27
U.S. issome-wherein thiszone
Frequency of CareFrequency of Care
Lif
e E
xpec
tan
cy
Lif
e E
xpec
tan
cy
Shape of the Benefit-Utilization Curve:Shape of the Benefit-Utilization Curve:Supply-Sensitive ServicesSupply-Sensitive Services
i.e. The problem of unwarranted variation in i.e. The problem of unwarranted variation in treatment of chronic illness is a problem intreatment of chronic illness is a problem in
overuse and waste, not underuse overuse and waste, not underuse and health care rationingand health care rationing
What Does Greater Medicare Spending Buy?What Does Greater Medicare Spending Buy? Medicare Per capita spending (306 regions: 2000-01)Medicare Per capita spending (306 regions: 2000-01)
3,5003,500
4,5004,500
5,5005,500
6,5006,500
7,5007,500
8,5008,500
9,5009,500
10,50010,500
More than 15% Above Average
0-15% Above Average
0-15% Below Average
More than 15% Below Average
What does Greater Per Capita Spending BUY?What does Greater Per Capita Spending BUY?not more effective or preference-sensitive carenot more effective or preference-sensitive care
1.00
1.00
1.00
1.18
0.98 1.04
1.38
0.97 1.03
1.66
1.00
0.99
0.00.0
0.40.4
0.80.8
1.21.2
1.61.6
2.02.0
Medicare ReimbursementsMedicare Reimbursements Effective CareEffective Care Preference-Sensitive CarePreference-Sensitive Care(Discretionary Surgery)(Discretionary Surgery)
Rat
io t
o L
ow
est
Sp
end
ing
Reg
ion
Rat
io t
o L
ow
est
Sp
end
ing
Reg
ion
More than 15% Below Average
0-15% Below Average
0-15% Above Average
More than 15% Above Average
What does Greater Per Capita Spending BUY?What does Greater Per Capita Spending BUY?More Supply-Sensitive Care!!More Supply-Sensitive Care!!
More than 15% Below Average
0-15% Below Average
0-15% Above Average
More than 15% Above Average
1.00
1.00
1.001.
23 1.41
1.41
1.26
1.82
1.80
1.69
2.54
2.53
0.00.0
0.50.5
1.01.0
1.51.5
2.02.0
2.52.5
3.03.0
Days in HospitalDays in Hospital Medical Specialist VisitsMedical Specialist Visits % Seeing 10 or More% Seeing 10 or MoreDoctorsDoctors
End of life careEnd of life care
Rat
io t
o L
ow
est
Sp
end
ing
reg
ion
sR
atio
to
Lo
wes
t S
pen
din
g r
egio
ns
Reducing Overuse: supply sensitive careReducing Overuse: supply sensitive care
• Major focus: At patient level, active chronic Major focus: At patient level, active chronic disease managementdisease management
Reducing Overuse: supply sensitive careReducing Overuse: supply sensitive care
• Major focus: At patient level, active chronic Major focus: At patient level, active chronic disease managementdisease management
• Major focus: At system level, control of capacity Major focus: At system level, control of capacity relative to size of population servedrelative to size of population served
Reducing Overuse: supply sensitive careReducing Overuse: supply sensitive care
• Major focus: At patient level, active chronic Major focus: At patient level, active chronic disease managementdisease management
• Major focus: At system level, control of capacity Major focus: At system level, control of capacity relative to size of population servedrelative to size of population served
• Major Impediment: adverse economic impact on Major Impediment: adverse economic impact on providers providers
8.08.0
12.012.0
16.016.0
20.020.0
24.024.0
28.028.0
Days in Hospitals During Last Six Months of Life Among Days in Hospitals During Last Six Months of Life Among Patients with severe chronic illness who received most of Patients with severe chronic illness who received most of their care in one of 77 “best” U.S. hospitalstheir care in one of 77 “best” U.S. hospitals
Supply-Sensitive CareSupply-Sensitive Care
