Geography & healthcare

Consumer Reports has published an article on the Dartmouth Atlas of Health Care - a wonderful thing. Consumer Reports is really on a tear about healthcare, and this article provides our friends and neighbors information about a big part of what's wrong with U.S. healthcare.

Because physicians are paid on a fee-for-procedure, cost-plus basis, the incentives are to do more procedures, rather than just the right procedures. Physicians and nurses are generally ethical people, but they're just human. Add the need to pay for that MRI machine to the old lady's son insisting on "Do whatever's necessary, doc," and you end up with unnecessarily aggressive treatments - something proven out by the crazy regional differences on how many procedures patients are getting some places - without better outcomes.

Geography and health care
The amount of medical care that people get for serious illnesses varies enormously from place to place. In the last two years of life, the average patient spent 11 days in the hospital in Bend, Ore., and 35 days in Manhattan. In those same two years, patients visited the doctor an average of 34 times in Ogden, Utah, and 109 times in Los Angeles.

The Dartmouth Atlas based those findings on the Medicare claims records of millions of patients who died from (in order of prevalence) congestive heart failure, chronic pulmonary (lung) disease, cancer, dementia, coronary artery disease, chronic kidney failure, peripheral vascular (circulatory) disease, diabetes with organ damage, and severe chronic liver disease. Together those ailments account for about 90 percent of deaths of people older than 65.

Over the years, Dartmouth research has yielded some startling insights:

• The local supply of doctors and hospitals has more influence on the amount and type of care that patients receive than their actual medical conditions have. The more medical resources a region has, the more aggressive the treatments are.
• In the regions that deliver the most care, patients have a slightly higher death rate than patients with the same conditions treated in areas that treat less aggressively.
• Patients treated most aggressively are no more satisfied with their care.
• The cost differences are vast. Average Medicare spending over the last two years of life for all hospitals ranged from a high of $81,143 in Manhattan to a low of $29,116 in Dubuque, Iowa.

So the Dartmouth folks are big on best practices, as are other medical systems that keep down healthcare costs - and simultaneously maintain good access. (Note in the Consumer Reports' articles that "Patients in the high-spending, aggressive-care regions waited longer in emergency rooms and doctors' offices than patients in lower-spending regions did.")

Linda Gorman, from the libertarian Independence Institute and a commissioner on Colorado's Blue Ribbon Commission for Health Care Reform, was always vehemently against "best practices." She argued that the science was too soft, that it was subjective, that by God if a patient wants bad care then it's their right to get it - or something along those lines.

These are folks who also consider the science behind global warming to be a bunch of hooey. I don't know whether they also think the moon landing was a hoax.

Part of progress - and survival - comes from measuring cause and effects and paying attention to the answers. Dartmouth has come up with some pretty good answers here - information that's important whether we get a healthcare system or remain stuck with laissez-faire, for-profit healthcare. If we had a healthcare system, we could move more quickly and surely with this information towards more efficient and humane standards. Until that day, we'll muddle through and probably get partway there. Or not.

Emergency room waits

A Harvard study shows that waiting times in U.S. emergency rooms, especially in urban areas, has doubled since 1997.

For patients ultimately diagnosed with heart attacks, the wait time rose from 8 minutes in 1997 to 20 minutes in 2004. Patients who needed attention within 15 minutes, according to triage nurses who evaluated them, waited 10 minutes in 1997 but 14 minutes in 2004.

In urban hospitals, the emergency room wait was 30 minutes compared with 15 minutes in nonurban locations.

For black patients, the wait took 31 minutes, for Hispanic patients it was 33 minutes, and for white patients it was 24 minutes. Women waited 26 minutes, one minute longer than men. The longer waits for black and Hispanic patients reflect greater crowding at hospitals serving mostly minority patients, the authors said. They did not find evidence of bias in how patients were triaged.

The longer wait times were tracked during a period when hospital emergency departments were being closed even though patient visits were going up, the authors say. Emergency visits climbed 78 percent from 1995 to 2003 but the number of emergency departments fell 12.4 percent from 1995 to 2003.

Fewer emergency departments could be one explanation for the longer wait times, but Wilper also pointed to a lack of beds for seriously ill patients once they are admitted to the hospital. This Globe story explored efforts in Massachusetts to reduce “boarding,” when admitted patients stay in the emergency department, sometimes for 10 or more hours until a regular hospital bed becomes available.

Other drivers of lengthening wait times could be a shortage of specialists on call to see patients in the emergency department and a lack of access to primary care for people who go to the emergency room for non-urgent needs.

It's difficult for most of us to get a handle on this -- hospitals moving to the suburbs, a lack of primary care for and increasing number of people, fewer physicians willing to do hospital work -- and how it all ties in to our asinine system of financing health care.

Mostly it's easier to set sights on those uninsured people, coming to the hospital for non-urgent needs. That needs to be stopped, eh? They should wait until their needs are urgent.

Like Paul did.