyscn
sitivc carc runs bclow thc radar scrccn ol objcctivc prolcssional discoursc. Tc
mcdical litcraturc is silcnt about how oltcn and lor which paticnts such carc
should bc providcd, in largc mcasurc bccausc thcrc is virtually no scicncc to
hclp physicians makc such discrctionary dccisions. !n thc abscncc ol scicntic
constraints on utilization, thc assumption holds that morc carc is bcttcr carc,
and thc agcncy rolc ol thc physician lcads naturally to thc usc ol availablc
rcsourccs up to thc point ol thcir cxhaustion.
Although thc qucstion ol thc appropriatc lrcqucncy ol thc usc ol supply
scnsitivc carc has bccn virtually untouchcd by clinical rcscarch, our studics
havc uscd thc populationbascd mcthods ol cpidcmiology to cvaluatc thc
morc is bcttcr assumption. Vc nd that paticnts with similar illncsscs living
in rcgions whcrc thc intcnsity ol carc is high havc no bcttcr, and somctimcs
worsc, outcomcs than thosc living in rcgions whcrc thc intcnsity ol carc is
low. Paticnts in highintcnsity rcgions also arc lcss satiscd with thcir carc,
and thcir providcrs tcnd to scorc worsc on objcctivc mcasurcs ol thc quality
ol carc.
Tc good ncws is that thc pattcrn ol variation wc scc rcccts ovcrusc in
highcost rcgions, rathcr than thc rationing ol carc in lowcost rcgions. Vc
should not spcnd morc to bring Minncapolis and Scattlc up to thc lcvcl ol
Miami and Los Angclcs. !ndccd, il thc nation wcrc ablc to bring carc intcn
sity down to thc pcr capita bcnchmarks providcd by such lowratc rcgions,
savings ol up to c in thc costs ol managing chronic illncss would bc rcal
izcd, morc than cnough to osct any incrcascs in public spcnding that might
rcsult lrom cxtcnding insurancc covcragc to thc uninsurcd.
Tc bad ncws is that thc rcmcdics lor unwarrantcd variation in supply
scnsitivc carc will bc di cult to implcmcnt. !t will dcpcnd on simultancously
addrcssing thc multiplc problcms that lic bchind thc variation: thc virtual
noncxistcncc ol thc clinical scicncc on which to basc guidclincs conccrning
thc lrcqucncy ol usc, thc discquilibrium bctwccn rcsourcc capacity and utili
zation, and disorganizcd carc systcms that arc prcscntly incapablc ol coordi
nating carc, controlling capacity, and lcarning lrom cxpcricncc in ways that
contributc to thc advanccmcnt ol clinical knowlcdgc.
Chaptcr .. prcscntcd somc idcas on how to rclorm thc dclivcry systcm
to rcducc unwarrantcd variation in supplyscnsitivc carc. Supplyscnsitivc
carc gocs mostly to paticnts with chronic illncss, and thc cpisodc ol ill
ncss lor thc chronically ill is indcnitc, a trajcctory that, lor most paticnts,
progrcsscs until thc cnd ol lilc and involvcs many scctors ol carc and many
dicrcnt providcrs. Tis would suggcst that wc nccd to movc bcyond thc
)nv cn~iivxcv ov vv~c)icv v~vi~)ioxs :6.
cmphasis on rcscuc mcdicinc and thc dominant rolc thc acutc carc hospital
now plays in managing carc. Tis will cntail carc coordination and a stratcgy
lor translcrring somc ol thc capital now ticd up in hospitals, skillcd nurs
ing lacilitics, and longtcrm carc hospitals into communitybascd carc. !t
rcmains to bc sccn, howcvcr, whcthcr thc cconomic inccntivcs cmbcddcd in
thc sharcd savings conccpt outlincd in Chaptcr .. arc strong cnough to put
highquality, lowcost systcms within thc rcach ol cvcry Amcrican.
ngaging Providcrs, thc Fcdcral Govcrnmcnt and Paycrs
Practicc variations posc a spccial challcngc to mcdical scicncc. Tc nation
looks to acadcmic mcdical ccntcrs and thc National !nstitutcs ol Hcalth
(N!H) as thc principal sourccs ol mcdical innovation, and guarantors ol
thc scicntic basis ol carc. Yct thc N!H and acadcmic mcdicinc havc paid
littlc attcntion to thc scicncc ol hcalth carc dclivcry. Tc conscqucnccs ol
this ncglcct arc cvidcnt in thc inconsistcnt practicc pattcrns ol thc acadcmic
mcdical ccntcrs thcmsclvcs: thc morc than twolold variation in thc numbcr
ol physicians and intcnsivc carc bcds uscd in managing chronic illncss, and
thc cvcn grcatcr variation in ratcs lor prclcrcnccscnsitivc surgcry.
Ncglcct ol thc scicnccs ol hcalth carc dclivcry has othcr conscqucnccs.
Amcricas mcdical schools do not tcach thc skills rcquircd to undcrstand
paticnt prclcrcnccs, cvaluatc mcdical practicc, asscss clinical cvidcncc, dcsign
and tcst clinical pathways, improvc quality, and undcrstand thc ccct ol sys
tcms ol carc on clinical practicc. Tc mcntorship ol physiciansintraining
takcs placc in thc contcxt ol widcly varying practicc pattcrns, such that thosc
traincd in Los Angclcs and Miami tcaching hospitals cncountcr an cntircly
dicrcnt stratcgy lor managing chronic illncss than thosc traincd in tcach
ing hospitals in Salt Lakc City, Portland, rcgon or Minncapolis. Surgical
training programs routincly takc placc in scttings whcrc inlormcd paticnt
choicc is not yct thc standard ol practicc lor cstablishing thc nccd lor clcctivc
proccdurcs.
Tis must changc. vcr thc past c ycars, thc N!H has bccn rcmarkably
succcsslul in promoting thc growth ol biomcdical scicnccs. Tis succcss is a
tcstimony to thc rcsponsivcncss ol thc nations mcdical schools and acadcmic
mcdical ccntcrs to thc inccntivcs cmbcddcd in an cnlightcncd lcdcral scicncc
policy. Now it is timc lor that scicncc policy to providc similar inccntivcs to
cstablish thc scicncc ol hcalth carc dclivcry. 8ut it isnt just a stablc sourcc ol
rcscarch lunds that is nccdcd. Tc rcsults ol this rcscarch can changc mcdi
cal thcorics and practicc pattcrns, and thus lcad to cconomic gain or loss to
:6: v~)nw~ys )o vvvov:
clinicians, hospitals, dcvicc makcrs and pharmaccutical companics, to namc
just a lcw ol thc playcrs in thc hcalth carc markct. Anything that thrcatcns
thcir rcvcnuc strcam is vulncrablc to attack, as ! lcarncd lrom cxpcricncc
(scc Chaptcr ). To avoid a latc similar to that ol thc Agcncy lor Hcalth
Policy and Rcscarch and thc paticnt outcomcs rcscarch tcams, it is csscntial
that thc lcdcral agcncy rcsponsiblc lor managing thc ncw mcdical rcscarch
agcndalor sctting prioritics, conducting pccr rcvicw and awarding grants
and contracts to rcscarchcrsbc strong cnough to protcct its agcnda and thc
scicntic tcams that conduct thc rcscarch.
