Health Policy: The Dartmouth Atlas Project gets it wrong
Big, big news in the world of national health policy is the release of this data and report:
http://www.dartmouthatlas.org/press/2006_atlas_press_release.shtm
The Dartmouth Atlas Project studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. The database is based on Medicare claims data for more than 4,300 hospitals in 306 regions. Using this database, researchers compared every region in the country to three regions that provide high-quality/low-cost care: Salt Lake City, Utah,
served primarily by Intermountain Health care; Rochester, Minn., served largely by the Mayo Clinic; and Portland, Ore., the largest and most metropolitan region in a state that has made improvement in end of life care a public policy goal.
The study points out that Salt Lake City, Utah, Rochester, Mn., and Portland, Or. are the high quality / low cost winners. The researchers of the data present the case that Salt Lake City and Rochester are dominated by Integrated Health Care markets, and Portland has taken (unstated) initiatives to improve itself in end of life care, and these are why these communities became the winners.
However, the data cannot clearly make this assertion. The limited data points collected versus the huge numbers within the population studied will naturally
leave broad gaps in detail about individual populations. These missing details can epically influence what we may otherwise understand from the data that was collected.
There will be other unique similarities not addressed in the study data that these three communities share within their population didactics compared with the rest of the nation. Perhaps there is a predominant ethnicity, family make-up, economic health, or local cultures or traditions that impact the quality / low cost of health care as much or more than the factors the researchers present.
The researchers state that a fundamental problem that contributes to both overspending and worse outcomes is that most acute care hospitals have become first-line providers of services to chronically ill elderly people, whose care would be better managed, safer and less expensive outside the hospital setting.
EMTALA and ERISA legislation essentially prevents even Integrated health systems in Salt Lake City and Rochester from directing sick people away from acute care. Also, if Medicare benefits, hospital admission criteria, and reimbursement methodology are
essentially the same across the country, how do the health care systems in the winning communities influence where or how Medicare beneficiaries go about
getting their care?
The researchers state that there are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists
or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness. Because there are not any of these formal guidelines, two factors drive decisions:
1. Both doctors and patients generally believe that more services - that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc. - produces better outcomes.
2. Based on the assumption that more is better, the supply of resources - not the incidence of illness - drives utilization of the services. In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.
McKesson Interqual (reg TM) or other such written evidence-based processes and guidelines are in place, and are being used nationwide. I can't imagine that
Salt Lake City, Rochester, or Portland were, or are, any further ahead, or behind, in using such tools than any other US health care community. Additionally, health care is a business nationwide. The the same economic influences are similarly present in the winning communities as elsewhere.
The report speaks clearly to the need to overhaul the way chronic illness is managed - to redirect resources away from acute care and invest in an infrastructure
that can better coordinate and integrate care outside of hospitals, for example home health and hospice care.
I argue that this needed "infrastructure" is not based within the health care delivery system. I am a long-time health care professional in the Salt Lake
City community. There is a predominant strong sense of community here, and a strong sense of family. There is a value system, especially among our Medicare-aged
population, that supports self-reliance and other values. As a home health case manager, my best outcomes were among those with strong family support, and, of course, among those who had planned for their golden years. These chronic-illness folks (with help from family and caring neighbors) managed their chronic illnesses and had prepared plans for what to do when they got sick. The result is a reduced need for acute care facilities and other high acuity care. Their attitudes about their disease and the care they received were, of course, fairly optimistic; hence,
higher quality outcomes are reported.
Contrast this with the chronic illness beneficiary who has no family member who is willing and/or able to help out. With neighbors and community that don't know
or don't care to help out. Who has nurtured the expectation that every level of health care is an entitlement, and who has come to depend on government for their essential domestic as well as health care needs.
I'd be willing to bet that the 3 winning communities are dominated by an educated working class, who still adhere to system of family and community values. Ironically ill beneficiaries have someone checking on them daily, their medications are followed and med-boxes are filled weekly. A responsible person accompanies them to doctor appointments and makes sure their domestic needs are met. And when the time comes, Hospice is served in the home by loved ones. Compared to other US metro areas, they have avoided the degree of societal sickness that fosters a dependence on
government programs. Their health system is not better managed than elswhere in the nation, but the system of values within the family and neighborhood is comparatively strong and intact.
The researchers of the Dartmouth Project do our society and collective health care community a diservice by falsely blaming the health care system itself for high costs and low perceived quality of care. The true blame rests primarily with the
individual. Each of us who do not accept the responsibility to watch out for the aged, chronically ill within our own families and neighborhoods. Each of us who do not plan for our own future health care needs. Each of us who do not foster a sense a values including self-reliance in our own children and communities.
