Managed Care - July 2008 - (Page 54) PLAN WATCH tem depends on revenue derived from utilization. Addressing the problem of excess acute care capacity will thus require reform of the payment system.” The study lists several reasons why care is more expensive but often less effective where capacity is greatest. One deals with the gray areas where clinical practice guidelines don’t and/or can’t apply. The tendency of providers is to play it safe and hospitalize the patient, especially if beds are available. “The decision whether the patient needs to come into the hospital or be in an intensive care unit: When you consider the hundreds of different possible causes and different circum- stances, that decision is not the sort that anyone could construct around a randomized clinical trial,” says Goodman. “Even observational studies are very difficult. There’s tremendous cost tied up with those decisions. Generally it makes very little difference in terms of patient outcomes.” Other reasons The study also cites “the general assumption among both physicians and patients that more medical care means better care; the marked variations in supply that emerge in an unplanned marketplace; and a fee-for-service payment system that rewards providers for staying More care isn’t always better care egions in the United States with plenty of physicians and hospital beds tend to spend much more on patients and yet not see any appreciable difference in quality, according to the 2008 edition of the Dartmouth Atlas of Health Care: Tracking the Care of Patients With Severe Chronic Illness. In fact, hospitals in high-spending regions often provide worse care than those in low-spending regions. The study looks at the costs of caring for chronically ill Medicare patients in the last two years of their lives. “Over the past ten years, a growing body of research has asked whether greater use of supply-sensitive care results in better quality of care or better health outcomes,” the study states. “And the answer is increasingly clear. Whether from patients’ perspective (satisfaction, technical quality, health outcomes) or from physicians’ perspective (quality of communication among physicians, continuity of care), higher spending and greater use of supplysensitive care is not associated with better care.” R How high-spending regions compare to low-spending ones Health care resources • Per capita supply of hospital beds 32 percent higher • Per capita supply of physicians 31 percent higher overall; 65 percent more medical specialists; 75 percent more general internists; 29 percent more surgeons; and 26 percent fewer family practitioners • Lower adherence to process-based measures of quality (quality worse) • Little difference in rates of elective surgery • More hospital stays, physician visits, specialists referrals, imaging, and minor tests and procedures • Mortality over a period of up to five years slightly higher following acute myocardial infarction, hip fracture, and colorectal cancer diagnosis • No difference in functional status • More likely to report poor communication among physicians • More likely to report inadequate continuity of patient care • Greater difficulty obtaining inpatient admissions or high-quality specialist referrals • Worse access to care and greater waiting times • No difference in patient-reported satisfaction with care • Although all U.S. regions had improvements in acute myocardial infarction survival between 1986 and 2002, regions with greater growth in spending had smaller gains than those with lower growth in spending Content and quality of care Health outcomes Physician perceptions of quality Patient-reported quality of care Trends Source: “Tracking the Care of Patients With Severe Chronic Illness,” Dartmouth Atlas of Health Care 2008, April 2008 54 MANAGED CARE / JULY 2008
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