Life Expectancy Shape of the Benefit-Utilization Curve: Supply-Sensitive Services U. S. is somewhere in this zone Frequency of Care
i. e. The problem of unwarranted variation in treatment of chronic illness is a problem in overuse and waste, not underuse and health care rationing
What Does Greater Medicare Spending Buy? Medicare Per capita spending (306 regions: 2000 -01) 10, 500 9, 500 8, 500 7, 500 6, 500 5, 500 4, 500 3, 500 More than 15% Above Average 0 -15% Below Average More than 15% Below Average
What does Greater Per Capita Spending BUY? 0. 99 1. 03 1. 04 1. 00 0. 97 0. 98 1. 00 1. 2 1. 18 1. 6 1. 38 1. 66 2. 0 1. 00 Ratio to Lowest Spending Region not more effective or preference-sensitive care 0. 8 0. 4 0. 0 Medicare Reimbursements More than 15% Below Average 0 -15% Above Average More than 15% Above Average Effective Care Preference-Sensitive Care (Discretionary Surgery)
2. 54 3. 0 1. 80 1. 41 1. 00 1. 41 1. 69 1. 26 1. 23 2. 0 1. 82 2. 5 1. 5 2. 53 More Supply-Sensitive Care!! 1. 00 Ratio to Lowest Spending regions What does Greater Per Capita Spending BUY? 0. 5 0. 0 Days in Hospital More than 15% Below Average 0 -15% Above Average More than 15% Above Average Medical Specialist Visits End of life care % Seeing 10 or More Doctors
Reducing Overuse: supply sensitive care • Major focus: At patient level, active chronic disease management
Reducing Overuse: supply sensitive care • Major focus: At patient level, active chronic disease management • Major focus: At system level, control of capacity relative to size of population served
Reducing Overuse: supply sensitive care • Major focus: At patient level, active chronic disease management • Major focus: At system level, control of capacity relative to size of population served • Major Impediment: adverse economic impact on providers
Days in Hospitals During Last Six Months of Life Among Patients with severe chronic illness who received most of their care in one of 77 “best” U. S. hospitals 28. 0 24. 0 20. 0 16. 0 12. 0 8. 0
Supply-Sensitive Care Days in Hospitals During Last Six Months of Life Among Patients assigned to Selected Academic Medical Centers 28. 0 NYU Medical Center 24. 0 20. 0 16. 0 12. 0 8. 0 27. 1 Mount Sinai Hospital NY Presbyterian Hospital Cedars-Sinai Medical Center 22. 8 21. 6 21. 3 Mass. General Hospital UCLA Medical Center Boston Medical Center 16. 5 16. 1 15. 6 Brigham & Women's Hospital Beth Israel Deaconess UCSF Medical Center Stanford University Hospital 13. 9 12. 2 11. 5 10. 1
Association Between Hospital Days for Cancer and for CHF patients during last six months of life: 77 Selected Academic Medical Centers Hospital day rate: CHF patients 35. 0 30. 0 25. 0 20. 0 15. 0 10. 0 5. 0 0. 0 R 2 = 0. 64 5. 0 10. 0 15. 0 20. 0 25. 0 30. 0 35. 0 Hospital day rate: Cancer patients
Association between hospital days for black and non-black patients during last six months of life among 50 “best” hospitals L 6 M hospital day rate: Black 30. 0 25. 0 20. 0 15. 0 10. 0 R 2 = 0. 75 5. 0 10. 0 15. 0 20. 0 25. 0 L 6 M hospital day rate: Non-Black 30. 0
Supply-Sensitive Care Physician Visits During the Last Six Months of Life Among Patients assigned to Selected Academic Medical Centers 80. 0 NYU Medical Center Cedars-Sinai Medical Center 66. 2 Mount Sinai Hospital 70. 0 76. 2 53. 9 UCLA Medical Center NY Presbyterian Hospital Mass. General Hospital 43. 9 40. 3 38. 8 Brigham & Women's Hospital Boston Medical Center Beth Israel Deaconess UCSF Medical Center Stanford University Hospital 31. 9 31. 5 29. 2 27. 2 22. 6 60. 0 50. 0 40. 0 30. 0 20. 0 10. 0
