End-of-life care costlier in Boston
US study highlights state's challenges
During their final years, chronically ill patients in Boston spend more time in the hospital, receive more care from specialists, and run up substantially steeper bills than senior citizens in much of the nation, according to a sweeping report released this morning.
Researchers from Dartmouth Medical School found some of the most striking differences exist at academic medical centers, the hospitals regarded as the nation's best. And there is little evidence, the researchers said, that more intensive treatment translates into superior medical care, even as it adds billions of dollars to the healthcare bottom line.
At Massachusetts General Hospital, patients suffering from heart failure, cancer, or other chronic ailments spent an average of 17 days in the hospital and had nearly 40 visits with doctors during the six months before they died. At the Mayo Clinic in Minnesota, comparable patients were hospitalized five fewer days and had 16 fewer physician encounters, either at the hospital or in the community.
The findings of the Dartmouth Atlas of Health Care 2008 highlight the immense challenge confronting Massachusetts authorities as they struggle to make sure that the state's campaign to provide health insurance to nearly all citizens does not go broke.
The report also reflects the failure of the nation's healthcare system to develop comprehensive standards for measuring quality and determining how much medical care should be given and when. That is especially crucial during the final two years of life - caring for such patients consumes one-third of all federal health spending on the elderly.
"When you're looking at end-of-life care, too often the care that is delivered is simply a shotgun approach: This person is really sick, so let's try this, this, this, and this," said Dr. JudyAnn Bigby, Massachusetts' health secretary. "People don't understand the limits of technology and providers don't, in a way that is understandable to people, discuss the risks and benefits of certain interventions.
"We are operating in an era where for the most part, the public thinks that consuming more healthcare is better for your health, and that's simply not true."
The Dartmouth team that wrote today's report has been recognized for decades as a forceful voice calling for greater rationality in the nation's healthcare system, and the study starkly demonstrates a lack of progress in reducing costs and standardizing care.
In an analysis requested by the Globe, the researchers found potentially big savings if Massachusetts's six major teaching hospitals had treated patients in the final six months of life with the same intensity as the Mayo Clinic: Medicare payments would have plummeted a total of $223 million from 2001 through 2005.
"It's a really disappointing commentary on us all that these guys have been publishing this stuff forever, and it hasn't had anywhere near the kind of impact you hope it would on what we do," said Charles Baker, president of Harvard Pilgrim Health Care.
The researchers examined the treatment provided to patients who died between 2001 and 2005 and were covered by Medicare, the federal insurance plan for senior citizens. Their experience mirrors treatment patterns for younger patients nearing death, health policy specialists said.
By restricting their analysis to patients with at least one of nine chronic conditions, the authors said, they hoped to make fair comparisons among hospitals. Similarly, by concentrating much of their report on academic medical centers, the researchers further leveled the playing field.
What they found, said one of the study's authors, Dr. David Goodman, stunned even them.
At some hospitals, patients during their last six months of life had average stays more than twice as long as patients at other academic centers. The number of visits with doctors varied even more profoundly, with patients at one New Mexico hospital averaging fewer than 20, while patients at a Los Angeles hospital had nearly 80 encounters with physicians.
Goodman attributed the differences, largely, to the availability of medical services. In essence, healthcare systems abhor a vacuum: If a region has a robust supply of physicians, patients are more prone to visit medical offices.
Minnesota, home to the Mayo Clinic, has the 14th-greatest concentration of doctors. No state has a higher concentration of physicians than Massachusetts.
"They are highly trained, well-meaning clinicians," Goodman said. "They want to be helpful, and the way we help as physicians is by delivering care."
But providing more care can endanger patients, potentially spawning a cascade of unnecessary treatments or resulting in exposure to dangerous germs circulating in hospitals.
There's another force driving high use of medical services in Massachusetts, according to Alan Sager, a health policy specialist at Boston University School of Public Health: the sheer number of academic medical centers. While the state does not have an especially high number of hospital beds overall, it does have an abundance of hospitals with large medical training programs.
"There are no villains in this," Sager said. "We end up with costly hospital care in part because the hospitals that our doctors choose to use, or are forced to use, are disproportionately the teaching hospitals that are so costly."
The Dartmouth researchers found large variations within Massachusetts as well as nationally. Using an index that combines the length of hospital stays and the frequency of doctor visits in the hospital, they reported that the intensity of care at Mass. General ranked in the 82d percentile nationally, while UMass Memorial Medical Center placed in the 47th percentile.
Top doctors at Boston teaching hospitals branded such comparisons as simplistic, contending that they obscure vital differences between the types of patients seen in Boston and elsewhere. Still, they acknowledged, it is important to understand why variations persist.
As a doctor, "you're trying to take the best care of the patient in front of you," said Dr. Gregg S. Meyer, senior vice president for quality and patient safety at Mass. General. "But at the same time, there is an additional obligation to be good stewards of resources.
"If people in other parts of the country are taking great care of people and using more limited resources, that's something that we all ought to learn from."
To narrow variations in care, the Dartmouth researchers call for enhancing scientific evidence used in making end-of-life care decisions. They also propose revising the calculus used to reimburse doctors; now, that formula rewards those who admit a high number of patients to the hospital and are more likely to care for them in intensive care units.
Dr. Andy Whittemore, chief medical officer at Brigham and Women's Hospital, said the push for universal healthcare in Massachusetts holds the promise of getting patients into care sooner so that more realistic expectations can be set. "A physician's job is to preserve a life, and families in general now want everything done for their loved ones," he said. "It's very hard to say no." 