Americans enjoy the most sophisticated medical care that money can buy - and one of the most vexing health-care-delivery systems. We spend about $1.2 trillion
each year, two to four times per capita what other developed nations spend, yet we can't find a way to provide health insurance for 41 million citizens. After
a brief respite in the 1990s when HMOs held down expenses by squeezing profits from doctors and hospitals, medical costs are once again soaring by 10 to 12 per cent a year. Yet reforms proposed by Congress and the White House are only nibbling around the edges of the problem.
Such political timidity is understandable, given the experience of would-be reformers of the past. Any attempt to expand coverage for the uninsured while holding down costs inevitably raises fear in the minds of voters that the only
way to accomplish these seemingly opposing goals is by restricting access to expensive, life-saving medical treatment. Sure, we feel bad about the 18,000 or so of our
fellow citizens who die prematurely each year because they lack health insurance, and about the seniors who are forced to choose between buying food and buying
medicine. But Americans want nothing to do with a system like England's, which,
for example, is reluctant to provide dialysis to the elderly, and most of us who
are now covered by either Medicare or private insurance have little stomach for
health-care reform that contains even a whiff of rationing.
Behind this fear lies an implicit assumption that more health care means better
health. But what if that assumption is wrong? In fact, what if more medicine can
sometimes be bad not just for our pocketbooks but also for our health?
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An increasing body of evidence points to precisely that conclusion. "There
is a certain level of care that helps you live as long and as well as possible,"
says John Wennberg, the director of the Center
for Evaluative Clinical Sciences at Dartmouth Medical School. "Then there's
excess care, which not only doesn't help you live longer but may shorten your
life or make it worse. Many Americans are getting excess care."
According to the center, 20 to 30 per cent of health-care spending goes for
procedures, office visits, drugs, hospitalization, and treatments that do absolutely
nothing to improve the quality or increase the length of our lives. At the same
time, the type of treatment that offers clear benefits is not reaching many Americans,
even those who are insured.
That's a sobering thought but it opens the possibility of a new way to look
at the conundrum of health-care reform. Lawmakers, insurers, and the health-care
industry might be able to save money if they were to concentrate on improving
the quality of medicine rather than on controlling costs. Better health care will,
of course, mean more medicine for some Americans, particularly the uninsured;
but for many of us it will mean less medicine.
Support for this idea can be found in The
Dartmouth Atlas of Health Care, a compendium of statistics and patterns
of medical spending in 306 regions of the country. The atlas is generated by a
group of nearly two dozen doctors, epidemiologists, and health-care economists,
using data from Medicare, large private insurers, and a variety of other sources.
Wennberg is the group's leader and the patron saint of the idea that more medicine
does not necessarily mean better health - a view that has not exactly endeared
him to the medical establishment over the years. These days, however, his ideas
are bolstered by the Institute of Medicine and
other independent researchers, and by new results coming from his Dartmouth research
team, which is showing precisely how the nation misspends its health-care dollars.
Take the regions surrounding Miami and Minneapolis, which represent the high
and low ends, respectively, of Medicare spending. A 65-year-old in Miami will
typically account for $50,000 more in Medicare expenses over the rest of his life
than a 65-year-old in Minneapolis. During the last six months of life, a period
that usually accounts for more than 20 percent of a patient's total Medicare expenditures,
a Miamian spends, on average, twice as many days in the hospital as his counterpart
in Minneapolis, and is twice as likely to see the inside of an intensive-care
unit.
This type of regional variation would make perfect sense if regions where citizens
were sickest were the ones that used the most medical services. After all, it's
only fair that we should spend more and do more in places where people need more
medical attention. But, as Wennberg and his colleagues Elliott Fisher and Jonathan
Skinner point out in a recent paper, "Geography
and the Debate Over Medicare Reform", which appeared online in the journal
Health Affairs, rates
of underlying illness do not account for the differences in spending among regions.
If they did, the region around Provo, Utah, one of the healthiest in the country,
would get 14 per cent fewer Medicare dollars than the national average because
its citizens are less likely to smoke, drink, or suffer from strokes, heart attacks,
and other ailments. Instead it receives seven per cent more than the national
average. In contrast, elderly people in the region around Richmond, Virginia,
tend to be sicker than the average American, and should be receiving 11 per cent
more - rather than 21 per cent less - than the national average. Nor are regional
differences explained by variations in the cost of care. Provo doctors are not,
for example, charging significantly more for office visits or lumpectomies than
doctors in Richmond, and their patients aren't getting costlier artificial hips.
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Rather, much of the variation among regions - about 41 per cent of it, by the
most recent estimate - is driven by hospital resources and numbers of doctors.
In other words, it is the supply of medical services rather than the demand for
them that determines the amount of care delivered. Where neonatal intensive-care
units are more abundant, more babies spend more days in the NICU. Where there
are more MRI machines, people get more diagnostic tests; where there are more
specialty practices, people see more specialists. It's probably safe to assume
that many people are gravely ill during the last six months of their lives no
matter where they live; but Medicare beneficiaries see, on average, 25 specialists
in a year in Miami versus two in Mason City, Iowa, largely because Miami is home
to a lot more specialists.
It would be one thing if all this lavish medical attention were helping people
in high-cost regions like Miami to live longer or better. But that doesn't appear
to be the case. Recent studies are beginning to show that excess spending in high-cost
regions does not buy citizens better health. Medicare patients visit doctors more
frequently in high-cost regions, to be sure, but they are no more likely than
citizens in low-cost regions to receive preventive care such as flu shots or careful
monitoring of their diabetes, and they don't live any longer. In fact, their lives
may be slightly shorter.
The most likely explanation for the increased mortality seen in high-cost regions
is that elderly people who live there spend more time in hospitals than do citizens
in low-cost regions, Wennberg says, "and we know that hospitals are risky
places". Patients who are hospitalized run the risk of suffering from medical
errors or drug interactions, receiving the wrong drug, getting an infection, or
being subjected to diagnostic testing that leads to unnecessary treatment.