Days in Hospitals During Last Six Months of LifeDays in Hospitals During Last Six Months of Life Among Among Patients assigned to Selected Academic Medical CentersPatients assigned to Selected Academic Medical Centers
8.08.0
12.012.0
16.016.0
20.020.0
24.024.0
28.028.0NYU Medical Center 27.1
Mount Sinai Hospital 22.8NY Presbyterian Hospital 21.6Cedars-Sinai Medical Center 21.3
Mass. General Hospital 16.5UCLA Medical Center 16.1Boston Medical Center 15.6
Brigham & Women's Hospital 13.9Beth Israel Deaconess 12.2UCSF Medical Center 11.5Stanford University Hospital 10.1
0.00.0
5.05.0
10.010.0
15.015.0
20.020.0
25.025.0
30.030.0
35.035.0
0.00.0 5.05.0 10.010.0 15.015.0 20.020.0 25.025.0 30.030.0 35.035.0
Hospital day rate: Cancer patientsHospital day rate: Cancer patients
Ho
spit
al d
ay r
ate:
CH
F p
atie
nts
Ho
spit
al d
ay r
ate:
CH
F p
atie
nts
R2 = 0.64
Association Between Hospital Days for Cancer and for CHF Association Between Hospital Days for Cancer and for CHF patients during last six months of life: 77 Selected Academic patients during last six months of life: 77 Selected Academic Medical CentersMedical Centers
5.05.0
10.010.0
15.015.0
20.020.0
25.025.0
30.030.0
5.05.0 10.010.0 15.015.0 20.020.0 25.025.0 30.030.0
L6M hospital day rate: Non-BlackL6M hospital day rate: Non-Black
L6M
ho
spit
al d
ay r
ate:
Bla
ckL
6M h
osp
ital
day
rat
e: B
lack
R2 = 0.75
Association between hospital days for black and non-black Association between hospital days for black and non-black patients during last six months of life among 50 “best” hospitalspatients during last six months of life among 50 “best” hospitals
Supply-Sensitive CareSupply-Sensitive Care Physician Visits During the Last Six Months of Life Among Physician Visits During the Last Six Months of Life Among Patients assigned to Selected Academic Medical CentersPatients assigned to Selected Academic Medical Centers
10.010.0
20.020.0
30.030.0
40.040.0
50.050.0
60.060.0
70.070.0
80.080.0NYU Medical Center 76.2
UCLA Medical Center 43.9NY Presbyterian Hospital 40.3Mass. General Hospital 38.8
Cedars-Sinai Medical Center 66.2
Mount Sinai Hospital 53.9
Brigham & Women's Hospital 31.9Boston Medical Center 31.5Beth Israel Deaconess 29.2UCSF Medical Center 27.2Stanford University Hospital 22.6
R2 = 0.6010.010.0
20.020.0
30.030.0
40.040.0
50.050.0
60.060.0
70.070.0
80.080.0
5.05.0 10.010.0 15.015.0 20.020.0 25.025.0 30.030.0
Hospital Day RateHospital Day Rate
Ph
ysic
ian
Vis
it R
ate
Ph
ysic
ian
Vis
it R
ate
Association Between Hospital Days and Physician Visits Association Between Hospital Days and Physician Visits During the Last Six Months of Life among patients receiving During the Last Six Months of Life among patients receiving most of their care in one of 77 “best” U.S. hospitalsmost of their care in one of 77 “best” U.S. hospitals
15.015.0
25.025.0
35.035.0
45.045.0
55.055.0
65.065.0
Mount Sinai Hospital 58.5NYU Medical Center 57.1
Stanford University Hospital 23.1
UCLA Medical Center 50.9Cedars-Sinai Medical Center 48.2
NY Presbyterian Hospital 37.7
UCSF Medical Center 30.3
Percent seeing 10 or more physicians during last six months Percent seeing 10 or more physicians during last six months of life among patients receiving most of their care in one of 77 of life among patients receiving most of their care in one of 77 “best” U.S. hospitals“best” U.S. hospitals
Association Between Medicare inpatient + Part B Payments Association Between Medicare inpatient + Part B Payments 19-24 Months and 0-6 Months Before Death: 77 hospital 19-24 Months and 0-6 Months Before Death: 77 hospital
cohorts (1999-01)cohorts (1999-01)..