Association Between Hospital Days and Physician Visits During the Last Six Months of Life among patients receiving most of their care in one of 77 “best” U. S. hospitals 80. 0 Physician Visit Rate 70. 0 60. 0 50. 0 40. 0 30. 0 20. 0 R 2 = 0. 60 10. 0 5. 0 10. 0 15. 0 20. 0 Hospital Day Rate 25. 0 30. 0
Percent seeing 10 or more physicians during last six months of life among patients receiving most of their care in one of 77 “best” U. S. hospitals 65. 0 58. 5 57. 1 UCLA Medical Center Cedars-Sinai Medical Center 50. 9 48. 2 NY Presbyterian Hospital 37. 7 UCSF Medical Center 55. 0 Mount Sinai Hospital NYU Medical Center 30. 3 Stanford University Hospital 23. 1 45. 0 35. 0 25. 0 15. 0
Payment in Last 6 Months Association Between Medicare inpatient + Part B Payments 19 -24 Months and 0 -6 Months Before Death: 77 hospital cohorts (1999 -01). 40, 000 35, 000 30, 000 25, 000 20, 000 15, 000 10, 000 5, 000 1, 500 R 2 = 0. 79 3, 500 5, 500 Payments 19 -24 Mos. Before Death 7, 500
Primary care + medical specialist S-FTE inputs per 1, 000 Medicare decedents: last six months of life among selected hospitals 28. 0 24. 0 NYU Medical Center 24. 6 20. 0 Cedars-Sinai Medical Center 20. 7 16. 0 Mount Sinai Hospital UCLA Medical Center New York Presbyterian 16. 4 14. 6 13. 8 12. 0 8. 0 4. 0 UCSF Medical Center Stanford University Hospital 9. 2 8. 7
Ratio: medical specialist/primary care 28. 0 24. 0 NYU Medical Center 1. 70 20. 0 Cedars-Sinai Medical Center 2. 19 16. 0 Mount Sinai Hospital UCLA Medical Center New York Presbyterian 1. 10 2. 86 1. 05 UCSF Medical Center Stanford University Hospital 0. 67 1. 31 12. 0 8. 0 4. 0
Medicare reimbursements per decedent during the last six months of life among California hospitals (weighted average in parentheses) (1999 -2003) 65, 000 55, 000 45, 000 35, 000 25, 000 15, 000 All Tenet CHW Sutter Adven. St. Kaiser Univ. Daughters HCA Scripps other tist Joseph of CA of Charity ($18, 165) ($29, 003) ($16, 824) ($17, 035) ($18, 422) ($14, 691) ($13, 445) ($27, 218) ($23, 727) ($18, 942) ($16, 795)
Hospital days per decedent during the last six months of life among California hospitals (weighted average in parentheses) (1999 -2003) 32. 0 29. 0 26. 0 23. 0 20. 0 17. 0 14. 0 11. 0 8. 0 5. 0 All other (13. 6) Tenet CHW Sutter (16. 9) (12. 6) (11. 4) Adventist (13. 3) St. Joseph (12. 0) Kaiser (10. 1) Univ. Daughters HCA of Charity (14. 2) (15. 9) (15. 0) Scripps (13. 1)
Total Payment in Last 6 Months Association Between Total Medicare Payments 18 -24 Months and 0 -6 Months Before Death: 77 hospital cohorts (1999 -01). 40, 000 35, 000 30, 000 25, 000 20, 000 15, 000 10, 000 5, 000 1, 500 R 2 = 0. 79 3, 500 5, 500 7, 500 Total Payments 18 -24 Mos. Before Death
What Preferred Providers should be asked to do: • • Eliminate Underservice of Effective Care Reduce Medical Mistakes Learn What Works (Outcomes Research) Assure Informed Patient Choice (Shared Decision Making) • Achieve Efficient and Effective Management of Supply-Sensitive Care (Target: Chronic Disease) • Achieve Efficient Allocation of Resources geared to Size of the Population Served
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