Tc succcss ol any rclorm cort to addrcss unwarrantcd variation will also
dcpcnd on thc cmcrgcncc ol prolcssional lcadcrship. n this point, ! am quitc
optimistic. Vhcn conlrontcd with practicc variation, practicing physicians,
nurscs and othcr hcalth prolcssionals havc stood up and donc thc right thing.
! havc told somc ol thcir storics in this book: thc actions ol thc physicians in
Morrisvillc, \crmont, that lcd to a rapid drop in thc misusc ol tonsillcctomy
in thcir own hospital, thc campaign ol an Hanlcy to cstablish lccdback on
variation in practicc pattcrns to providcrs in Mainc, and crcatc thc Mainc
Mcdical Asscssmcnt Foundation, thc cngagcmcnt ol Maincs urologists in a
tcnycar study ol thcir own practicc pattcrns, to namc only a lcw.
Tc lcadcrs ol organizcd systcms ol carcprivatc scctor organizations such
as thc Mayo Clinic, Clcvcland Clinic and !ntcrmountain Hcalthcarc, as wcll
as thc nations largcst public scctor systcms, thc U.S. Military Hcalth Systcm
and thc \ctcrans Hcalth Administrationbcar a spccial rcsponsibility lor
addrcssing unwarrantcd variation. First, bccausc thcsc systcms arc organizcd,
thcy arc uniqucly situatcd to adopt thc principlcs ol inlormcd paticnt choicc
as a standard ol practicc, coordinatc carc lor thcir chronically ill paticnts across
scctors ol carc and, bccausc thcy scrvc a dcncd population, control capac
ity and growth through populationbascd planning ol rcsourcc allocation.
Sccond, bccausc thcy havc thc ncccssary inlrastructurc, including clcctronic
mcdical rccords, thcy arc uniqucly situatcd to conduct thc scicncc ol hcalth
carc dclivcry: to dcvclop and validatc clinical pathways to rationalizc thc usc
ol supplyscnsitivc carc and assurc high quality sharcd dccision making. From
such rcscarch, thcy (and thc nation) will lcarn thc rcsourccs (thc dollars, thc
pcr capita worklorcc and lacilitics) nccdcd to providc cost ccctivc carc lor
thosc with chronic illncss and undcrstand thc dcmand lor discrctionary sur
gcry and othcr lorms ol prclcrcnccscnsitivc carc. Finally, organizcd systcms
ol carc, particularly thosc in thc privatc scctor, should acccpt thc rcsponsibility
to grow: to cntcr into ncw markcts and hclp thc nation convcrt disorganizcd
systcms ol carc. !n Chaptcr .., ! discusscd somc idcas as to how sharcd savings
programs could crcatc thc inccntivcs to makc this happcn.
)nv cn~iivxcv ov vv~c)icv v~vi~)ioxs :6.
Tc challcngc to paycrs cmcrgcs lrom thc spccial rcquircmcnts lor mcct
ing thc nancial nccds ol providcrs who implcmcnt sharcd dccision making,
rcducc ovcrusc, and coordinatc carc lor paticnts with chronic illncss ovcr timc
and across scctors ol carcin othcr words, who arc committcd to rcducing
unwarrantcd variation. To mcct thcsc nccds, thc nancial inccntivcs acct
ing a givcn providcr nccd to bc cohcrcnt across paycrs: lor cxamplc, policics
govcrning thc sharing ol savings and othcr pay lor pcrlormancc stratcgics
must bc similar lor all chronically ill paticnts and inccntivcs to providc sharcd
dccision making must apply to all candidatcs lor surgcry, not just thosc who
arc covcrcd by a particular paycr. Tc challcngc is thus to movc away lrom thc
traditional volumcdrivcn modcl lor rcimburscmcnt and compctition among
paycrs bascd on discounts on thc pricc pcr unit ol scrvicc, to ncw modcls that
support, indccd promotc, providcrs who strugglc to implcmcnt thc principlcs
ol hcalth carc rclorm.
Tc Challcngc to Paticnts and Familics
Ultimatcly, thc succcss ol any rclorm cort to makc inlormcd paticnt choicc
thc standard ol practicc, to rcducc ovcrusc, and to promotc organizcd carc
will rcquirc support lrom a broad constitucncy. Tc natural appcal ol sharcd
dccision making to thc paticnt, combincd with thc corts on thc part ol
statc lcgislaturcs to promotc it, bodcs wcll lor accclcrating thc transition to
inlormcd paticnt choicc as thc standard ol practicc. Strcngthcning thc rolc ol
thc primary carc physician as prolcssional advocatc lor sharcd dccision mak
ing and thc introduction ol lcdcral lcgislation to support its implcmcntation
givc mc hopc that onc day, pcrhaps in thc nottoodistant luturc, paticnts will
no longcr rcccivc clcctivc scrviccs that thcy would not havc choscn had thcy
undcrstood thc tradcos.
Gaining support lor addrcssing thc problcms associatcd with thc ovcr
usc ol acutc carc in managing chronic illncss will bc thc grcatcr challcngc.
Providcrs who arc thrcatcncd with thc prospcct that limits might bc placcd
on thcir highintcnsity pattcrns ol practicc might rcsort to what Robcrt
vans, thc Canadian cconomist, calls shroud waving, raising thc spcctcr
ol hcalth carc rationing. !ndccd, somc alrcady havc. Tc cpidcmiologic cvi
dcncc that grcatcr carc intcnsity is not producing longcr lilc, highcr quality ol
carc, or grcatcr paticnt satislaction should hclp kccp thc dcbatc locuscd, and
artmouth Atlas data dcscribing on a hospitalspccic basis thc paticnts
cxpcricncc ol carc at thc cnd ol lilc could hclp paticnts and lamilics avoid
hospitals that dclivcr unncccssary carc.
