Regional variations among utilization, treatment protocols, and medical costs demonstrate a central issue for improvement. For many years, CHCF has participated in the funding of variation research, both by the Dartmouth Atlas of Health Care and other researchers. Below, we take a look at the implications and questions posed by this body of research and identify some areas ripe for further exploration.
The Dartmouth Atlas
The Dartmouth research, now led by Elliott S. Fisher and David C. Goodman, has been seminal in identifying and communicating the significant and unexplained variation that exists in medical care across the country. (The Dartmouth Atlas of Health Care)
The Dartmouth Atlas team has undertaken a number of studies focused on California, including:
Other Variation Studies
CHCF-funded research on patients over and under age 65 found that practice patterns for certain surgeries vary dramatically from place to place. Data maps present elective surgery and other procedure rates across California relative to state averages and show widely varying rates in spite of data adjustments for population characteristics and other factors. While some geographic variation in surgical rates is expected due to differences in the disease prevalence, much of the variation cannot be explained by illness rates. The consistency of results across all payers makes this a significant contribution to the literature documenting regional variation. The reports are based on estimates developed by Laurence Baker in collaboration with Maryann O'Sullivan and the staff and leadership of the Campaign for Effective Patient Care. (CHCF, All Over the Map: Elective Procedure Rates in California Vary Widely, September 2011)
Continuing Areas of Interest
Price versus service utilization. The California Public Employee Retirement System (CalPERS) fund has long been concerned that its aggregate health plan costs are much higher in Northern California than in Southern California. Yet the Dartmouth Atlas work shows that Sacramento providers are more efficient. How can Sacramento be a low-cost market for Medicare and a high-priced market for CalPERS? One explanation may be in price differences. Medicare prices are formula-driven and therefore more consistent within a region. However, health plans negotiate individually with each hospital, resulting in much greater differences in price per inpatient day. This means there may be more days of care provided in Los Angeles, but since each day carries a lower cost, it does not result in higher overall costs.
The role of accountable care organizations (ACOs). To a large extent the success of ACOs will depend on how closely aligned the partners are and which financial incentives are at play. Dartmouth Atlas research found that even leading systems, such as the Mayo Clinics, continue to show variation in treatment among Medicare FFS patients, although the degree of variation was less where hospitals and physicians were more tightly affiliated. (The Dartmouth Atlas of Health Care 2008, Chapter 3)
Laurence Baker's research with Kaiser Permanente in California found that although variation continued to exist between hospitals in Northern California and Southern California, the differences were not as great as those seen north and south with non-Kaiser hospitals. (CHCF, Same Disease, Different Care: How Patient Health Coverage Drives Treatment Patterns in California, April 2008)
Higher hospital resource use and mortality rates. A CHCF-funded study by the University of California's five medical centers and Cedars-Sinai Medical Center in Los Angeles examined variations in medical treatment, cost, and patient outcomes among hospitals treating Medicare beneficiaries with congestive heart failure. Researchers found lower mortality rates at facilities that used more health care resources, compared with those at hospitals that used fewer resources. The findings suggested that more resource-intensive care may prolong life among certain patients with heart failure. Further work is underway to examine quality-of-life issues and potential interventions to ensure care is beneficial and warranted. ("Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients with Heart Failure," M. K. Ong et al., Circulation: Cardiovascular Quality and Outcomes, October 13, 2009)
MRI scanners and surgeries. Magnetic resonance imaging (MRI) is frequently used to evaluate low-back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions that may result. In a Health Affairs Web Exclusive, Jacqueline Baras and Laurence Baker analyzed the relationship between MRI supply and care for FFS Medicare patients with low-back pain. More scanners are associated with more scans and more surgeries for enrollees. ("Magnetic Resonance Imaging and Low Back Pain Care for Medicare Patients," Health Affairs, October 2009)
Research referenced here is available through the links above.