How Much Do Patients’ Preferences Contribute to Resource Use?

Health Affairs
Anthony DL, Herndon MB, Gallagher PM, Barnato AE, Bynum JPW, Gottlieb DJ, Fisher ES and Skinner JS

Regional variation in health care use may stem, in part, from the fact that patients in high-utilization regions demand and receive more-intensive care. We examine the association between patients’ care-seeking preferences and use of services, using a national survey of Medicare patients. Patients’ preferences, in addition to health and socio-demographic characteristics, are associated with differences in individuals’ use of office visits. However, we find that patients’ preferences for seeking primary and specialty medical care do not play a significant role in explaining regional variation in health care use.

Getting Past Denial — The High Cost of Health Care in the United States

New England Journal of Medicine
Jason M. Sutherland, Ph.D., Elliott S. Fisher, M.D., M.P.H., and Jonathan S. Skinner, Ph.D.

What seemed to be a golden opportunity to achieve badly needed health care reform now appears to be threatened. Many Americans believe that we simply cannot afford to cover the uninsured, since doing so would require taxes to be raised beyond the level the public can sustain. Others believe that we can slow spending growth only by rationing needed care. Neither option is attractive. Evidence regarding regional variations in spending and growth, however, points to a more hopeful alternative: we should be able to reorganize and improve care to eliminate wasteful and unnecessary services.

Hospital Quality And Intensity Of Spending: Is There An Association?

Health Affairs
Yasaitis L, Fisher ES, Skinner JS, and Chandra A

Numerous studies in the United States have examined the association between quality and spending at the regional level. In this paper we evaluate this relationship at the level of individual hospitals, which are a more natural unit of analysis for reporting on and improving accountability. For all of the quality indicators studied, the association with spending is either nil or negative. The absence of positive correlations suggests that some institutions achieve exemplary performance on quality measures in settings that feature lower intensity of care. This finding highlights the need for reporting information on both quality and spending.

Churning: The Association between Health Care Transitions and Feeding Tube Insertion for Nursing Home Residents with Advanced Cognitive Impairment

Journal of Palliative Medicine
Teno JM, Mitchell SL, Skinner JS, Kuo S, Fisher ES, Intrator O, Rhodes R, Mor V

There is a tenfold variation across U.S. states in the prevalence of feeding tube use among elderly nursing home residents (NHR) with advanced cognitive impairment. The goal of this study was to examine whether regions with higher rates of health care transitions at the end of life are more likely to use feeding tubes in patients with severe cognitive impairment.

Slowing the Growth of Health Care Costs – Lessons from Regional Variation

New England Journal of Medicine
Fisher, ES, Bynum JP, and Skinner JS

The expansion of health insurance coverage in the United States is likely to be on the front burner of health care reform efforts in the new presidential administration. But boiling on the back burner is perhaps the most serious threat to Americans’ access to care: rapid growth in health care costs.

Pessimism abounds. Most observers see rising costs as an inexorable force, blame advancing technology, and conclude that only by rationing beneficial care or making draconian price cuts can we slow the growth of health care costs.

But a careful look at variations in spending growth and spending patterns among U.S. regions reveals a more optimistic picture. By learning from regions that have attained sustainable growth rates and building on successful models of delivery-system and payment-system reform, we might, with adequate physician leadership, manage to “bend the cost curve.”

Fostering Accountable Health Care: Moving Forward In Medicare

Health Affairs
Elliott S. Fisher, Mark B. McClellan, John Bertko, Steven M. Lieberman, Julie J. Lee, Julie L. Lewis, and Jonathan S. Skinner

To succeed, health care reform must slow spending growth while improving quality. We propose a new approach to help achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and “shared savings” payment reform. The approach is practical and feasible: it is voluntary for providers, builds on current referral patterns, requires no change in benefits or lock-in for beneficiaries, and offers the possibility of sustained provider incomes even as total costs are constrained. We simulate the potential expenditure impact and show that significant Medicare savings are possible.

Inpatient Care Intensity And Patients’ Ratings Of Their Hospital Experiences

Health Affairs
Wennberg JE, Bronner K, Skinner JS, Fisher ES, Goodman DC

The intensity of hospital care provided to chronically ill Medicare patients varies greatly among regions, independent of illness. We examined the associations among hospital care intensity, the technical quality of hospital care, and patients’ ratings of their hospital experiences. Greater inpatient care intensity was associated with lower quality scores and lower patient ratings; lower quality scores were associated with lower patient ratings. The common thread linking greater care intensity with lower quality and less favorable patient experiences may be poorly coordinated care.

Racial and ethnic differences in preferences for end-of-life treatment

Journal of General Internal Medicine
Barnato AE, Anthony DL, Skinner, JS, Gallagher PM, Fisher ES

Studies using local samples suggest that racial minorities anticipate a greater preference for life-sustaining treatment when faced with a terminal illness. These studies are limited by size, representation, and insufficient exploration of sociocultural covariables.