reducing regional disparities in health spending: framing the debate david wennberg and friends...
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Reducing Regional Disparities in Health Spending: Framing the Debate
David Wennberg and FriendsMaine Medical Center
Center for the Evaluative Clinical Sciences
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?
Elliott Fisher, MD, MPElliott Fisher, MD, MPHH Therese Therese Stukel, PhD Stukel, PhD
Dan Dan Gottlieb, MSGottlieb, MSF. L. F. L. Lucas, PhLucas, PhDD Etoile Etoile Pinder, MSPinder, MS
Unwarranted variations in medical practice: a framework for thinking about the delivery (or non-delivery)
of care…
Unwarranted? Variations that cannot be explained by:Illness or need --- and dictates of evidence based medicine
Patient Preferences
Categories of variationEffective care
Preference sensitive care
Supply-sensitive services
Causes and remedies differ for each category
Dartmouth Atlas of Health CareUnited States Hospital Referral Regions
Step 2: Group by regional spending level -- assigned based upon End-of-Life Expenditure Index
Step 1: Select Cohorts
Step 3: Validation(1) are patients the same at baseline?(2) does subsequent treatment differ?
Step 4: Assess outcomesFollow cohorts for up to five years.
Myocardial Infarction Colorectal Cancer
Hip FractureMedicare Population (MCBS)
Elderly (U.S. Medicare) Study Design
Q1 HRRs
Q2 HRRs
Q3 HRRs
Q4 HRRs
Q5HRRs
Low Spending High
Process / Quality of Care / Survival
$ 3,922$ 4,439$ 4,940$ 5,444$ 6,304
Spending
Regional Variations in the End-of-Life Expenditure Index (EOL-EI)
and average per-capita Medicare spending
$ 9,074$ 10,636$11,559$ 12,598$ 14,644
EOL-EI
EOL-EI highly correlated (r = 0.81) with average per-capita Medicare spending
Effective Care
Services of proven effectiveness….
It involves no significant tradeoffs--all with specific needs should receive them
Conflict between patients and providers is minimal
Effective Care: Ratio of Rates in Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Reperfusion in 12 hours for AMI
Beta Blockers at admissionAspirin at admission
Beta Blockers at dischargeAspirin at Discharge
Acute MI
Mammogram, Women 65-69
Flu shot during past yearPap Smear, Women 65+
Pneumococcal Immunization (ever)
General Population
Lower in High Spending Regions Higher in High Spending Regions
Exercise Test w/in 30 d
Preference-Sensitive Care
Involves tradeoffs among outcomes
Decision should reflect preferences of patient
Scientific uncertainty often substantial
Preference-Sensitive Care: Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Coronary Artery Bypass Surgery (CABG)
Coronary Angioplasty
Procedures after AMI
Cholecystectomy
Hernia RepairCataract Extraction
Total Hip Replacement
Major Surgery (all cohorts combined)
Total Knee ReplacementBack SurgeryCarotid Endarterectomy
Lower in High Spending Regions Higher in High Spending Regions
Angiography
Angiography among appropriate cases
Supply Sensitive Services
Care strongly correlated with supply
Generally provided in absence of strong clinical theory
Evidence weak or non-existent on benefits.
Supply-Sensitive Care : Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Office Visits
Initial Inpatient Specialist ConsultationsInpatient Visits
Psychotherapy Visits% of Patients seeing 10 or more MDs
Physician Visits
Electrocardiogram
Ambulatory ECG (Holter)Echocardiogram
Diagnostic Cardiology Procedures
Lower in High Spending Regions Higher in High Spending Regions
Chest X-ray
Ventilation Perfusion ScanCT / MRI Brain
Imaging Tests
Supply-Sensitive Care : Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Discharges
Inpatient Days in ICU or CCUTotal Inpatient Days
Hospital Utilization
Inpatient Days
Feeding Tube PlacementICU or CCU days
Emergency Intubation
Care in Last Six Months of Life
Vena Cava Filter
Lower in High Spending Regions Higher in High Spending Regions
Upper GI Endoscopy
Pulmonary Function TestBronchoscopy
Electroencephelogram (EEG)
Specialist Procedures
FindingsMortality
Decreased Risk
Relative Risk of Death across Quintiles of Spending
1.00 1.05 1.100.95
1.00 1.05 1.100.95
ColorectalCancer
Q1Q2Q3Q4Q5
Hip Fracture Q1Q2Q3Q4Q5
MyocardialInfarction
Q1Q2Q3Q4Q5
Increased Risk
Decreased Risk
Change in relative risk of death per 10% increment in regional practice intensity: Acute Myocardial Infarction Cohort
1.00 1.02 1.040.98
1.00 1.02 1.040.98
Age < 80Age > 80
Increased Risk
FemaleMale
BlackNon-black
Other location
Non-Q MIAnterior MIInferior MI
Low risk (<15% 1yr)Moderate (15-30%)High Risk (> 30%)
Summary of Findings
Increased spending across regions is largely devoted to “supply-sensitive services”
Visit frequency, specialist services, tests, inpatient and ICU care.
Residents of higher spending regions:
Slightly worse basic access to care
Equal use of major (potentially beneficial) procedures
Quality measures generally somewhat worse
No gain in function, survival or satisfaction
Implications
Costs reflect the capacity of the system
Spending and capacity: the role of beds and medical specialists
Low MDHigh Bed
High MDLow Bed
Low MDLow Bed
High MDHigh Bed
1.19
1.34 1.35
1.18
1.59
Implications
Costs reflect the capacity of the system
Greater capacity is not necessarily better
Implications
Costs reflect the capacity of the system
Greater capacity is not necessarily better
We’re wasting 30% of current spending on supply sensitive
care alone…
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?
Effective Care Poorly understood care processes
Failure to learn
Variation Cause
Develop systems of care capable of improvement
Reward those who provide high quality care
Construct benefits to ‘incent’ beneficiaries to become active consumers and to seek ‘high quality providers’
Remedy
Principles to Guide Interventions
Variation Cause
Effective Care and Patient Safety
Poorly understood care processes
Develop systems of care capable of improvement
MD-dominated decisions
Preference Sensitive Care
Shared Decision Making
Construct Benefits to ‘Steer’ insured to high quality providers AND ‘incent’ them to seek SDM information and coaching
Reward providers for participating in SDM
Remedy
Principles to Guide Interventions
Variation Cause
Supply Sensitive Care
Variations in supply Assumption that more is better
Micro: selective contracting with longitudinally efficient providers
Demand excellence in effective care and preference sensitive care
Macro: discourage continual increases in system capacity
Effective Careand Patient Safety
Poorly understood care processes
Develop systems of care capable of improvement
MD-dominated decisions
Preference Sensitive Care
Shared Decision making
Remedy
Principles to Guide Interventions
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?