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.

Relationship Between Regional Per Capita Medicare Expenditures and Patient Perceptions of Quality of Care

JAMA
Fowler FJ, Gallagher PM, Anthony DL, Larsen K, Skinner JS

Wide variations in Medicare expenditures exist across regions, but little is known about whether beneficiaries residing in low-expenditure regions perceive receiving lower-quality care than those in high-expenditure regions. Our objective was to evaluate how Medicare beneficiaries’ perceptions of their health care are related to per capita expenditure in the areas where they live.


Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences?

Medical Care
Barnato AE, Herndon MB, Anthony DL, Gallagher, Skinner JS, Bynum, JPW, Fisher ES

We sought to test whether variations across regions in end-of-life (EOL) treatment intensity are associated with regional differences in patient preferences for EOL care.

Extending The P4P Agenda, Part 2: How Medicare Can Reduce Waste And Improve The Care of the Chronically Ill

Health Affairs
Wennberg JE, Fisher ES, Skinner JS, Bronner KK

The care of Americans with severe chronic illnesses is disorganized, unnecessarily costly, and undisciplined by sound clinical science. The federal government should invest in a crash program to improve the scientific basis of managing chronic illness, and the Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to ensure that within ten years all Americans with severe chronic illnesses have access to accountable health care organizations providing evidence-based prospective care. This paper recommends a strategy for achieving this goal.

Surgical vs Nonoperative Treatment for Lumbar Disk Herniation The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial

JAMA
Weinstein J, Tosteson T, Lurie JD, Tosteson ANA, Hancome B, Skinner JS, Abdu WA, Hilibrand, AS, Boden SD, Deyo RA

Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.

Surgical vs Nonoperative Treatment for Lumbar Disk Herniation The Spine Patient Outcomes Research Trial (SPORT): Observational Cohort

JAMA
Weinstein J, Lurie JD, Tosteson T, Skinner JS, Hanscom B, Tosteson ANA, Herkowitz H, Fischgrund J, Cammisa F, Albert T, Deyo R

For patients with lumbar disk herniation, the Spine Patient Outcomes Research Trial (SPORT) randomized trial intent-to-treat analysis showed small but not statistically significant differences in favor of diskectomy compared with usual care. However, the large numbers of patients who crossed over between assigned groups precluded any conclusions about the comparative effectiveness of operative therapy vs usual care.

The Influence of Income and Race on Total Knee Arthroplasty in the United States

Journal of Bone and Joint Surgery
Skinner JS, Zhou W, Weinstein J

The associations among income, total knee arthroplasty, and underlying rates of knee osteoarthritis are not well understood. We study whether high income Medicare recipients are more likely to have a knee arthroplasty and less likely to suffer from knee osteoarthritis.

Is Technological Change In Medicine Always Worth It? The Case Of Acute Myocardial Infarction

Health Affairs
Skinner JS, Staiger D, Fisher ES

We examine Medicare costs and survival gains for acute myocardial infarction (AMI) during 1986–2002. As David Cutler and Mark McClellan did in earlier work, we find that overall gains in post-AMI survival more than justified the increases in costs during this period. Since 1996, however, survival gains have stagnated, while spending has continued to increase. We also consider changes in spending and outcomes at the regional level. Regions experiencing the largest spending gains were not those realizing the greatest improvements in survival. Factors yielding the greatest benefits to health were not the factors that drove up costs, and vice versa.

Mortality After Acute Myocardial Infarction in Hospitals that Disproportionately Treat African-Americans

Circulation
Skinner JS, Chandra A. Staiger D. Lee J, McClellan M

African-Americans are more likely be seen by physicians with less clinical training or treated at hospitals with deficient times to acute reperfusion therapies. Less is known about differences in health outcomes. This paper compares risk-adjusted mortality following Acute Myocardial Infarction (AMI) between U.S. hospitals with high and low fractions of elderly black AMI patients.

Geographic Variation in Health Care and the Problem of Measuring Racial Disparities

Perspectives in Biology and Medicine
Baicker K, Chandra A, Skinner JS

In its study of racial and ethnic disparities in health care, the Institute of Medicine (IOM) concluded that there were large and significant disparities in the quality and quantity of health care received by minority groups in the United States. This article shows that where a patient lives can itself have a large impact on the level and quality of health care the patient receives. Since black or Hispanic populations tend to live in different areas from non-Hispanic white populations, location matters in the measurement and interpretation of health (and health care) disparities. There is wide variation in racial disparities across geographic lines: some areas have substantial disparities, while others have equal treatment. Furthermore, there is no consistent pattern of disparities: some areas may have a wide disparity in one treatment but no disparity in another. The problem of differences in quality of care across regions, as opposed to racial disparities in care, should remain the target of policy makers, as reducing quality disparities would play a major role in improving the health care received by all Americans and by minority Americans in particular.

Will Volume-Based Referral Strategies Reduce Costs or Just Save Lives?

Health Affairs
Birkmeyer J., Skinner J.S., and Wennberg D.

Although recent policy initiatives aimed at concentrating selected surgical procedures in high-volume hospitals may reduce mortality, their economic implications have not been considered fully. From the hospital perspective, the primary effect of these policies will be to redistribute surgical profits to bigger centers. From the payer perspective, prices paid for procedures will likely increase in some geographic areas. From the societal perspective, how these policies will affect the true cost of providing surgical care is uncertain, but use of discretionary procedures will likely increase. For these reasons, the primary argument for volume-based referral strategies should be improving quality, not reducing costs.

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