:6 v~)nw~ys )o vvvov:
8ut statistics, it has bccn said, arc pcoplc with thc tcars wipcd o. Gctting
bcyond thc morc is bcttcr assumption will likcly rcquirc a national dcbatc
on thc limitations ol mcdicincs powcr to hcal and curc, and on thc quality ol
carc at thc cnd ol lilc. Tc dccisivc voicc in such a dcbatc may comc lrom thc
cxpcricnccs ol thc 8aby 8oomcrs, who arc about to cntcr thc pcriod ol lilc
whcn chronic illncss bcgins to takc hold. Many arc alrcady gaining rsthand
cxpcricncc with thc problcm ol ovcrusc as thcy strugglc to hclp thcir aging
parcnts copc with chronic discasc and carc at thc cnd ol lilc.
Rclorming our hcalth carc dclivcry systcm rcquircs a transition lrom todays
mostly disorganizcd carc to organizcd, coordinatcd systcms ol carc, and lrom
dclcgatcd or rational agcnt dccision making to sharcd dccision making and
inlormcd paticnt choicc. Tis will not bc casy. Altcr all, it rcquircs translorm
ing thc culturc ol mcdicinc and rccnginccring an industry that accounts lor
ncarly . ol thc U.S. gross domcstic product. 8ut such is thc cyc ol thc
nccdlc through which wc must pass to achicvc signicant rclorm.
:6
Tc Paticnt Protcction and Aordablc Carc Act, passcd and signcd into law
in March :c.c, is a landmark piccc ol lcgislation that not only covcrs thc
majority ol thc nations uninsurcd but also bcgins to addrcss thc dclivcry
systcm. Vhilc most ol thc public dcbatc lcading up to its passagc ccntcrcd
on covcragc, many mcmbcrs ol thc U.S. Congrcss also rccognizcd thc nccd
to translorm thc way hcalth carc is dclivcrcd, and thc law contains a num
bcr ol provisions that spccically and dclibcratcly promotc thrcc ol thc lour
goals lor rclorm laid out in this book: building organizcd carc, cstablish
ing inlormcd paticnt choicc, and building thc scicncc ol hcalth carc dclivcry.
A crucial mcchanism lor achicving thcsc goals was built into thc lcgisla
tion in thc lorm ol a wclllundcd !nnovation Ccntcr within thc Ccntcrs lor
Mcdicarc and Mcdicaid Scrviccs (CMS). Tis ccntcr is intcndcd to stimulatc
and coordinatc innovation in thc way providcrs arc paid and thc mcasurcs
uscd to rcward thcm. Tc lcgislation also contains two policy lcvcrs lor thc
lourth goal ol rclorm, constraining undisciplincd growth and spcnding, but
it docs not pursuc this goal as dircctly as thc othcr thrcc.
Tc lcgislation attacks thc task ol building organizcd systcms ol carc lrom
scvcral dicrcnt anglcs. Tcrc arc provisions lor thc crcation ol accountablc
carc organizations (morc or lcss along thc linc discusscd in Chaptcr ..), thc
bundling ol paymcnts to cnsurc coordinatcd carc lor at lcast .c days altcr
dischargc lrom hospitals, and thc cstablishmcnt ol primary carc mcdical
Epilogue
:66 vviiociv
homc pilot projccts. ach ol thcsc initiativcs promotcs grcatcr continuity
ol carc ovcr timc and providcs lor ncw paymcnt modcls that lrcc providcrs
lrom thc constraints ol lcclorscrvicc mcdicinc. Tc bottom linc hcrc is that
CMS now has authority to work with providcrs to modily Mcdicarcs lcc
lorscrvicc paymcnt in support ol organizcd systcms ol carc that arc capablc
ol managing thc illncsscs ol thcir paticnts ovcr timc. Tc savings glcancd
whcn providcrs rcducc thcir dcpcndcncy on acutc carc hospital rcscuc mcd
icinc can bc sharcd bctwccn CMS and thc providcr and rcinvcstcd in morc
c cicnt, communitybascd practiccs. Sharcd savings thus ocr providcrs a
glidc path, an inccntivc to improvc c cicncy couplcd with a way ol solt
cning thc blow ol rcduccd volumc ol carc (and thus rcduccd rcvcnuc). Tis
should providc a mcchanism lor convcrting incomc that traditionally has
bccn gcncratcd by providcrs through lcclorscrvicc into budgcts that will
allow thcm to build organizcd carc.
As outlincd in Chaptcr .., thc sharcd savings programs could providc thc
inccntivcs that group practiccs, acadcmic mcdical ccntcrs, hospital systcms,
and primary carc nctworks nccd to translorm hcalth carc as last as possiblc.
8ut to do this, providcrs nccd to changc thc way thcy carc lor all paticnts, not
just thosc covcrcd by Mcdicarc and Mcdicaid. Vhat is missing is a public
privatc partncrship that crcatcs an intcgratcd nancial modcl lor all insurcd
paticnts who arc carcd lor by any givcn organizcd providcr systcma modcl
that combincs thc Mcdicarc and Mcdicaid paymcnt rclorms with ncw rcim
burscmcnt mcthods lrom cmploycrs and privatc insurancc companics. Vc
hopc thc dcvclopmcnt ol such a partncrship bccomcs a major goal ol public
and privatc paycrs ovcr thc ncxt lcw ycars.
Tc placc to start such a partncrship could bc with thc approximatcly .cc
million Amcricansmorc than hall ol workcrswho arc covcrcd undcr
scllinsurcd plans, many ol thcm through largc privatc cmploycrs and statc
govcrnmcnt. Fcdcral rcgulations pcrmit scllinsurcd cmploycrs to contract
dircctly with providcrs, opcning thc door lor thcm to rcward accountabil
ity and organization through sharcd savings in parallcl with CMS projccts.
Robust cxpcrimcnts in thc rcdcsign ol hcalth carc, oncs that tcst an allpaycr
modcl lor systcm translormation, may bccomc possiblc. !t would also hclp thc
proccss along il hcalth scrviccs rcscarchcrs and CMS had an allpaycr data
basc. Privatc insurcrs havc thus lar bccn rcluctant to sharc claims data, and it
would sccm that lcgislation may bc thc only way to gct mcaninglul acccss.
Allpaycr data will bc particularly important lor thc statcs as thcy scck
to implcmcnt thc insurancc cxchangcs callcd lor in thc lcgislation. Tracking
unwarrantcd variation in utilization and thc growth in pcr capita spcnding
is not just a problcm lor Mcdicarc. As suggcstcd in Chaptcr ., thc gap in
vviiociv :6
inlormation can and should bc llcd by thc pooling ol claims data lrom vari
ous paycrs (and othcr rclcvant data) to providc populationbascd pcrlormancc
mcasurcs on a statc, rcgional, and hospitalspccic basis lor all Amcricans.