Dale
http://www.dartmouthatlas.org/press/2006_atlas_press_release.shtm
The Dartmouth Atlas Project studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. The database is based on Medicare claims data for more than 4,300 hospitals in 306 regions. Using this database, researchers compared every region in the country to three regions that provide high-quality/low-cost care: Salt Lake City, Utah,
served primarily by Intermountain Health care; Rochester, Minn., served largely by the Mayo Clinic; and Portland, Ore., the largest and most metropolitan region in a state that has made improvement in end of life care a public policy goal.
The study points out that Salt Lake City, Utah, Rochester, Mn., and Portland, Or. are the high quality / low cost winners. The researchers of the data present the case that Salt Lake City and Rochester are dominated by Integrated Health Care markets, and Portland has taken (unstated) initiatives to improve itself in end of life care, and these are why these communities became the winners.
However, the data cannot clearly make this assertion. The limited data points collected versus the huge numbers within the population studied will naturally
leave broad gaps in detail about individual populations. These missing details can epically influence what we may otherwise understand from the data that was collected.
There will be other unique similarities not addressed in the study data that these three communities share within their population didactics compared with the rest of the nation. Perhaps there is a predominant ethnicity, family make-up, economic health, or local cultures or traditions that impact the quality / low cost of health care as much or more than the factors the researchers present.
The researchers state that a fundamental problem that contributes to both overspending and worse outcomes is that most acute care hospitals have become first-line providers of services to chronically ill elderly people, whose care would be better managed, safer and less expensive outside the hospital setting.
EMTALA and ERISA legislation essentially prevents even Integrated health systems in Salt Lake City and Rochester from directing sick people away from acute care. Also, if Medicare benefits, hospital admission criteria, and reimbursement methodology are
essentially the same across the country, how do the health care systems in the winning communities influence where or how Medicare beneficiaries go about
getting their care?
The researchers state that there are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists
or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness. Because there are not any of these formal guidelines, two factors drive decisions:
1. Both doctors and patients generally believe that more services - that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc. - produces better outcomes.
2. Based on the assumption that more is better, the supply of resources - not the incidence of illness - drives utilization of the services. In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.
McKesson Interqual (reg TM) or other such written evidence-based processes and guidelines are in place, and are being used nationwide. I can't imagine that
Salt Lake City, Rochester, or Portland were, or are, any further ahead, or behind, in using such tools than any other US health care community. Additionally, health care is a business nationwide. The the same economic influences are similarly present in the winning communities as elsewhere.
The report speaks clearly to the need to overhaul the way chronic illness is managed - to redirect resources away from acute care and invest in an infrastructure
that can better coordinate and integrate care outside of hospitals, for example home health and hospice care.
I argue that this needed "infrastructure" is not based within the health care delivery system. I am a long-time health care professional in the Salt Lake
City community. There is a predominant strong sense of community here, and a strong sense of family. There is a value system, especially among our Medicare-aged
population, that supports self-reliance and other values. As a home health case manager, my best outcomes were among those with strong family support, and, of course, among those who had planned for their golden years. These chronic-illness folks (with help from family and caring neighbors) managed their chronic illnesses and had prepared plans for what to do when they got sick. The result is a reduced need for acute care facilities and other high acuity care. Their attitudes about their disease and the care they received were, of course, fairly optimistic; hence,
higher quality outcomes are reported.
Contrast this with the chronic illness beneficiary who has no family member who is willing and/or able to help out. With neighbors and community that don't know
or don't care to help out. Who has nurtured the expectation that every level of health care is an entitlement, and who has come to depend on government for their essential domestic as well as health care needs.
I'd be willing to bet that the 3 winning communities are dominated by an educated working class, who still adhere to system of family and community values. Ironically ill beneficiaries have someone checking on them daily, their medications are followed and med-boxes are filled weekly. A responsible person accompanies them to doctor appointments and makes sure their domestic needs are met. And when the time comes, Hospice is served in the home by loved ones. Compared to other US metro areas, they have avoided the degree of societal sickness that fosters a dependence on
government programs. Their health system is not better managed than elswhere in the nation, but the system of values within the family and neighborhood is comparatively strong and intact.
The researchers of the Dartmouth Project do our society and collective health care community a diservice by falsely blaming the health care system itself for high costs and low perceived quality of care. The true blame rests primarily with the
individual. Each of us who do not accept the responsibility to watch out for the aged, chronically ill within our own families and neighborhoods. Each of us who do not plan for our own future health care needs. Each of us who do not foster a sense a values including self-reliance in our own children and communities.
Dale
posted by nawledge at
5:12 PM
0 Comments:
Post a Comment
<< Home