No, it isn’t Greensboro’s much more boring nightlife, less innovative cuisine, and lack of beachside martinis leading to less drinking, carousing, and a longer but presumably duller life. What’s actually going on is regional variation in how doctors and hospitals diagnose and treat patients. Researchers from Dartmouth have proven for years that some regions of the country have much higher use of health care services – and much higher health care costs — than other regions. And, regardless of the amount of treatment received, outcomes and survival rates remain basically the same, meaning that living in a higher intensity care region doesn’t give people any longer or better life than if one lives in a lower intensity care region.
This month in the New England Journal of Medicine, some of these same researchers ask a new and interesting related question. What happens to people and their health status when they move either into a region of higher intensity care or, conversely, lower intensity care? After the fact, it seems obvious, but is nonetheless startling. People who moved into a higher intensity region of care had more diagnosed disease, saw more specialists, and received more treatment. The opposite was true if they moved into a lower intensity region – rates of diagnoses fell and people appeared to become healthier.
Therefore, on paper, someone who was perfectly healthy in Greensboro (a relatively lower intensity of care region) could have a pretty good chance of being diagnosed with more disease if he moved to Miami, one of the highest intensity care regions in the country. Again, survival rates remained the same regardless of the move.
As the researchers point out, this finding has pretty important implications for health care reform and attempts to improve care and control costs. One of the main ways that we can possibly control costs is by changing the way we pay for care. Paying for “episodes” of care instead of piecemeal for each test and procedure has already been shown in various settings to reduce overall health costs and improve health care outcomes. That seems to make sense – if doctors can focus on just treating the patient and not have to feel pressure to bill every test and procedure, everyone benefits. However, a major issue with this payment change is how to account for populations that are sicker. Obviously, if groups of patients being seen by a hospital or physician practice are sicker than average, then they will cost more to treat and payments should be higher.
But if the patient group being “sicker” is really just an artifact of the higher than average intensity of care delivered in that particular area, aren’t we just rewarding behavior that is inefficient and ineffective? This is the problem these Dartmouth researchers are demonstrating. Containing health care costs is the greatest challenge of health reform implementation. Reform is giving us the opportunity to innovate our way to lower costs and better health care, but it isn’t going to be easy, as this article shows.