We all have heard that “spending more” on health care does not necessarily lead to better care. In fact, in regions of the country where care is more intensive and more expensive, sometimes outcomes are worse. This is the basic thrust of what has become known as the “Dartmouth research,” and most medical researchers agree.
But a paper just published in the Annals of Internal Medicine suggests that specific types of higher hospital spending may lead to better outcomes. After examining the records of some 2.5 million patients admitted to 208 California hospitals from 1999 to 2008 a group of researchers from the University of Southern California and Harvard Medical School report that patients who received more costly and aggressive care were less likely to die while in the hospital.
Let me be clear: this study is not trying to prove that the Dartmouth research is “wrong." The investigators, led by John Romley of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, begin by acknowledging that “a convincing set of studies demonstrates that U.S. regions that spend more on medical care–using more specialists, diagnostic tests, imaging, and inpatient hospital care–have similar or poorer patient outcomes than areas that spend less. (Here they footnote the Dartmouth Atlas and this article by Dartmouth’s Elliott Fisher, et.al.
The Most Important Question
But this group set out to take a step beyond the Dartmouth research, examining the murky relationship between money and outcomes in more detail. While granting that Dartmouth’s investigation “of total medical spending across regions provides an informative overall picture,” they suggest that for certain patients “medical spending may lead to better patient outcomes in some circumstances (for example, inpatient hospital spending) but not in others.”
This is why Dartmouth economist Jon Skinner, is intrigued by their work: “We need to get beyond the simple ‘Is more better?’ question,” Skinner explains. “Finding that high-spending regions don’t necessarily achieve better outcomes is old news. Finding that Mayo or Intermountain get good results at low cost is also old news.” What we don’t know is why some hospitals are more successful. And this new article looking at inpatient spending and outcomes is a good first step in that direction.
What the Data Shows
Zeroing in on patients suffering from six common conditions—acute myocardial infarction; acute stroke, congestive heart failure; gastrointestinal hemorrhage; hip fracture and pneumonia—Romley, et. al., found “an association between high hospital spending and fewer inpatient deaths.”
What is striking is how widely spending varied across hospitals treating similar patients. For instance, between 2004 and 2008, the amount spent on patients who suffered from heart attacks was about $5,168 at the least expensive hospitals, while the total bill topped $21,000 at the costliest institutions. (Total spending included physician visits, hospital room charges, laboratory testing, diagnostic imaging, medication administration and procedures.) The tab for GI hemorrhages ran from roughly $5,000 to well over $21,000. (These figures reflect the cost of caring for patients who ultimately died in the hospital.)
The range of outcomes is almost as striking. After adjusting for risk factors such as age, socio-economic factors and co-morbidities, investigators found that patients who had suffered heart attacks and were admitted from 1999 and 2003 were 14% less likely to die in the more expensive hospitals; those who entered the hospital between 2004 and 2006 were 26% less likely to die before being discharged. Pneumonia patients who received costlier care were 27% less likely to die. Extra spending was not always associated with better patient outcomes. Patients admitted with hip fractures, and GI hemorrhages between 1999 and 2003 showed no benefit, but between 2004 and 2008, bigger outlays appeared to make a difference.
Beware of the Headlines
It is all too easy to simplify these findings, especially in a headline. “High Cost California Hospitals Have Lower Mortality” announces one blog. “More Hospital Spending May Save More Lives” reports another. Even the L.A. Times could not resist telling readers what they want to hear: “Money Can Buy Better Health, Study Finds” The story begins by suggesting that the link between money and survival is clear-cut: “When it comes to heart attacks, strokes and some other types of medical emergencies that could land you in the hospital, you get what you pay for.” If you’re rich, you’re safe.
But read a little further, and the L.A. Times reporter acknowledges that while the researchers believe that “their results may show that certain kinds of acute-care spending are worthwhile, unfortunately, there weren't enough data to identify the specific interventions that made the difference…they speculated that the list would include ‘early and more frequent coronary revascularization’ for heart attack patients and ‘upper and lower endoscopies’ for patients with GI hemorrhages.” But they don’t really know.
In fact, Romley, et. al. don’t go quite as far as the story suggests: “Although our analysis demonstrates that intensive spending by hospitals is associated with lower mortality, it does not identify the specific costly interventions that high spending hospitals undertake to achieve this mortality benefit,” they write. “Prior work suggests that patients at moderate and high risk for death have lower mortality when admitted to hospitals in which larger proportions of patients spend time in the intensive care unit, undergo mechanical ventilation, or receive dialysis.”
But, they emphasize: “These interventions are probably only proxies for the additional costly diagnostic work-up and management that higher-spending hospitals may do.” In other words, ICU care, and the use of mechanical ventilation may only be “markers” for the care that led to survival, not the cause. (All medical research is limited in some ways; these investigators deserve a hat-tip for making what they do know—and what they don’t know—so clear.)
