The Healthcare Imperative Lowering Costs and Improving Outcomes: Workshop Series Summary (2010) / Chapter Skim
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2 Unnecessary Services
2 Unnecessary Services
Pages 85-108
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From page 85... ...
. To further explore this area, speakers in this session examine the provision of unnecessary services, highlighting the sequelae of scientific uncertainty, perverse economic and practice incentives, and lack of patient engagement in decisions.
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From page 86... ...
Narrowing the focus to individual clinical decisions, David Wennberg of Health Dialog discusses the use of shared decision-making models as a method for reducing costs as well as for more effectively empowering patients to take control of their treatment decisions. By empowering informed and shared choice by patients through the use of decision aides, Wennberg concludes that the use of surgical procedures, for instance, could be reduced by 20 percent compared to controls.
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From page 87... ...
We examined 10 measures that collectively encompass care delivered for acute myocardial infarction, congestive heart failure, and pneumonia. Our measure of spending was the portion of end-of-life spending on Medicare beneficiaries that can be attributed to differences in the intensity of use, as opposed to payments that reflect differences in price levels, Disproportionate Share Hospital payments for treating low-income patients, or graduate medical education.
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From page 88... ...
Providers in the lowest performance cell are those who have the highest costs and highest mortality, while those in the highest performance cell deliver the best care at the lowest cost. Providers FIGURE 2-1 Relationship between 1-year survival rates and total inpatient costs for Medicare beneficiaries with three common conditions, 2003-2005.
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From page 89... ...
, the differences in mortality are even larger: a 5-percentage point difference in 1-year mortality (on a base mortality rate of 30 percent) represents a 17 percent higher mortality rate in the lower-performing hospitals relative to the best providers (Figure 2-4)
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From page 90... ...
. The cost savings would be a little over $1 billion annually, with half of the savings occurring as a result of efficiency improvements in the Part B program.
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From page 91... ...
The key is to remember that most hospitals are in the middle group, and for these hospitals the savings are much smaller. Moving the lowest-performing providers to middle performance would yield $68 million in Medicare savings annually, and moving both the lowest- and low-performing providers to middle performance would yield $155 million annually (Figure 2-5)
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From page 92... ...
These regional policies may be more palatable to providers. Conclusion Our analysis examined the association between 1-year survival and spending for three cohorts of Medicare patients who were admitted for acute myocardial infarction, hip fractures, and colorectal cancer.
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From page 93... ...
Because hospital performance is not tightly correlated across different conditions, had (some who are good for heart attack treatments may not be good at treating hip fractures) we done a separate analysis for each condition, we would have predicted greater savings.
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From page 94... ...
Bundled payments try to reduce the incentives to overuse care of uncertain value by combining reimbursements for inpatient, outpatient, and home health into a single payment. If bundled payments work (they did reasonably well with the introduction of the Medicare inpatient hospital prospective payment system, or PPS)
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From page 95... ...
hospital referral regions (HRRs) suggest that, even within the current administrative, payment, and legal systems, substantial savings might be possible.
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From page 96... ...
Studies examining the technical quality of care -- for example, adherence to evidence-based practices such as the use of preventive services or proper inpatient treatment for patients with pneumonia, congestive heart failure, and heart attacks -- have consistently found low-spending regions and states to provide better care (Baicker and Chandra, 2004; Fisher et al., 2003a, 2003b)
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From page 97... ...
Estimating Potential Savings To estimate the potential savings that could be achieved if all U.S. hospital referral regions could adopt the practice patterns of low-spending regions, we first categorized all U.S.
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From page 98... ...
For the estimates of Medicare savings, we used total price-adjusted per capita spending in each HRR. This estimate removes any effect of regional differences in prices or policy payments (Medicare pays more to both physicians and hospitals in some regions to account for higher rents and salaries; similarly, Medicare makes additional policy-related payments for graduate medical education and for hospitals that provide care to low-income or uninsured populations)
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From page 99... ...
hospital referral regions grouped according to increasing care intensity, measured by the EOL-EI.
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From page 100... ...
TABLE 2-2 Potential Reductions in Overall Medicare Use Rates for Specific Services if All U.S. Regions Adopted the Practice Patterns of Best Performing Quintile or Decile of Regions, Based on Stratification Using the End-of-Life Expenditure Index Care Intensity Benchmark Best Quintile Best Decile Percent reduction in spending, 2006 17.6% 19.8% Savings to Medicare, 2006 $47.8 billion $53.9 billion
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From page 101... ...
OPPORTUNITIES TO REDUCE UNWARRANTED CARE DIFFERENCES David Wennberg, M.D., M.P.H. Health Dialog Patients make a surprisingly large number of medical decisions each year: 82 percent of adults over the age of 40 have made a decision about having a surgery or screening test done or taking a new medication in the past 2 years (Dartmouth Medical School, 2005)
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From page 102... ...
Because the current state of health care is for patients to rely on physicians to drive the treatment decisions without much of their input -- delegated decision making -- excess use of expensive treatment options has been high. Patients assume their physicians are able to adequately assess their values and preferences when recommending a treatment plan.
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From page 103... ...
. The review is a systematic assessment of the peer-reviewed literature on decision aids for screening tests and treatment decisions.
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From page 104... ...
. One large randomized population-based trial of the effect of decision aids and health coaching on total healthcare expenditures has been presented in abstract form (Wennberg, 2007)
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From page 105... ...
Despite these caveats, shared decision making is a powerful tool in patient care. For shared decision making to have a significant impact on the healthcare delivery system, patient choice must be established as the standard of care.
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From page 106... ...
1999. Decision aids for patients facing health treatment or screening decisions: Systematic review.
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From page 107... ...
2009. Inpatient care intensity and patients' ratings of their hospital experiences.
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