Vc hopc thc quality mcasurc dcvclopmcnt provisions undcr Scction o.. ol
thc Act will stimulatc thc building ol such databascs.
vcn bclorc thc bill passcd, corts to cstablish informed patient choice as
a standard ol practicc sccm to havc rcachcd a critical juncturc. For cxam
plc, thc Amcrican Canccr Socicty, which has bccn an unwavcring advocatc
ol many canccr scrccning tcsts, publishcd a ncw guidclinc in :c.c, spccil
ically promoting sharcd dccision making and inlormcd paticnt choicc lor
middlcagcd mcn lacing thc dccision about whcthcr to undcrgo a prostatc
spccic antigcn (PSA) tcst. Tc lcadcrship ol primary carc physicians has
also bcgun to cmbracc thc task ol promoting sharcd dccision making. At thc
statc lcvcl, scvcral lcgislaturcs havc passcd, and othcrs arc contcmplating, bills
that would promotc inlormcd paticnt choicc and thc usc ol paticnt dccision
aids. Tc Paticnt Protcction and Aordablc Carc Act takcs lurthcr stcps.
!t cstablishcs a proccss lor ccrtication ol paticnt dccision aids that would
cnsurc that thcy arc uptodatc, accuratc, and unbiascd. !t also providcs lunds
lor dcvcloping dccision aids and calls lor dcmonstration projccts to cstablish
paymcnt modcls lor intcgrating sharcd dccision making into cvcryday prac
ticc. ncc again, privatc paycrs should participatc.
Tc lcgislation also takcs important stcps toward improving thc knowlcdgc
basc lor clinical practicc, by :c.., morc than scc million will bc availablc
annually lor comparativc ccctivcncss rcscarch, which will locus primarily
on comparing thc risks and bcncts ol drugs and dcviccs. Tis will improvc
our undcrstanding ol thc ccctivcncss ol many trcatmcnt options. Howcvcr,
comparativc ccctivcncss rcscarch as it is currcntly conccivcd is too narrowly
locuscd. Tc prioritics do not cxplicitly includc rcscarch into ways to improvc
clinical dccision making whcn choicc should dcpcnd on paticnt prclcrcnccs.
Tis is csscntial to achicving thc goal ol rcducing unwarrantcd variation in
clcctivc surgcry and scrccning cxaminations such as thc PSA tcst.
Nor docs thc lcgislation givc priority to rcscarch that addrcsscs thc cxpcn
sivc dicrcnccs in thc way chronically ill paticnts arc managcd. Tis is crucial
to bcnding thc cost curvc, bccausc variation in carc intcnsitylrcqucncy in
thc usc ol physician visits, rclcrrals, imaging cxaminations, and acutc carc
hospitalsaccounts lor most ol thc variation in Mcdicarc pcr capita spcnd
ing among rcgions and acadcmic mcdical ccntcrs. Tc lcgislation also docs
not providc thc broadbascd support ncccssary lor sccuring a commitmcnt
to the science of health care delivery lrom thc nations mcdical schools and aca
dcmic mcdical ccntcrs. Tis is unlortunatc. Changing thc culturc ol mcdicinc
:6 vviiociv
dcpcnds on cstablishing thc cvaluativc scicnccs as ccntral to mcdical cdu
cation, a corc compctcncy rcquircd lor practicing mcdicinc. A ncw lcdcral
initiativc cmbracing thc scicncc ol hcalth carc dclivcry, cquivalcnt in scopc
to thc lounding ol thc National !nstitutcs ol Hcalth or thc National Scicncc
Foundation, rcmains to bc madc.
Tc lourth goal ol hcalth carc rclorm listcd in this book, constraining
undisciplined growth, will bc di cult to accomplish through comparativc
ccctivcncss rcscarch and thc gradual promotion ol grcatcr organization in
thc dclivcry systcm, and wc think it is risky to assumc that thcsc aspccts ol
thc lcgislation will control spcnding in a mcaninglul way in thc ncar luturc.
8ut thc ncws is not all bad. Tc lcgislation contains two provisions that could
stabilizc thc hcalth carc cconomy whilc buying timc, and pcrhaps cvcn acccl
crating thc transition lrom disorganizcd to organizcd carc and lrom dclc
gatcd dccision making to inlormcd paticnt choicc.
nc ol thosc provisions conccrns thc growth ol thc physician worklorcc.
Givcn thc importancc ol rcsourcc supply to utilization and costs, any dcci
sion that accts thc sizc and spccialty composition ol rcsidcncy slots will
bc among thc most important choiccs that Congrcss will makc in thc ncxt
lcw ycars. To hclp lcgislators lormulatc a scicnccbascd worklorcc policy,
thc lcgislation cstablishcs a Vorklorcc Commission, whosc rcsponsibilitics
includc an annual rcport to Congrcss that rcvicws thc currcnt worklorcc
supply and distribution and makcs projcctions on thc dcmand lor hcalth
carc workcrs ovcr thc ncxt .c and : ycars. !n vicw ol thc goal to promotc
organizcd carc, wc bclicvc thc Commission and Congrcss should pay spccial
attcntion to thc worklorcc rcquircmcnts ol organizcd dclivcry systcms. As
outlincd in Chaptcr ., thc nation alrcady has cnough physicians to mcct
thc cmploymcnt nccds ol organizcd systcms wcll into thc luturc. Morcovcr,
adding morc physicians will not curc thc symptoms ol scarcity. Look at
Massachusctts, thc statc with thc most physicians pcr capita (including pri
mary carc). Tc di culty thc ncwly insurcd havc nding physicians and gct
ting carc is thc rcsult ol a disorganizcd systcm and nancial disinccntivcs to
taking on ncw paticnts, not lack ol supply. Adding morc physicians will not
curc thc symptoms ol pscudoscarcity in Massachusctts, or in othcr rcgions
that alrcady havc a largc supply ol doctors, but it will raisc costs. Tc oppor
tunity to rcthink thc nations worklorcc policicsparticularly thc nccds ol
organizcd systcms with advanccd mcdical rccordsis also an opportunity
to bcnd thc cost curvc.
