Managed Care - July 2008 - (Page 53) PLAN WATCH High Hospital Capacity Raises Quality Concerns Health plans should look into why medical centers that spend the most per capita don’t necessarily deliver the best care By Frank Diamond ealth plans need to find some way to insert themselves into the conversation when hospitals they contract with consider whether to launch building programs to add beds or attract physicians, says one of the authors of a report that reminds us that bigger is not always better when it comes to quality of care. “Hospitals, God bless them,” says David Goodman, MD, co-author of the 2008 edition of the Dartmouth Atlas of Health Care: Tracking the Care of Patients With Severe Chronic Illness. “I’m sitting in a medical center right now. Of course we care about patients, but we too often see the needs for patients through the lens of our institutions.” Decisions about whether to increase the capacity of hospitals are usually based on present capacity (if the facility is almost filled, the inclination is to build) or philanthropic donations. Neither necessarily bears any relation to patients’ needs or preferences, says Goodman, a professor of pediatrics and community and family medicine at Dartmouth-Hitchcock Medical Center. “Once those beds are added they are inevitably filled as physician practices adjust to that greater supply of resources.” Goodman’s study has received some attention because it posits this “if you build it, they will come” view of hospital capacity: The more beds, the more patients and, often, worse care. Patients are not necessarily the ones demanding this and, in fact, the study states that there must be “increasing recognition that some chronically ill and dying Americans are receiving too much care — more than they and their families actually want or benefit from.” The study focuses on Medicare patients with serious chronic conditions in the last two years of life. Says Goodman: “When capacity is added, H “When capacity is added, more beds or ICU units or physicians, it is inevitably health plans that are going to pay for it,” says David Goodman, MD, a co-author of the Dartmouth Atlas. more beds, or ICU units, or physicians, it is inevitably health plans that are going to pay for it. Plans need to be able to join in the prospective planning of capacity. Trying to manage costs after the fact is likely to be foiled because this puts the health plan in a position of essentially starving a certain facility. That’s not been very successful. It’s a hard current to fight against when there’s already high capacity in a region and a medical culture that tends to use it.” Thanks to the Dartmouth Atlas, it is now well known that the frequency of hospitalization and of visits to primary care physicians and specialists varies greatly depending on geographic location. “Most Americans would assume that these variations are due primarily to difference in how sick people are,” the study says. “And most would assume that those living in the regions getting more care would be getting better care and achieving better health outcomes. But neither of these assumptions holds true.” Best facilities The latest study looks at some of the finest medical institutions in the country, facilities where generally accepted best practice guidelines are followed. Yet even at these prestigious facilities, geographic location and large capacity trumps protocol (See “More Care Isn’t Always Better Care” on page 54). “Because the payment system continues to reward the expansion of acute care facilities, there is little incentive for providers to pay attention to the volume of care they provide or to develop systems for managing and coordinating the care of patients with chronic illness,” the study states. “And hospitals are accountable — either to their stockholders or to those who hold their bonds — for their financial performance, which under the current payment sys- JULY 2008 / MANAGED CARE 53
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