Reducing Regional Disparities in Health
Spending: Framing the Debate
Regional disparities in health care spending
Part 1 -- Unwarranted variations in U.S. health care: findings
from the ‘Is More Better?’ studies
Part 2 -- What can be done about it?
David Wennberg and Friends
Maine Medical Center
Center for the Evaluative Clinical Sciences
Unwarranted variations in medical practice:
a framework for thinking about the delivery (or non-delivery)
of care…
Unwarranted?
Elliott Fisher, MD, MPH
MPH
Therese Stukel,
Stukel, PhD
Dan Gottlieb, MS
F. L. Lucas, PhD
PhD
Etoile Pinder,
Pinder, MS
Variations that cannot be explained by:
Illness or need --- and dictates of evidence based medicine
Patient Preferences
Categories of variation
Effective care
Preference sensitive care
Supply-sensitive services
Causes and remedies differ for each category
Elderly (U.S. Medicare) Study Design
Dartmouth Atlas of Health Care
United States Hospital Referral Regions
Myocardial Infarction
Colorectal Cancer
Hip Fracture
Medicare Population (MCBS)
Step 1: Select Cohorts
Step 2: Group by regional spending
level -- assigned based upon End-ofLife Expenditure Index
Step 3: Validation
(1) are patients the same at baseline?
(2) does subsequent treatment differ?
Step 4: Assess outcomes
Follow cohorts for up to five years.
Q1
HRRs
Low
Q2
HRRs
Q3
HRRs
Q4
HRRs
Spending
Q5
HRRs
High
Process / Quality of Care / Survival
1
Regional Variations in the End-of-Life Expenditure Index (EOL-EI)
and average per-capita Medicare spending
Effective Care
Services of proven effectiveness….
It involves no significant tradeoffs--all with specific needs
should receive them
EOL-EI
$ 9,074
$ 10,636
$11,559
$ 12,598
$ 14,644
Spending
Conflict between patients and providers is minimal
$ 3,922
$ 4,439
$ 4,940
$ 5,444
$ 6,304
EOL-EI highly correlated (r = 0.81) with average per-capita Medicare spending
Effective Care: Ratio of Rates in Highest vs Lowest Spending Regions
0.5
1.00
1.5
2.0
25
Preference-Sensitive Care
3.0
Acute MI
Reperfusion in 12 hours for AMI
Aspirin at admission
Beta Blockers at admission
Aspirin at Discharge
Beta Blockers at discharge
Exercise Test w/in 30 d
Involves tradeoffs among outcomes
Decision should reflect preferences of patient
General Population
Scientific uncertainty often substantial
Mammogram, Women 65-69
Pap Smear, Women 65+
Flu shot during past year
Pneumococcal Immunization (ever)
0.5
Lower in High Spending Regions
1.00
1.5
2.0
25
3.0
Higher in High Spending Regions
Preference-Sensitive Care: Highest vs Lowest Spending Regions
0.5
1.00
1.5
2.0
25
Supply Sensitive Services
3.0
Procedures after AMI
Angiography
Angiography among appropriate cases
Coronary Angioplasty
Coronary Artery Bypass Surgery (CABG)
Care strongly correlated with supply
Generally provided in absence of strong clinical theory
Evidence weak or non-existent on benefits.
