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Katherine Baicker and Amitabh Chandra, Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care, Health Affairs Web Exclusive, April 7, 2004 [Abstract] [PDF] [HTML Version] [Reprints & Permissions]

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Lack of Consideration of Medical Comorbidity or Patient Health

Jeffrey M. Bumpous, M.D., F.A.C.S.   ( 5 May 2004 )

Re: Lack of Consideration of Medical Comorbidity or Patient Health

Katherine Baicker, Amitabh Chandra, Dartmouth and NBER   ( 5 May 2004 )

Spending, Workforce, and Quality: A Response

Roland A Goertz, MD, MBA   ( 12 July 2004 )

Lack of Consideration of Medical Comorbidity or Patient Health 5 May 2004
Jeffrey M. Bumpous, M.D., F.A.C.S., Chief, Otolaryngology-HNS University of Louisville School of Medicine Send comment to journal: Re: Lack of Consideration of Medical Comorbidity or Patient Health jmbump01{at}louisville.edu Jeffrey M. Bumpous, M.D., F.A.C.S.	The article by Katherine Baicker and Amitabh Chandra, using data from the Dartmouth study, is a worthy read for all physicians, particularly those taking care of a preponderance of geriatric (and therefore Medicare) patients. I found a couple of aspects of the article disturbing and quite frankly "apples to oranges," types of comparisons. I believe that it is reaching somewhat far to conclude that more high-expenditure states do not improve the health of Medicare beneficiaries. If you look at this purely economically or from an actuarial viewpoint, that may be true, but I would submit that the Medicare beneficiaries of my home state of Kentucky and other states with high rates of tobacco use have a very different patient population, specialist utilization rate, and cost profile than healthier, more homogenous populations such as New Hampshire and Vermont that appear high on the article's quality graphics. Without taking regard for comorbidities and underlying measures of the geriatric population's overall health and incidence of critical diseases, this article falls well short of its conclusions. On the other hand, if sufficient measures are placed to adjust for varying comorbidity and health status among states or geographical regions of the country, the study could prove quite valuable in gaining insight in to the value of the Medicare dollar that is spent. Thank you for the opportunity to comment.
Re: Lack of Consideration of Medical Comorbidity or Patient Health 5 May 2004
Katherine Baicker, Assistant Professor Dartmouth and NBER, Amitabh Chandra, Dartmouth and NBER Send comment to journal: Re: Re: Lack of Consideration of Medical Comorbidity or Patient Health kbaicker{at}dartmouth.edu Katherine Baicker, et al.	Dr. Bumpous raises an important point that we were very concerned with as well: We did not want our estimates of the relationship between spending and the quality of health care to be confounded by unmeasured differences in the underlying health of the Medicare populations. We used three strategies to deal with this possibility: (1) We examined 24 procedures that should not be affected by comorbidities (such as the use of beta-blockers or aspirin in heart-attack patients with no contraindications for use). For the negative relationship between spending and quality to be driven by unmeasured health differences, sicker populations would have to require less of this care, a possibility that is not medically justified. (2) We controlled for the incidence of heart attacks and other demographics, which should capture underlying differences in health. (3) Perhaps most importantly, we looked at differences in spending and quality over time within states to control for any persistent differences in health, income, or demographics between the populations of, for example, Kentucky and New Hampshire. The results in our Exhibit 5 show a consistent negative relationship between spending and quality netting out any differences in the health of beneficiaries in each state. We hope that these strategies allay this concern.
Spending, Workforce, and Quality: A Response 12 July 2004
Roland A Goertz, MD, MBA, Executive Director Heart of Texas Community Health Center, Inc. Send comment to journal: Re: Spending, Workforce, and Quality: A Response Rgoertz{at}wacofpc.org Roland A Goertz, MD, MBA	This letter pertains to the Health Affairs article, "Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care," and recent comments challenging its premise. Anyone who suggests a continuous positive linear relationship between cost of health care or number of any type of physician and quality of care is sadly in error. There is not now and never has been any proof to support this postulate. The economic premise of diminishing returns applies to this aspect of health care as it does to virtually all other systems. Here is an example I have used when teaching medical students and residents: You are taking care of a patient in the ICU. You have done every test and procedure you know to do and have done everything that all the consultants have recommended. I now tell you that you must spend another $5,000 (originally I used $1,000) to improve the patient’s quality of care. What would you do with the money? By this point the student or resident is in a bit of a quandary because they are not quite sure how to use the additional money. If there were a continuing positive linear relationship, it should be reasonably easy to suggest more things that result in improved patient care. Generally the suggestions are more, or repeated, tests and procedures. I respond to the common answers with a statement that if you do more tests or procedures, you could in fact make the patient worse. How? If you do more tests, all tests have false positives and negatives. How will you use results that contradict earlier tests? With again more tests, and the subsequent potential for much more confusion. If you repeat or do another procedure, how do you interpret the results? Also, procedures generally have potential side effects or complications, so again you have a very high risk of NOT improving quality or outcome with more money. I have also rarely seen adding another physician to the consultation pool improve quality when the patient already has more than a few consultants. However, adding the "right" physician with the "right" knowledge or experience may make a difference and improve care, but if you have many already, the odds are small that quality will be improved by simply adding another. Again, no continuing positive linear relationship is supported. Once in a while, a student or resident will respond to the proposed scenario with "I would use the money to help the family." Quite a novel approach that likely would have more impact! The process of health care remarkably follows the economic curve of diminishing returns. There is little doubt that care is improved at the beginning of the curve with more money or physicians, but eventually you do not get improvement unless there is a "new" and proven breakthrough that may cost more or require another doctor. Until then, you fall off the curve if all you do is spend more money or add another doctor. (Interestingly, there is a general positive linear relationship between the cost of care and the number of physicians, hospitals, and population. This should not surprise anyone. It is at the heart of the “special interest” problems that mire our system in its current form and prevent us from doing well compared to other countries. The United States does not rank well on health parameters with which we are compared to other countries. There is little mystery of why we do so poorly even though we outspend all other countries. Systems analysis provides the answer: "Every system is set up to get exactly the results it is intended to get." Our system was set up long ago to take care of urgencies and "fix" (cure) diseases. The world has changed, but we still want the old system to work the same way because we all have huge vested special interests (i.e., research money, procedural income, desire to be “fixed”). We do not primarily deal with illnesses that can be cured anymore. Chronic illnesses cannot be efficiently handled with the current (old) system, yet changing it is VERY difficult because of special interests. We will not be ranked high in comparative health parameters used by the World Health Organization because we have not changed the system to drive those desired results. We still preferentially (and hugely) fund curing and “fixing.” How long will we continue the “old” model?