Moreover, the researchers claim only an “association” between higher spending and fewer inpatient deaths—this does not imply causality. As the Annal’s editors point out in a blue box near the top of the story: “This observational study cannot establish cause and effect.”
In other words, the fact that patients underwent more procedures or saw more specialists may or may not have led to fewer deaths.
Perhaps the more costly hospitals are simply better-staffed, and the nurse-patient ratio explains much of the difference. When more nurses are watching patients they are likely to spot complications sooner. And if the floor is fully staffed, nurses who are not trying to do the jobs of two people are less likely to make mistakes. Is it also possible that more “attending” physicians are supervising residents at hospitals that charge more per day. This too, could explain fewer inpatient mortalities.
In Health Services Research, Skinner and Elliott Fisher reply to another 2010 study which links more spending with better outcomes thirty days after surgery. There, they write: “We know that spending for specific clinical treatments appears to be associated with better outcomes—whether beta-blockers, aspirin, and reperfusion for heart attack patients” (Skinner and Staiger 2009), a greater supply of neonatologists in regions with low supply (Goodman et al. 2002), or intensive care for tourists . . . about whom little is known . . . admitted to emergency rooms in Florida (Doyle 2010). “These studies point to plausible clinical mechanisms by which more spending could yield benefits,” they add.
But, Fisher and Skinner write: “earlier research …suggests that additional spending devoted to treating patients with chronic disease in the hospital as opposed to the outpatient setting does not offer benefits. A recent study finds that hospitals with intensive end-of-life treatment patterns are also far more likely to use feeding tubes in patients with advanced dementia——a practice that is both expensive and clinically inappropriate.”(Teno et al. 2010).
They conclude: “For policy makers, the media, and even for some investigators, there is a temptation to over-interpret studies relating to spending and outcomes. Some might hope to conclude from some of our studies that to get better quality, we need only cut spending or reimbursement rates in high-cost regions or health systems. Others interpret positive associations between intensity and mortality as causal and conclude that lower intensity would cause higher mortality. We disagree with these interpretations.” Ultimately, Skinner speculates that “better outcomes probably have less to do with how much you spend than how you spend it.” Spending money to ensure coordinated care in the hospital will yield benefits to patients; spending more money on feeding tubes for patients with advanced dementia (as in Teno’s study above) will not.
Fisher agrees that “how you spend it” is key. “The papers that we published in the Annals of Internal Medicine show that in the high-cost hospitals, the money is often spent on frequent readmissions, seeing more specialists, and the attendant tests. We would rather avoid frequent readmissions. On the other hand, appropriate use of the ICU can save lives.
What Happened to Patients After They Left the Hospital?
Finally, it is important to keep in mind that the recent study done by Romley, et. al., only tracks how many patients survived while still in the hospital. What happened to them after they were discharged?
Again, the researchers are unusually candid: “Our findings should be interpreted with caution. The cost-effectiveness of hospital spending depends on its effect on inpatient and post discharge mortality, the latter of which we could not assess with our data. Hence, important questions about the efficacy and value of hospital care remain to be asked and answered.”
How did the patients who received the most intensive treatments fare after leaving the hospital? Presumably some went home; some landed in a nursing home; some found safe haven in a hospice. How many died two weeks or a month after discharge? There is a danger that, rather than prolonging life, in many cases, the high-intensity hospitals only prolonged the process of dying. Perhaps the money would have been better spent—and patients would have suffered less—if dollars invested in more hi-tech care had been spent on palliative care.
We know that, in some cases, more aggressive care helps patients survive just a little bit longer, long enough to make it home, where most patients prefer to die. As a 2010 study by Amber Barnato et. al. published in Medical Care suggests, the effects of intensive end of life care may be “fleeting.” After studying the records of more than a million patients in 169 Pennsylvania acute care hospitals, Barnato’s team concluded that, “Admission to higher end-of-life treatment intensity hospitals is associated with small gains in post admission survival. The marginal returns to intensity diminish for admission to hospitals [that offer] above average end-of-life treatment intensity and wane with time.”
In other cases, patients are transferred to a nursing home when the hospital’s doctors realize that they have done all that they can do. It would be misleading to suggest that, for these patients, more spending improved outcomes. Many will never return to their normal lives; they simply will be warehoused in nursing homes. On the other hand, is it safe to assume that some patients discharged from the costliest institutions went home to play with their grandchildren and enjoyed another ten years of high-quality life? We just don’t have the numbers.
In the end, everyone agrees, more work needs to be done. Where should we start? “Step one is better clinical data to understand where the extra money is being spent, and what high-performance hospitals do differently,” Skinner commented. “But we also need to know what happens to patients after they leave the hospital – are they being seen by their primary care physician? Are they getting the rehab services they need?”
Ideally, we want to learn more about how to achieve the win/win that health care reformers aim for: higher quality care at a lower cost.