More
Medicine Is Not Better Medicine
By Elliott S. Fisher, the New York Times
December 1, 2003
HANOVER
,
N.H.
— No one in
Washington
is completely satisfied with the Medicare legislation that Congress
approved last week. For many conservatives, the shift toward private
health plans is too limited; for many liberals, the new prescription-drug
benefit is too stingy. Yet almost everyone agrees that the current bill
worsens the program's long-term financial stability.
Constructive debate about Medicare's costs,
however, is hampered by a flawed assumption that both helps and is
reinforced by the health care industry: that more care — and more
expensive care — is better care.
Earlier this year five colleagues and I
published a study of regional variations in Medicare spending. In 2000,
for example, per capita Medicare spending was $10,550 in
Manhattan
, but only $4,823 in
Portland
,
Ore.
Despite such a disparity, we found that neither the quality of care nor
patients' satisfaction with it was related to costs.
The difference in spending is almost
entirely due to the way medicine is practiced in high-cost regions.
Compared with similar patients in
Portland
, Medicare enrollees in
Manhattan
spent more than twice as much time in the hospital and had twice as many
doctor visits per year. The additional services provided in higher
spending regions are largely discretionary, like more frequent visits to
specialists, longer hospital stays and more frequent use of diagnostic
tests and minor procedures. Remarkably, more spending does not lead to
more people receiving expensive and proven treatments, like cardiac bypass
surgery or hip replacement.
Because regional patterns of medical
practice are similar for Medicare and non-Medicare patients, the findings
have substantial implications for
America
's health care system. We could be wasting hundreds of billions of dollars
each year.
But the most important findings aren't about
money. They are about quality and safety.
As have other studies, we found that the
average quality of care received by Americans is uneven. What was
surprising is that quality was actually somewhat worse in regions that
provided more care, with less frequent use of proven treatments for heart
attack patients and of preventive services. Meanwhile, access to care and
satisfaction were worse or no better than in regions that provided less
care.
Safety was also a bigger problem in higher
spending regions: mortality rates were 2 percent to 5 percent higher in
regions that spent more. And this was not because of differences in the
underlying health of the populations in different regions: in every
analysis, mortality was no better or worse in the higher spending regions.
How might more care actually be worse?
Having more doctors involved can make communication more difficult and
make it harder to know not only what's already been done, but also who is
responsible for ordering the simple but important tests or treatments that
are known to make a difference. And because almost all interventions
involve some risk, unnecessary tests, treatments and time in the hospital
can be harmful.
Yet the belief that more medical care means
better medical care is deeply entrenched. News reports tout the latest
medical tests and breakthroughs, often based upon preliminary accounts of
studies. The pharmaceutical industry provides a daily barrage of often
misleading advertising.
The incentives for doctors and hospitals to
provide more care are pervasive. Most doctors are paid more only when we
do more; and all fear malpractice, where errors of omission pose a greater
risk than errors of commission. Hospitals, outpatient clinics and imaging
centers depend upon a continued flow of patients. And the profits of drug
and device manufacturers depend upon sales.
To improve the quality, safety and
efficiency of care — and reduce the risk of harm from too much care —
better information and better incentives are necessary.
Patients should receive accurate and
balanced information on the benefits and risks of the medical choices they
face. They also need much better information about the organizations where
they receive care — not only about quality, safety and costs but also
about incentives. How are doctors paid? How are hospital and health plan
executives rewarded? What are their relationships to drug and device
manufacturers?
Better information will allow us to get the
incentives right. The backlash against "managed care," which was
evident in the Congressional debate over Medicare, has been driven largely
by the fear that beneficial treatments were being denied because doctors
were paid more to provide less. But unmanaged care and unfettered growth
can also be dangerous. If health care organizations were held accountable
for improving the quality and efficiency of care, patients might believe
that excellent care and lower costs are compatible.
Our study suggests that perhaps a third of
medical spending is now devoted to services that don't appear to improve
health or the quality of care — and may make things worse. It also shows
that we have sufficient current capacity to cover the uninsured —
without necessarily increasing spending. (All that would happen is that
the well-insured would see their doctors less often and, perhaps to their
benefit, spend less time in the hospital.)
Members of Congress are right to be
concerned about increases in federal spending. The debate over Medicare
underscores the challenge: how to pay for better care, not just more care.
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