Tc lcgislations sccond policy lcvcr lor limiting growth and unwar
rantcd variation lics in thc cstablishmcnt ol thc !ndcpcndcnt Mcdicarc
Advisory 8oard. Tis ncw cntity will havc broad authority to dcvclop
vviiociv :6o
proposals lor ncw rcimburscmcnt stratcgics, which will bc implcmcntcd
il Mcdicarc spcnding grows in cxccss ol amounts spccicd in thc lcgis
lation.
!
Tc 8oard must givc priority to rccommcndations that improvc
thc hcalth carc dclivcry systcm, and it is instructcd to targct rcductions
in spcnding at thc sourccs ol cxccss cost growth. ata about thc ratcs ol
growth in utilization and spcnding, and thc pattcrns ol variation among
rcgions and hospitals, could hclp thc board carry out this task, and through
its dccisions, it could bcgin to limit spcnding according to thc dcgrcc ol
ovcrusc by spccic providcrs in highusc rcgions. nc stratcgy lor idcnti
lying such outlicrs was outlincd in Chaptcr .. As argucd thcrc, wc bclicvc
thc mcrc cxistcncc ol a clcar policy to addrcss ovcrusc by outlicrs could havc
an immcdiatc ccct on markct bchavior: it should accclcratc thc growth ol
organizcd carc, particularly in highcost rcgions, whcrc providcrs will bc
motivatcd to avoid pcnaltics by participating in CMSs (much lcss oncr
ous) sharcd savings programs. Vc also anticipatc that CMSs ncwlound
authority will makc it incrcasingly di cult lor hospitals that ovcrusc carc
to obtain nancing lrom thc bond or cquity markcts,
2
thus lurthcr limiting
thc inccntivcs lor undisciplincd growth.
Pcrhaps thc most gratilying aspcct ol thc lcgislation is that much ol it
rcccts a growing rccognition ol thc ccntral rolc gcographic variation plays
in our hcalth carc markcts. Tc critical rst stcp to undcrstanding practicc
variation and containing pcr capita spcnding is mcasurcmcntthc track
ing ol providcrs pcrlormancc using routinc, unilormly collcctcd data. As thc
artmouth Atlas Projcct dcmonstratcs, claims data can providc much ol thc
inlormation nccdcd to documcnt inc cicncics and ovcrusc ol carc. Claims
data pcrmit thc mcasurcmcnt ol pcr capita spcnding and rcsourcc inputs such
as physician labor and hospital bcds, and kcy aspccts ol thc paticnt cxpcricncc
such as carc intcnsity at thc cnd ol lilc, usc ol scrccning cxaminations and
surgical proccdurcs, and copaymcnts. Claims data can also providc inlorma
tion on thc pricc ol carc as wcll as thc volumc ol carc in ordcr to cvaluatc thcir
rclativc contributions to ovcrall pcr capita spcnding.
No onc would arguc that thc lcgislation is pcrlcct, or that thc law as writ
tcn has idcnticd all thc answcrs to our hcalth carc dclivcry systcm wocs. !t
is a pastichc ol programs, inccntivcs, and cxpcrimcnts, somc ol which may
wind up working against cach othcr, and many ol which will undoubtcdly
bc abandoncd il thcy lail to producc in short ordcr thc kinds ol changcs
in thc structurc ol hcalth carc dclivcry that arc nccdcd. !t would bc lool
ish ol administrators and providcrs to givc up too quickly il programs do
not producc instant rcsults. Altcr all, wc arc talking about translorming a
gargantuan industry whosc growth has bccn drivcn in part by dccply hcld,
:c vviiociv
but noncthclcss laulty, bclicls about thc naturc ol hcalth carc markcts, thc
scicntic undcrpinnings ol mcdicinc, and thc powcr ol morc carc to hcal.
8y thc samc tokcn, CMS and othcr paycrs should not cling to old rcmcdics
that arc not working. bviously thcrc arc many ways lor hcalth carc rclorm
to lail, but wc arc optimistic that this lcgislation, couplcd with thc growing
undcrstanding ol gcographic variation and thc rolc ol supply in inucncing
utilization, will lcad to a bcttcr systcm.
John E. Wennberg and Shannon Brownlee
:.
Dening Hospital Service Areas
Hospital scrvicc arcas (HSAs) rcprcscnt local hcalth carc markcts lor com
munitybascd inpaticnt carc. HSAs wcrc originally dcncd in thrcc stcps
using .oo. providcr lcs and .oo: through .oo. utilization data. First, all acutc
carc hospitals in thc lty statcs and thc istrict ol Columbia wcrc idcnticd
lrom thc Amcrican Hospital Association Annual Survcy ol Hospitals and
thc Mcdicarc Providcr ol Scrviccs lcs and assigncd to a location within a
town or city. Tc list ol towns or citics with at lcast onc acutc carc hospital
(N - .,o.) dcncd thc maximum numbcr ol possiblc HSAs. Sccond, all
.oo: and .oo. acutc carc hospitalizations ol thc Mcdicarc population wcrc
analyzcd according to Z!P Codc to dctcrminc thc proportion ol rcsidcnts
hospital stays that occurrcd in cach ol thc .,o. candidatc HSAs. Z!P Codcs
wcrc initially assigncd to thc HSA whcrc thc grcatcst proportion (plurality)
ol rcsidcnts was hospitalizcd. Approximatcly cc ol thc candidatc HSAs did
not qualily as indcpcndcnt HSAs bccausc thc plurality ol paticnts rcsidcnt in
thosc HSAs was hospitalizcd in othcr HSAs.
Tc third stcp rcquircd visual cxamination ol thc Z!P Codcs uscd to dcnc
cach HSA. Maps ol Z!P Codc boundarics wcrc madc using lcs obtaincd
lrom Gcographic ata Tcchnologics (GT) and cach HSAs componcnt
Z!P Codcs wcrc cxamincd. To achicvc contiguity ol thc componcnt Z!P
Appendix on Methods
:: ~vvvxbix
Codcs lor cach HSA, island Z!P Codcs wcrc rcassigncd to thc cnclosing
HSA and/or HSAs wcrc groupcd into largcr HSAs. (Scc thc Appcndix in thc
.ooo Dartmouth Atlas of Health Care lor an illustration.) Ccrtain Z!P Codcs
uscd in thc Mcdicarc lcs wcrc rcstrictcd in thcir usc to spccic institutions
(c.g., a nursing homc) or a post o cc. Tcsc point Z!Ps wcrc assigncd to
thcir cnclosing Z!P Codc bascd on thc Z!P Codc boundary map.