R2 = 0.795,0005,000
10,00010,000
15,00015,000
20,00020,000
25,00025,000
30,00030,000
35,00035,000
40,00040,000
1,5001,500 3,5003,500 5,5005,500 7,5007,500
Payments 19-24 Mos. Before DeathPayments 19-24 Mos. Before Death
Pa
yme
nt
in L
as
t 6
Mo
nth
sP
aym
en
t in
La
st
6 M
on
ths
4.04.0
8.08.0
12.012.0
16.016.0
20.020.0
24.024.0
28.028.0
NYU Medical Center 24.6
Cedars-Sinai Medical Center 20.7
Mount Sinai Hospital 16.4UCLA Medical Center 14.6New York Presbyterian 13.8
UCSF Medical Center 9.2Stanford University Hospital 8.7
Primary care + medical specialist S-FTE inputs per Primary care + medical specialist S-FTE inputs per 1,000 Medicare decedents: last six months of life 1,000 Medicare decedents: last six months of life among selected hospitalsamong selected hospitals
4.04.0
8.08.0
12.012.0
16.016.0
20.020.0
24.024.0
28.028.0
NYU Medical Center 1.70
Cedars-Sinai Medical Center 2.19
Mount Sinai Hospital 1.10UCLA Medical Center 2.86New York Presbyterian 1.05
UCSF Medical Center 0.67Stanford University Hospital 1.31
Ratio: medical specialist/primary careRatio: medical specialist/primary care
Medicare reimbursements per decedent during the Medicare reimbursements per decedent during the last six months of life among California hospitals last six months of life among California hospitals
(weighted average in parentheses) (1999-2003)(weighted average in parentheses) (1999-2003)
5,0005,000
15,00015,000
25,00025,000
35,00035,000
45,00045,000
55,00055,000
65,00065,000
Allother
($18,165)
Sutter
($17,035)
CHW
($16,824)
Tenet
($29,003)
Adven-tist
($18,422)
St.Joseph
($14,691)
Kaiser
($13,445)
Univ.of CA
($27,218)
Daughtersof Charity($23,727)
HCA
($18,942)
Scripps
($16,795)
Hospital days per decedent during the last six Hospital days per decedent during the last six months of life among California hospitals (weighted months of life among California hospitals (weighted
average in parentheses) (1999-2003)average in parentheses) (1999-2003)
5.05.0
8.08.0
11.011.0
14.014.0
17.017.0
20.020.0
23.023.0
26.026.0
29.029.0
32.032.0
Allother(13.6)
Sutter
(11.4)
CHW
(12.6)
Tenet
(16.9)
Adven-tist
(13.3)
St.Joseph(12.0)
Kaiser
(10.1)
Univ.of CA(14.2)
Daughtersof Charity
(15.9)
HCA
(15.0)
Scripps
(13.1)
Association Between Total Medicare Payments 18-24 Months Association Between Total Medicare Payments 18-24 Months
and 0-6 Months Before Death: 77 hospital cohorts (1999-01)and 0-6 Months Before Death: 77 hospital cohorts (1999-01)..
R2 = 0.795,0005,000
10,00010,000
15,00015,000
20,00020,000
25,00025,000
30,00030,000
35,00035,000
40,00040,000
1,5001,500 3,5003,500 5,5005,500 7,5007,500
Total Payments 18-24 Mos. Before DeathTotal Payments 18-24 Mos. Before Death
To
tal P
aym
ent
in L
ast
6 M
on
ths
To
tal P
aym
ent
in L
ast
6 M
on
ths
What Preferred Providers should be What Preferred Providers should be asked to do:asked to do:• Eliminate Underservice of Effective CareEliminate Underservice of Effective Care• Reduce Medical Mistakes Reduce Medical Mistakes • Learn What Works (Outcomes Research)Learn What Works (Outcomes Research)• Assure Informed Patient Choice (Shared Decision Assure Informed Patient Choice (Shared Decision
Making)Making)• Achieve Efficient and Effective Management of Achieve Efficient and Effective Management of
Supply-Sensitive Care (Target: Chronic Disease)Supply-Sensitive Care (Target: Chronic Disease)• Achieve Efficient Allocation of Resources geared Achieve Efficient Allocation of Resources geared
to Size of the Population Servedto Size of the Population Served
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