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“We find that palliative care for hospitalized patients definitely saves money, and the patient satisfaction is frequently higher than on other units of the hospital,” Elam explains. Studies that show only marginal cost savings from hospice care usually fail to compare appropriate time periods, he contends. Hospice care is most common in the last days of life, and comparisons that reflect that, show it costs less than other interventions and is embraced by patients and their families at the same time, he explains.
“Better care costs less — that’s important,” observes Elam, an associate professor of Medicine.
Too much of a good thing?
That assertion — that better care costs less — is the seemingly counterintuitive research outcome of the Dartmouth Atlas Project. The 2008 study found that for chronically ill Medicare patients more health care interventions — doctors’ visits, hospital stays and the like — increased spending but did not produce better patient outcomes or satisfaction. Two-thirds of patients in the study were diagnosed with one or more of these diseases — cancer, congestive heart failure and chronic lung disease.
“The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they or their families actually want or need,” said Risa Lavizzo-Mourey, M.D., M.B.A. Lavizzo-Mourey is president and chief executive officer of the Robert Wood Johnson Foundation, which provided principal funding for the research project done by the Institute for Health Policy and Clinical Practice at Dartmouth Medical School.
The Dartmouth Atlas Project found huge variations in dollars spent on chronically ill Medicare patients in the last two years of life, from a high of $59,379 per patient in New Jersey to a low of $32,523 per patient in North Dakota. In Tennessee, expenditures hit $42,478; the U.S. average was $46,412. The number of services patients received was driven by the number of health care providers and facilities in the area. One-third of annual Medicare dollars are expended on chronically ill patients who are in the last two years of their lives, the study says. Spending on Medicare and health care overall is predicted to skyrocket in the next decade as the baby boomers age.
“We need to benchmark the best systems and use policy to drive providers toward the benchmark by holding them accountable for the volume of services they deliver,” asserted study co-author Elliott S. Fisher, M.D., M.P.H., and director of the Center for Health Policy Research in the Dartmouth Institute. The study suggests academic medical centers and federal agencies need to lead the way by conducting research on when chronically ill people should be hospitalized, referred to specialists and recommended for other tests, treatments and services.
The health care cost-benefit conundrum
As the outsized baby boom generation moves through the health care system in the next few decades, some observers suggest that studies like the Dartmouth Atlas Project could be used to promote health care allocation in America. People develop more chronic health problems and use more health care dollars as they age; life expectancy has continued to climb in the United States to a record high of 78.1 years. By 2030, the number of Americans age 65 and older is expected to double to 71 million, which will account for 20 percent of the U.S. population.
Government policymakers already balance the cost of saving lives against the benefit gained based on economic models that weigh identified amounts of risk against people’s willingness to pay to contain it. Vanderbilt economist W. Kip Viscusi, Ph.D., has done a lot of these analyses, which rely on input from people who will be affected to quantify the tradeoff between money and small risks of death. He understands that might make some people uncomfortable.
“When people hear that economists are putting a dollar value on human life, they imagine how we are conceptualizing that number,” observes Viscusi, the co-director of Vanderbilt’s new Ph.D. Program in Law and Economics and the first University Distinguished Professor.
“All the numbers I use are based on the preferences of people who actually face risk,” explains Viscusi, one of the world’s leading experts on cost-benefit analysis whose estimates of the value of risks to life and health have been used extensively by the Environmental Protection Agency, the Federal Aviation Administration and other government regulators. “What matters is people’s preferences, what they say, their willingness to pay for risk reduction. You ask the people who are affected.”
While health care economic models often use “quality-of-life” adjustments that reduce the value of saving the lives of older people because they have more health problems and less time to live, Viscusi thinks this methodology is misguided and without theoretical basis. Research shows that neither patients with a chronic illness nor older individuals are willing to take big risks with their personal safety, an indication, Viscusi says, that they continue to place a high value on their lives regardless of physical limitations or aging. <<back continued>> |
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