Tis proccss rcsultcd in thc idcntication ol .,.6 HSAs, ranging in total
.oo6 population lrom 6c (Turtlc Lakc, North akota) to .,c6,.6 (Houston,
Tcxas) in thc .ooo cdition ol thc Atlas. Tus, thc HSA boundarics rcmaincd
thc samc but thc HSA populations might havc changcd bctwccn thc two
cditions ol thc Atlas. !n most HSAs, thc majority ol Mcdicarc hospitaliza
tions occurrcd in a hospital or hospitals locatcd within thc HSA. (Scc thc
Appcndix in thc .ooo Dartmouth Atlas of Health Care lor lurthcr dctails.)
Dening Hospital Referral Regions
Hospital rclcrral rcgions (HRRs) rcprcscnt hcalth carc markcts lor tcrtiary
mcdical carc. ach HRR containcd at lcast onc HSA that had a hospital or
hospitals that pcrlormcd major cardiovascular proccdurcs and ncurosurgcry
in .oo: through .oo.. Trcc stcps wcrc takcn to dcnc HRRs.
First, thc candidatc hospitals and HRRs wcrc idcnticd. A total ol 6:
hospitals pcrlormcd at lcast tcn major cardiovascular proccdurcs (RGs .c.
.c) on Mcdicarc cnrollccs in both ycars. Tcsc hospitals wcrc locatcd within
HSAs, thcrcby dcning thc maximum numbcr ol possiblc HRRs. Furthcr
chccks vcricd that all HSAs includcd at lcast onc hospital pcrlorming
thc spccicd major ncurosurgical proccdurcs (RGs .. and ).
Sccond, wc calculatcd in cach ol thc .,.6 HSAs in thc Unitcd Statcs thc
proportion ol major cardiovascular proccdurcs pcrlormcd in cach ol thc
candidatc HRRs in .oo: through .oo.. ach HSA was thcn assigncd provi
sionally to thc candidatc HRR whcrc most paticnts wcnt lor thcsc scrviccs.
Tird, HSAs wcrc rcassigncd or lurthcr groupcd to achicvc (a) gcographic
contiguity, unlcss major travcl routcs (c.g., intcrstatc highways) justicd scp
aration (this occurrcd in only two cascsthc Ncw Havcn, Connccticut, and
lmira, Ncw York, HRRs), (b) a minimum population sizc ol .:c,ccc, and (c)
a high localization indcx. 8ccausc ol thc largc numbcr ol hospitals providing
cardiovascular scrviccs in Calilornia, scvcral candidatc Calilornia HRRs mct
thc abovc critcria but wcrc lound to pcrlorm small numbcrs ol cardiovascular
proccdurcs. Tcsc HRRs wcrc lurthcr aggrcgatcd according to county bound
arics to achicvc stability ol cardiovascular surgcry ratcs within thc arcas.
~vvvxbix :.
Tc proccss rcsultcd in thc dcnition ol .c6 hospital rclcrral rcgions,
which rangcd in total .oo6 population lrom .:6,.:o (Minot, North akota)
to o,:,6o (Los Angclcs, Calilornia).
Measures of Association (R
6. c.c.
All hospitalizcd dcccdcnts ,66,::. ..
ata arc bascd on a .cc samplc ol Mcdicarc cnrollccs.
NonU.S. hospitals includc thosc in U.S. tcrritorics such as Pucrto Rico, thc U.S. \irgin !slands,
Guam, Amcrican Samoa, and othcrs.
~vvvxbix :
Mcasurcs ol Rcsourcc !nputs
Mcasurcs ol rcsourcc inputs, including physician labor, hospital bcds, intcn
sivc carc bcds, and Mcdicarc program spcnding (rcimburscmcnts), arc prc
scntcd as summary mcasurcs ovcr thc last six months or two ycars ol lilc.
8cd input ratcs arc calculatcd by summing paticnt days and dividing by .6.
Physician labor inputs arc mcasurcd by summing thc work rclativc valuc units
(R\Us) on a spccialtyspccic basis and dividing by thc avcragc annual num
bcr ol work R\Us produccd by that spccialty. Tc mcasurc is uscd to cstimatc
thc standardizcd lulltimc cquivalcnt (FT) physician clinical labor input.
8oth bcd and FT physician rcsourccs arc cxprcsscd as inputs pcr .,ccc
dcccdcnts. !npaticnt rcimburscmcnts wcrc calculatcd by summing Mcdicarc
rcimburscmcnts lrom thc McdPAR rccord and rccct total rcimburscmcnts,
including indircct costs lor mcdical cducation, disproportionatc sharc pay
mcnts, and outlicr paymcnts. Part 8 paymcnts arc lor all scrviccs includcd in
thc Part 8 Physician Supplicr Filc, likcwisc, paymcnts lor utpaticnt, Skillcd
Nursing Facilitics, Hospicc, Homc Hcalth, and urablc Mcdical quipmcnt
scrviccs rccct all scrviccs includcd in thcir rcspcctivc lcs. !npaticnt rcim
burscmcnts and paymcnts lrom Part 8 and all othcr lcs arc mcasurcd as
Tablc A... cccdcnts :cc. through :cc, according to Cohort Mcmbcrship Status
2001 to 2005 Geographic Database
Number of
Decedents
Percent of Decedents
Percent of
Chronically Ill
Percent of all
Decedents
Chronic illncss cohort .,:,o. .cc.cc o:..6
Hospitalspccic cohort o6, . c.c
Chronic illncss, hospital surgcry only 6,. .. .co
Hospital, othcr mcdical illncss 6,.6. : .
Hospital, othcr surgcry ..,66 ..co ..c.
Assigncd to nonU.S. hospitals .o c.c. c.c.
Not hospitalizcd ..,o .:..c ....6
xcludcd dcccdcnts (without chronic illncss)
Hospitalizcd dcccdcnts .,oo :..
Not hospitalizcd 6,:. ..
Total dcccdcnts .,..,.. .cc.cc
Tc hospitalspccic chronic illncss cohort corrcsponds to thc cohorts dcscribcd in Tablcs A.. and
A.:, but is smallcr duc to thc usc ol a :c samplc ol cnrollccs.
: ~vvvxbix
spcnding pcr dcccdcnt. All rcsourcc input ratcs wcrc calculatcd bascd on thc
total cxpcricncc ol thc population ovcr thc givcn pcriod ol timc, not only
lrom thc carc rcccivcd at thc assigncd hospital or physicians associatcd with
that hospital. !n thc casc ol thc gcographic studics, it includcs carc givcn by
providcrs locatcd outsidc ol thc rcgion as wcll as within thc rcgion.
