Policy Implications of Mapping Healthcare Outcomes

John D Rockefeller JD MPHAssociate Dean and Lecturer

Geisel School of MedicineDartmouth College

4TH LATIN AMERICAN MEETING ON THE RIGHT TO HEALTH AND HEALTH SYSTEMS, Bogotá, Colombia. April 2 to 4, 2014

1973 – Measuring Health Care in Vermont

Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973;182:1102-8.

1993: From the ashes of the Clinton Health Care Reform was born the Dartmouth Atlas of Health Care

6 billion Medicare claims a year x many many years of data= lots of terabytes of data

www.dartmouthatlas.org

The Dartmouth Atlas of Health Care provides national public reporting of health system performance over time through the lens of variation in utilization, cost,

quality, and patient experience.

The Atlas highlights variation, its causes, and its consequences in order to provide target audiences with compelling data to effect positive changes in the

health care system.

2014: The Dartmouth Atlas of Health Care

Robert Wood Johnson FoundationCalifornia HealthCare Foundation

Charles H. Hood Foundation

Current Funders

Medicare is terrifically important, but so too are other populations:(U.S. Population by Insurance Type – 2010)

Total Population = 305 million

< 19 19-25 26-34 35-44 45-54 55-64 ≥ 65

Age

79m 30m 37m 40m 44m 37m 39mPopulation:

Medicare fee-for-service

Medicare “HMO”

Medicaid

Private/commercial

Uninsured

The Dartmouth Atlas of Health Care

David Goodman, MD MS (Co-PI)Elliott Fisher, MD MPH (Co-PI)Jonathan Skinner, PhDJohn Wennberg, MD MPH (Founder)Kristen Bronner, MA (Managing Editor)Scott Chasan-Taber, PhD (Director of Atlas Analytics)

Julie Bynum, MD MPHNancy Morden, MD MPHShannon Brownlee, MSChiang-hua Chang, PhDTherese Stukel, PhDJeff Munson, MDJohn Erik-Bell, MD MSDouglas Staiger, PhDJames Weinstein, MD MSPhil Goodney, MD MS

Leadership Group Faculty (a dynamic cohort)

6

Elisabeth Bryan, MSThomas Bubolz, PhDDonald Carmichael, MDivJulie DohertyJennifer Dong, MSDaniel Gottlieb, MSJia Lan, MSMartha Lane, MAStephanie Raymond, MA

Nancy Marth, MSSally Sharp, SMJeremy Smith, MPHYunjie Song, PhDDean Stanley, RHCEAndrew Toler, MSStephanie Tomlin, MPARebecca Zaha, MPHWeiping Zhou, MS

The Amazing Staff

Price-adjusted Medicare spending per beneficiaryamong hospital referral regions (2010)

$10,420 to 13,830 (61)9,770 to < 10,420 (62)8,920 to < 9,770 (60)8,100 to < 8,920 (61)6,910 to < 8,100 (62)

Not populated

What causes the variation in spending?

What is the right rate?

How can we make fair comparisons?

Are there different causes of variation in utilization?

How can we improve the value of health care?

Percent of Medicare diabetics with eye exams hospital service areas (2010)

Effective care

October 15, 2013

tdi.dartmouth.edu

Use of drugs to treat osteoporosis following fragility fracture among hospital referral regions (2006-10)

17.4 to 28 .1% (48)15.2 to < 17 .4% (50)13.8 to < 15 .2% (46)12.3 to < 13 .8% (50)

6.8 to < 12 .3% (48)Insufficient data (64)Not populated

Effective care

Use of beta-blockers 7-12 months following discharge for AMI (2008-10)

92 % or More (0)84 % to < 92 % (42)76 % to < 84 % (164)68 % to < 76 % (86)Less than 68% (13)Insufficient data (1)Not populated

Effective care

Quality Dartboards for large Northern New England hospital service areas

Children < 18 yrs – all payer claims data, 2007-10 average

Quality Dartboards for large Northern New England hospital service areas

Children < 18 yrs – all payer claims data, 2007-10 average

Variation in Effective Care

• The choice of service is dictated by strong evidence of effectiveness for almost all targeted patients.

• The benefits almost always outweigh any adverse effects.• Risk adjustment is often not necessary.• The right rate is usually obvious.

17

TURP for BPH discharges per 1,000 male Medicare enrollees (2007)

age-sex-race adjusted

Red dots indicate highest 3, lowest, and HRRs with at least 300,000 FFS Medicare beneficiaries

Idaho Falls, ID 2.79Panama City, FL 2.56Gulfport, MS 2.46Boston, MA 1.19St. Louis, MO 1.07Camden, NJ 1.07Houston, TX 1.05Los Angeles, CA 1.04Manhattan, NY 1.03Philadelphia, PA 1.01Indianapolis, IN 1.00East Long Island, NY 0.82Orlando, FL 0.77Atlanta, GA 0.71Dallas, TX 0.62Salinas, CA 0.24

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Rat

io o

f TU

RP

for

BP

H r

ate

to U

.S.

aver

age

18

Preference-Sensitive Care

• Involves tradeoffs.• Scientific uncertainty often substantial.• The effect of supply (e.g. physicians) is variable.• Patient and provider values are often different.• Decisions that should be based on the patient’s own

preferences.• Decision quality is improved through shared decision-

making and decision aids.

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Percent of cancer patients dying in hospital among academic medical centers and NCI Cancer Centers (2010)adj. for age-sex-race, cancer type, non cancer conditions

10

15

20

25

30

35

40

45

50

55

Perc

ent d

ying

in h

ospi

tal

Allegheny General Hospital (Pittsburgh, PA) 16.6Univ Hospitals of Cleveland (Cleveland, OH) 16.5Univ of Kentucky Hospital (Lexington, KY) 16.5Akron General Medical Center (Akron, OH) 12.2St. Luke's Hospital (Bethlehem, PA) 11.5

Lenox Hill Hospital (New York, NY) 49.8Maimonides Medical Center (Brooklyn, NY) 48.1New York Methodist Hospital (Brooklyn, NY) 47.3Mount Sinai Hospital (New York, NY) 46.9Beth Israel Medical Center (New York, NY) 44.9

2.0

4.0

6.0

8.0

10.0

12.0

3.0 6.0 9.0 12.0 15.0 18.0

Acute Myocardial InfarctionRate per 1,000 Medicare Enrollees

age-sex-race adjusted

Car

diol

ogis

ts p

er 1

00K

Source: Wennberg, et al. Dartmouth Cardiovascular Atlas

There is virtually no relationship between regional physician supply and health

needs.

Capacity (i.e. supply) is often located without respect for need

22

R2 = 0.49

Nu

mb

er

of V

isits

per

ben

efic

iary

0.0

0.5

1.0

1.5

2.0

2.5

0.0 2.5 5.0 7.5 10.0 12.5 15.0

Number of Cardiologists per 100,000

Physician Supply and Physician Visitsage-sex-race adj.

Cardiologists

Head CT Scans per 1,000 Children(2007-10, age-sex-payer adj.)

14.7 to 19.7 (13)12.3 to < 14.7 (14)10.5 to < 12.3 (14)

8.9 to < 10.5 (14)4.2 to < 8.9 (13)

Insufficient data (1)Not populated

3

5

7

9

11

13

15

17

19

21

Hea

d CT

sca

ns p

er 1

,000

chi

ldre

n

Bangor, ME 11.1Portland, ME 9.7Lebanon, NH 8.9Burlington, VT 8.4