The Users' Guide to the Health Reform Galaxy

'Bending the Cost Curve' by Tackling Overuse of Diagnostic Imaging

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, examines how some communities are using evidence-based  guidelines to rein in a conspicuous source of health care overspending. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

If you look closely in Aligning Forces for Quality communities, you can see how local laboratories are grappling with some of the most vexing delivery issues in health care. And there is probably no more vexing issue than overuse of health services—an issue that has figured prominently in the health care debate as Congress and the president wrestled with the question of how best to control costs.

Dartmouth researchers have estimated that as much as 30 percent of health care spending is for care that doesn’t improve people’s health—and don’t just take their word for it. Thompson Reuters came out with a new study last October attesting to the reasonableness of this estimate.

Diagnostic imaging, especially when it involves lower-back pain, is one case drawing the attention of overuse detectives. Lower-back pain is the fifth-most-common reason Americans see a doctor, and the common use of expensive imaging technology to diagnose it has become controversial. For more than a decade, guidelines for treating lower-back pain have recommend delaying imaging use for most patients because their backs typically get better, and their pain often subsides, within a month. A recent study published in Health Affairs took a look at the relationship between the supply of MRI machines, and their use for lower-back pain. Surprise, surprise: The researchers found “a clear relationship between MRI availability and MRI use for low back pain patients.”

'Cost of Dying' on 60 Minutes looks at human and financial toll of system

It's worth taking a look at “The Cost of Dying,” which aired Nov. 22 on CBS News’ 60 Minutes and explores the extraordinary amount of money spent on medical care at the very end of people’s lives.

In 2008, Medicare paid $50 billion for doctor and hospital bills during the last two months of patients' lives – with as much as 20 to 30 percent deemed to have had no meaningful impact, Steve Kroft reported.

Dr. Elliot Fisher of Dartmouth Institute for Health Policy and Clinical Practice noted that as many as one-fifth of Americans end up dying costly deaths in intensive-care units because "it's the path of least resistance" - the easiest way for doctors to manage them.

But the report is at its most powerful tackling the human costs of such a system.

Families cannot imagine there could be anything worse than their loved one dying," said Dr. Ira Byock, who heads the palliative care program at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, NH. "But in fact, there are things worse. Most generally, it's having someone you love die badly-dying, suffering, dying connected to machines."

The high cost of health care: getting past denial

      

Jonathan S. Skinner, Elliott S. Fisher, and Jonathan Sutherland of the Dartmouth Atlas Project at the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth College write about the opportunities to pay for health care reform by reducing unnecessary spending.

The President’s recent speech called on Congress to move forward with much needed health care reform.  He wisely argued that reducing the waste in our current health care system can help provide the savings needed to cover the costs of expanding coverage to the uninsured.  This might appear to be obvious – many studies (including this one from the Commonwealth Fund) have shown the U.S. spends twice as much as other countries on health care, yet often lags behind in quality.  Furthermore, a number of studies from the Dartmouth Atlas group (here and here) have pointed to the dramatic differences in both levels of health care spending -- $16,351 per Medicare beneficiary during 2006 in Miami, compared to $6,604 in Richmond Virginia – and the apparent lack of better outcomes in these higher cost regions.

But not everyone is convinced.  One recent critic today even claimed that all regional variations in spending can be justified by medical need and poverty: The reason why Medicare spends so much more for patients in Newark, N.J. than it does for patients at the Mayo Clinic in Minnesota is because people in Newark are poorer and sicker.   In a recent article published online in the New England Journal of Medicine, we test this hypothesis rigorously using a large nationally representative sample of more than 15,000 Medicare enrollees.  By using individual data reporting income, health status, price-adjusted Medicare expenditures (to account for the fact that cost-of-living in New York is greater than in Oklahoma City), and other factors, we sought to gain the most accurate picture of what explains regional variations in spending – and more importantly, what doesn’t.

How'd they do that - and how can we do it elsewhere?

John Lumpkin writes about how we might provide better care for less money based on the experiences of 10 communities that have done it successfully.

 

 

I want to start this post with a quick exercise in the geography of health care spending. So to start, please spend a minute with our interactive map of U.S. Medicare spending by clicking here, and then hit your return button.

Back with me? Now ask yourself: Why are some areas of the countries a lighter shade of green than others? If you answered, “because they spend less money on Medicare than the darker green areas,” you are right.

Now ask yourself, “How do they do that?”

That was the question posed to health care leaders from 10 of the light green areas on the map who were invited to a symposium I attended yesterday in Washington called, “How Do They Do That? Low-Cost, High-Quality Health Care in America.”