Mcasurcs ol Utilization
Tc mcasurcs ol utilization arc lor inpaticnt carc and physician scrviccs. Vc
calculatcd hospital days, intcnsivc carc unit days (highintcnsity and intcrmc
diatcintcnsity days, scparatcly), and physician visits (ovcrall and scparatcly
lor primary carc physicians and mcdical spccialists) lor cach paticnt ovcr thc
last six months and thc last two ycars ol lilc, additional mcasurcs includcd
homc hcalth visits, and days spcnt in skillcd nursing lacilitics, longtcrm and
rchabilitation hospitals, and hospicc. Physician visits wcrc also calculatcd by
thc placc ol scrvicc. Utilization ratcs wcrc calculatcd on thc total cxpcricncc
ol thc cohort, not just thc scrviccs providcd by thc hospital and thc physicians
associatcd with thc hospital to which thc dcccdcnt was assigncd. Tc propor
tion ol total hospital carc providcd by thc assigncd hospital (loyalty) is high,
so thc variations in utilization among hospital cohorts primarily rccct clini
cal choiccs madc by thc associatcd physicians. Similarly, in thc gcographic
studics, most carc is providcd by hospitals and physicians locatcd within thc
statc or rcgion. Tc mcasurcs ol utilizationpaticnt days in thc hospital and
othcr lacilitics, paticnt days in intcnsivc carc units, and physician visitsarc
traditional cpidcmiologic, populationbascd ratcs ol cvcnts occurring ovcr a
dcsignatcd pcriod ol timc.
uality ol Carc !ndicators
Two claimsbascd qualityolcarc mcasurcs wcrc uscd. Tc pcrccntagc ol
paticnts sccing tcn or morc physicians is a mcasurc ol thc propcnsity to rclcr
paticnts. High scorcs on this mcasurc may indicatc lack ol continuity ol carc.
Tc pcrccntagc ol dcaths occurring during a hospitalization that involvcd
onc or morc stays in an intcnsivc carc unit is an indicator ol thc aggrcs
sivcncss with which tcrminal paticnts arc trcatcd. Similarly, thc pcrccntagc
ol dcccdcnts rccciving hospicc bcncts indicatcs lcss aggrcssivc carc at thc
cnd ol lilc. !n light ol thc cvidcncc that morc aggrcssivc carc in managing
paticnt populations with chronic illncss docs not lcad to longcr lcngth ol lilc
~vvvxbix :o
or improvcd quality ol lilc, highcr scorcs on this mcasurc can bc vicwcd as an
indicator ol lowcr quality ol dcath.
Vc also rcport quality mcasurcs rcgarding thc proccsscs ol carc, spcci
cally thc undcrusc ol ccctivc carc dcrivcd lrom thc conscnsus mcasurc sct ol
thc Hospital uality Alliancc (HA), thc rst initiativc to routincly rcport
data on U.S. hospitals nationally. ata arc postcd on thc CMS wcbsitc.
6
Vc providc summary scorcs on vc mcasurcs lor managing acutc myocar
dial inlarction (AM!), two lor congcstivc hcart lailurc (CHF), and thrcc lor
pncumonia, lor all rcporting hospitals locatcd within cach HRR. !n addition,
wc rcport a compositc scorc, which is thc wcightcd avcragc ol thc thrcc con
ditionspccic summary scorcs. For individual hospitals, summary scorcs arc
bascd on mcasurcs lor which thcrc arc twcntyvc or morc cligiblc paticnts
in calcndar ycar :cc.
7
Statistical Mcthods
Vc comparcd mcasurcs ol rcsourcc inputs, utilization, and quality at xcd
intcrvals prior to dcath among gcographic rcgions and hospitals. All utiliza
tion and rcsourcc input mcasurcs arc lurthcr adjustcd lor dicrcnccs in agc,
scx, racc, and thc rclativc prcdominancc ol thc ninc chronic conditions, using
ordinary lcast squarcs lor Mcdicarc spcnding variablcs
8
and ovcrdispcrscd
Poisson rcgrcssion modcls lor all othcr variablcs, oth pcrccntilc condcncc
limits wcrc calculatcd lor all variablcs. Tc HA tcchnical proccss quality ol
carc mcasurcs wcrc not adjustcd lor dicrcnccs in casc mix among hospitals,
as thcy arc spccically rcstrictcd to thosc paticnts cligiblc lor thc spccic
trcatmcnt, and thcrclorc do not nccd adjustmcnt.
Cavcats and Limitations
Ccrtain limitations ol our mcasurcs nccd to bc mcntioncd.
Sample sizes and data issues. Tc data arc lor traditional Mcdicarc (Part A and
Part 8) and do not includc Mcdicarc cnrollccs cnrollcd in managcd carc orga
nizations undcr Mcdicarc Part C. Tc mcasurcs ol physician rcsourcc input
and utilization arc bascd on a :c samplc, rcducing thc prccision ol our csti
matcs. For hospitalspccic cohorts, wc addrcsscd this by limiting rcporting
lor thcsc scrviccs to :oo hospitals with cc dcccdcnts (cxpcctcd :c samplc
sizc lor vc ycars - c dcaths). ata clds lor mcasurcs bascd on Part 8 arc
lclt blank lor hospitals with lcss than cc dcccdcnts. Approximatcly . ol
:c ~vvvxbix
hospitals lailcd to rcport on thcir usc ol intcnsivc carc bcds, and lor thcsc
hospitals, this mcasurc is lclt blank. ur mcasurc ol thc usc ol multiplc phy
siciansthc pcrccntagc ol dcccdcnts sccing tcn or morc physiciansdcpcnds
on thc accuracy ol thc coding ol individual physician cncountcrs using thc
physician idcntication numbcr, il a givcn paticnt is sccn by multiplc physi
cians but only onc physician idcntication numbcr is rccordcd, this would
rcsult in an undcrcstimatc ol thc numbcr ol individual physicians sccn.
Denominator for hospital-specic cohorts. Tc hospitalspccic studics arc bascd
on Mcdicarc dcccdcnts with onc or morc mcdical hospitalizations during
thc last two ycars ol lilc (as shown in Tablc A.:). 8ccausc wc had no rcliablc
mcthod lor assigning nonhospitalizcd paticnts with chronic illncss to hospi
tals, dcccdcnts who wcrc not hospitalizcd arc not includcd in thc dcnomina
tor uscd in calculating populationbascd rcsourcc input and utilization ratcs
lor thc hospitalspccic cohort. Tis limitation docs not cxist at thc rcgional
lcvcl whcrc paticnts arc assigncd to rcgions on thc basis ol thcir placc ol
rcsidcncc, making it possiblc to idcntily paticnts who wcrc not hospitalizcd.