Major Surgery (all cohorts combined)
Cholecystectomy
Cataract Extraction
Hernia Repair
Total Hip Replacement
Total Knee Replacement
Back Surgery
Carotid Endarterectomy
0.5
Lower in High Spending Regions
1.00
1.5
2.0
25
3.0
Higher in High Spending Regions
2
Supply-Sensitive Care : Highest vs Lowest Spending Regions
0.5
1.00
1.5
2.0
25
Supply-Sensitive Care : Highest vs Lowest Spending Regions
3.0
Physician Visits
0.5
1.00
0.5
1.00
1.5
2.0
25
3.0
1.5
2.0
25
3.0
Specialist Procedures
Office Visits
Inpatient Visits
Initial Inpatient Specialist Consultations
% of Patients seeing 10 or more MDs
Psychotherapy Visits
Upper GI Endoscopy
Bronchoscopy
Pulmonary Function Test
Electroencephelogram (EEG)
Hospital Utilization
Diagnostic Cardiology Procedures
Discharges
Total Inpatient Days
Inpatient Days in ICU or CCU
Electrocardiogram
Echocardiogram
Ambulatory ECG (Holter)
Care in Last Six Months of Life
Imaging Tests
Inpatient Days
ICU or CCU days
Feeding Tube Placement
Emergency Intubation
Vena Cava Filter
Chest X-ray
CT / MRI Brain
Ventilation Perfusion Scan
0.5
Lower in High Spending Regions
1.00
1.5
2.0
25
3.0
Higher in High Spending Regions
Lower in High Spending Regions
Higher in High Spending Regions
Relative Risk of Death across Quintiles of Spending
Decreased Risk
0.95
Hip Fracture
Q1
Q2
Q3
Q4
Q5
Colorectal
Cancer
Q1
Q2
Q3
Q4
Q5
Myocardial
Infarction
Q1
Q2
Q3
Q4
Q5
Findings
Mortality
0.95
Change in relative risk of death per 10% increment in regional
practice intensity: Acute Myocardial Infarction Cohort
Decreased Risk
0.98
Increased Risk
1.00
1.02
1.04
Age < 80
Age > 80
Increased Risk
1.00
1.05
1.10
1.00
1.05
1.10
Summary of Findings
Increased spending across regions is largely devoted to
“supply-sensitive services”
Visit frequency, specialist services, tests, inpatient and ICU care.
Female
Male
Residents of higher spending regions:
Black
Non-black
Slightly worse basic access to care
Non-Q MI
Anterior MI
Inferior MI
Other location
Equal use of major (potentially beneficial) procedures
Low risk (<15% 1yr)
Moderate (15-30%)
High Risk (> 30%)
No gain in function, survival or satisfaction
Quality measures generally somewhat worse
0.98
1.00
1.02
1.04
3
Spending and capacity:
the role of beds and medical specialists
Implications
High MD
High Bed
Costs reflect the capacity of the system
1.35
1.34
Low MD
High Bed
High MD
Low Bed
1.59
1.19
1.18
Low MD
Low Bed
Implications
Implications
Costs reflect the capacity of the system
Costs reflect the capacity of the system
Greater capacity is not necessarily better
Greater capacity is not necessarily better
We’re wasting 30% of current spending on supply sensitive
care alone…
Principles to Guide Interventions
Regional disparities in health care spending
Variation
Part 1 -- Unwarranted variations in U.S. health care: findings
from the ‘Is More Better?’ studies
Part 2 -- What can be done about it?
Effective Care
Cause
Remedy
Poorly understood
care processes
Develop systems of care
capable of improvement
Failure to learn
Reward those who provide
high quality care
Construct benefits to
‘incent’ beneficiaries to
become active consumers
and to seek ‘high quality
providers’
4
Principles to Guide Interventions
Variation
Cause
Remedy
Principles to Guide Interventions
Variation
Cause
Remedy
Effective Care
and Patient Safety
Poorly understood
care processes
Develop systems of care
capable of improvement
Effective Care
and Patient Safety
Preference Sensitive
Care
MD-dominated
decisions
Shared Decision Making
Preference Sensitive
Care
MD-dominated
decisions
Shared Decision
making
Supply Sensitive
Care
Variations in supply
Assumption that more
is better
Micro: selective
contracting with
longitudinally efficient
providers
Construct Benefits to ‘Steer’
insured to high quality
providers AND ‘incent’ them
to seek SDM information and
coaching
Reward providers for
participating in SDM
Poorly understood
care processes
Develop systems of care
capable of improvement
Demand excellence in
effective care and
preference sensitive care
Macro: discourage
continual increases in
system capacity
Regional disparities in health care spending
Part 1 -- Unwarranted variations in U.S. health care: findings
from the ‘Is More Better?’ studies
Part 2 -- What can be done about it?
5