End-of-life care expenditures lowest at Mayo Clinic, highest at UCLA; wide variations found

End-of-life expenditures for chronically ill Medicare beneficiaries at the nation’s leading academic medical centers varies widely, according to a new study in the Dartmouth Atlas of Health Care. Dartmouth has been studying variations medical practice patterns around the country since the late 1970s, and the studies apparently have done little to change the variations. Practice variations reflect the influence of medical schools, teaching hospitals’ cultures and patient demographics. Patients in some markets demand more intense care than those in others do, according to researchers quoted in the stories that I’ve linked to below.

So far, nobody has come up with effective financial incentives that are acceptable to physicians, payers and patients that change practice patterns so that they are uniform around the country or even from one medical center to a neighboring one. Dartmouth compared end-of-life treatment expenditures in 93 teaching hospitals but not for community hospitals and other providers, most of which probably offer less intensive and expensive services. Services in community hospitals vary just like they do in the big name academic medical centers. The Salt Lake Tribune asked Dartmouth to replicate the study on Utah hospitals and found differences in the intensity of care delivered by the community hosptials and between them and University hospital. Naturally, the latter disputed the methodology, which is what hospitals always do when they don’t look good. The story is worth reading, after you get by the featurish lede graphs.

The Wall Street Journal’s Health Blog reports:

The latest edition of the Dartmouth Atlas of Health Care is out today, showing that the cost of individual medical services isn’t the big driver of Medicare spending, at least for chronically ill patients in their last two years. It’s the intensity of care, such as the number of specialist visits and days in the ICU, that matters most, the WSJ reports. Sheer availability of services has a lot to do with how much gets spent.

Nearly as notable as the Atlas’ findings–that Medicare could have saved as much as $50 billion over five years if all U.S. hospitals cared for dying, chronically ill patients the way the most efficient facilities do– are its proposals for change.

The NY Times reports that:

Dartmouth researchers say that total Medicare spending in the last two years of life ranges from an average of $93,842 for patients who receive most of their care at U.C.L.A. Medical Center to $53,432 at the Mayo Clinic’s main teaching hospital in Rochester, Minn.

Other top-ranked hospitals fell in between. Medicare spending averaged $85,729 for those who used Johns Hopkins Hospital in Baltimore, $78,666 at Massachusetts General and $55,333 at the Cleveland Clinic.

Differences in the last six months of life were even more striking. Medicare spent an average of $52,911 for U.C.L.A. patients and $28,763 for those who used the Mayo hospital, St. Marys.

USA Today reported:

Researchers also found:

•Hahnemann University Hospital in Philadelphia was the most expensive. Patients spent an average of 34.8 days there.

“The next (Dartmouth) report will show a much lower reimbursement at Hahnemann,” said Steven Campanini, spokesman for the hospital’s parent company, Tenet. He says the report does not fully reflect lower across the-board charges Tenet adopted nationally in 2003 after federal investigators alleged the company unfairly raised prices to collect special payments from Medicare.

•Scott & White hospital in Temple, Texas, was the least expensive, and patients spent an average of 15.9 days there.

David Lindzey, Scott & White associate chief medical officer, credits use of electronic records and good communication with physicians for the lower costs.

“We have no evidence that, on average, the care in a system like Hahnemann is better than in a conservative system such as Scott & White,” Fisher says.

The Dartmouth data may not account for differences among hospitals and the communities they serve, says Atul Grover of the Association of American Medical Colleges, which represents teaching hospitals.

While hospitals that do more than is necessary may reap financial rewards, he adds, “there are clearly parts of the country where people aren’t getting the care they need.”

Please comment here.

Rob Cunningham comments on the Health Affairs blog.

 

 

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