To cstimatc thc impact ol not including nonhospitalizcd paticnts with
chronic illncss in thc dcnominator lor calculating ratcs lor thc hospital
spccic cohort, wc comparcd ratcs lor rcgions calculatcd without thc inclusion
ol nonhospitalizcd chronically ill dcccdcnts in thc dcnominator (Hospitalizcd
Cohort cnominator Mcthod) to ratcs calculatcd with thc inclusion ol
nonhospitalizcd dcccdcnts (Full Cohort cnominator Mcthod).
Tis analysis comparcd ratcs undcr cach ol thcsc two mcthods, which wcrc
calculatcd lor thc .c6 rcgions lor dcaths occurring in :ccc through :cc.. Tc
kcy ndings wcrc as lollows:
First, thc proportion ol Mcdicarc dcccdcnts with scvcrc chronic illncss
obtaincd by thc two mcthods, it bccamc apparcnt that (.) thc cor
rclation bctwccn thc ratcs gcncratcd using thc two mcthods was vcry
high: R
2
- c.o (Figurc C), and (:) variation was lcss (mcasurcd by thc
cxtrcmal rangc, intcrquartilc ratio, and coc cicnt ol variation) whcn
thc ratcs wcrc calculatcd using thc Hospitalizcd Cohort cnominator
Mcthod.
Tcsc studics show that thc Hospitalizcd Cohort cnominator Mcthod
(which wc usc lor our hospitalspccic analyscs) undcrcstimatcs thc truc
populationbascd ratcs to a grcatcr cxtcnt in rcgions with lowcr utilization
ratcs. A rcasonablc inlcrcncc would bc that our hospitalspccic analyscs
undcrcstimatc thc variation across hospitals and that thosc hospitals with
lowcr paticnt day ratcs would actually bc cvcn morc conscrvativc (and havc
cvcn lowcr ratcs) than wc rcport il wc wcrc ablc to includc all dcccdcnts carcd
lor by thc hospital and its associatcd physicians.
Exclusion of isolated surgical hospitalizations. Tc hospitalspccic lollowback
studics ol chronic illncss wcrc dcsigncd to rcquirc at lcast onc mcdical (non
surgical) hospitalization to qualily lor inclusion. Tis was donc to avoid con
lusing (.) a surgical rclcrral as cvidcncc that a givcn hospital was involvcd in
thc mcdical managcmcnt ol chronic illncss and (:) a surgical dcath as a dcath
lrom chronic illncss. !n thc rcgional analysis, our intcrcst in accounting lor all
Mcdicarc spcnding and utilization in paticnts with chronic illncss lcd us to
includc all Mcdicarc hospitalizations (and Part 8 scrviccs) in thc ratcs.
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:.
Glossary
CMS Ccntcrs lor Mcdicarc & Mcdicaid Scrviccs: Unitcd Statcs lcdcral agcncy
that administcrs Mcdicarc and Mcdicaid and thc Childrcns Hcalth !nsurancc
Program
Clinically appropriate intervention A trcatmcnt or scrccning proccdurc to
diagnosc discasc, whosc usc is sanctioncd by clinical tradition or prolcssional con
scnsus and codicd into clinical guidclincs
Coe cient of variation (CV) A statistical mcasurc ol variation dcncd as thc
ratio ol thc standard dcviation to thc mcan. Tc grcatcr thc ratio, thc morc thc varia
tion. Tc C\ is uscd in this book to comparc thc dispcrsion ol utilization ratcs
among rcgions lor dicrcnt conditions or trcatmcnts.
Delegated decision making Traditional proccss ol clinical dccision making in
which paticnts dclcgatc dccisions to physicians who act as thcir agcnts in dcning
mcdical nccd and prcscribing trcatmcnts. ccisions arc dclcgatcd by paticnts undcr
thc assumption that physicians know which trcatmcnt is bcst lor a givcn paticnt.
Tis proccss lcads to inlormcd conscnt.
Eective care vidcnccbascd intcrvcntions whcrc thc bcncts arc thought to
cxcccd thc harms and thus all paticnts in nccd arc urgcd to bc trcatcd
Evidence-based intervention A trcatmcnt or scrccning proccdurc to diagnosc a
discasc, whosc usc is supportcd by strong cvidcncc conccrning c cacy
: cioss~vy
Hospital service area (HSAs) A gcographic arca in which most rcsidcnts rcccivc
thcir carc lrom local hospitals. Hospital scrvicc arcas do not always lall within
political boundarics, as paticnts may cross statc lincs to gct to thc ncarcst hospital.
HSAs link populations with thc hospitals that thcy usc most and thus arc usclul lor
studying thc inucncc ol local providcrs on populationbascd ratcs ol hcalth carc
dclivcry (lor dctails, scc Appcndix).
Hospital referral region (HRRs) An aggrcgation ol hospital scrvicc arcas into
largcr rcgions bascd on usc ol cardiac surgcry and ncurosurgcry (lor dctails, scc
Appcndix). HRRs arc usclul lor studying rcgional systcms.
Informed consent Tc traditional normativc standard lor dctcrmining mcdical
ncccssity bascd on paticnt conscnting to thc rccommcndation ol thc physician
Informed patient choice A ncw normativc standard lor dctcrmining mcdical
ncccssity bascd on paticnt undcrstanding ol thc harms and bcncts ol trcatmcnt
options and participation in a sharcd dccisionmaking proccss to cnsurc that thc
trcatmcnt choscn is in kccping with thc paticnts own valucs and prclcrcnccs
Population-based rate A mcasurc ol utilization composcd ol a numcrator (thc
numbcr ol cvcnts ovcr a givcn pcriod ol timc) and a dcnominator (thc population
cligiblc lor thc cvcnt ovcr thc samc pcriod ol timc)lor cxamplc, thc numbcr ol
hospitalizations cxpcricnccd by rcsidcnts ol Mainc in :cco dividcd by thc numbcr ol
rcsidcnts in Mainc in :cco. Ratcs arc typically cxprcsscd as cvcnts pcr .,ccc and arc
adjustcd to rcmovc thc possiblc cccts ol agc, scx, and racc.
Preference-sensitive care Proccdurcs, tcsts, and surgcrics lor conditions lor
which thcrc is morc than onc clinically appropriatc trcatmcnt option. Undcr
thc inlormcd paticnt choicc normativc standard, thc choicc ol trcatmcnt should
dcpcnd on thc paticnts prclcrcnccs (c.g., thc choicc bctwccn lumpcctomy and
mastcctomy lor carlystagc brcast canccr).
R