Research Suggests More Health Care May Not Be Better
July 21, 2002
By GINA KOLATA
A growing body of research is leading many medical experts
to ask whether more is really better when it comes to
health care.
Some medical specialties and geographical areas are
suffering from a glut of doctors and hospitals, these
experts say. Supply seems to drive demand. More hospitals
in an area mean many more days spent in hospitals with no
discernible improvements in health. More medical
specialists mean many more specialist visits and
procedures.
"If there are twice as many physicians, patients will come
in for twice as many visits," said Dr. John E. Wennberg of
Dartmouth Medical School, where much of the new work is
being done.
The Dartmouth researchers acknowledge that their findings
are unexpected, and some experts say more work is needed to
sort out cause from effect.
"These relationships are very difficult to disentangle,"
said Dr. Rodney Hayward, professor of health policy and
management at the University of Michigan. Patients in some
regions may be demanding more care, either because they are
sicker or because they have come to expect it, Dr. Hayward
said; doctors cluster in areas where there is more demand.
Still, Dr. Wennberg and his colleagues say the disparities
are too stark to be explained entirely by such factors. In
a paper published in February in the journal Health
Affairs, they wrote that Medicare's typical lifetime
spending for a 65-year-old in Miami is more than $50,000
higher than for a 65-year-old in Minneapolis. In a further
analysis, they found that in Miami, where medical services
are particularly abundant, the federal Medicare program
pays more than twice as much per person per year as it does
in Minneapolis: $7,847 in Miami, $3,663 in Minneapolis.
Nor can the gap be explained by regional differences in
medical costs, said Dr. Elliott S. Fisher, an author of the
paper who is co-director of the Outcomes Group at the
Veterans Affairs Medical Center in White River Junction,
Vt., and a professor of medicine at Dartmouth. Older
Miamians simply went to doctors and hospitals more often.
In their last six months of life, they had more than six
times as many visits to medical specialists as those in
Minneapolis, spent twice as much time in the hospital and
were admitted to intensive care units more than twice as
often.
Life expectancy is no greater in regions that have more
intensive medical care, the researchers find, and Medicare
surveys find that their quality of care is no better.
"What increased spending buys you is generally unpleasant
interventions like intensive care units and feeding tubes,"
Dr. Wennberg said.
Another recent study, on the distribution of newborn
intensive-care specialists and the death rate among
infants, reached a similar conclusion. A tripling of the
numbers of these specialists did not result in any
improvement in infant mortality.
The Dartmouth findings are controversial, coming when much
of the national conversation is about Americans who are
receiving too little care - not too much - either because
they lack insurance or because they cannot afford
prescription drugs. Still, the research is attracting
attention from mainstream medical groups, even those who
say it is too preliminary to draw any firm conclusions.
"They are excellent scientists," said Dr. Yank D. Coble,
president of the American Medical Association. But he added
that many factors other than supply might be driving demand
for medical services, including the cultural preferences in
an area and the underlying health of its population.
Carmela Coyle, the senior vice president for policy at the
American Hospital Association, acknowledged that more
doctors and more hospitals led to more care, but she asked:
"The question is, what level of care is the right level of
care? We should ask the questions, have the conversation,
but not jump to the conclusion that more is better or less
is better."
But other doctors not connected with the Dartmouth research
say that the body of evidence pointing to overuse is
compelling.
"If you want to predict the amount of use, all you have to
know is the supply," said Dr. Donald M. Berwick, president
of the Institute for Healthcare Improvement, a nonprofit
group in Boston. He says he regards the Dartmouth research
as the most important in this area in the past
quarter-century.
"When all is said and done," Dr. Berwick said, "the people
who have been most serious about it rarely think we are
underresourced. The evidence to my mind is so strong. More
is not better, and it often is very, very much worse."
Dr. Wennberg is the director of Dartmouth's Center for
Evaluative Clinical Sciences. A 68-year-old professor who
specializes in family and community medicine and in public
health, he has spent his career studying variations in
medical care across the country.
But nothing, Dr. Wennberg says, is so counterintuitive as
the peculiarities that keep cropping up in the use of
medical services. Whether it is the frequency of visits to
a doctor or how often people have diagnostic tests or how
much time people with chronic diseases spend in intensive
care units or how often they are hospitalized, the data are
consistent, he says: the greater the supply, the greater
the use.
If medical care were just another commodity, the opposite
would happen, he notes. "In areas where there are too many
doctors it would be like areas where there are too many
McDonald's," Dr. Wennberg said. Offices would be
half-empty, doctors would see fewer patients.
Instead, without even realizing it, doctors in such areas
simply see their patients twice as often, monitoring their
conditions ever more closely, Dr. Wennberg said. Yet he and
others say there is no evidence that patients in these
regions are healthier. His colleague Dr. Fisher noted that
four large studies of Medicare patients, by the Dartmouth
group and three others, found no improvement in mortality
in areas that spend more.
Dr. John Skinner, an economist who is part of the Dartmouth
research team, says the researchers focused on medical care
at the end of life to control for any regional differences
in the underlying health of the population - the
possibility that people in Miami might need more medical
services because they are sicker than those in Minneapolis.
"People in their last six months of life tend to be pretty
sick no matter where they live," Dr. Skinner said. "This is
what I use to effectively split the country into different
quintiles of intensity and test whether the
higher-intensity regions enjoy better life expectancy,
since they certainly spend more over all on health care."
"Why do some regions spend more?" Dr. Skinner asked. "I
don't think there's very good scientific evidence on when
to stop. In some areas they just keep working until the
very last minute."
The Dartmouth group recently asked the same questions about
medical care at the start of life, in its study on the
relationship between supplies of newborn intensive care
specialists and the death rate among infants in the United
States.
The reason for focusing on high-risk newborns, Dr. Fisher
said, is that an infant's birth weight is an excellent
indicator of the baby's risk of death. That allowed the
researchers to compare outcomes for similar babies in
regions with more, or fewer, newborn intensive care beds.
The result, they reported in May in The New England Journal
of Medicine, was that the specialists were not distributed
according to need. Regions with more low-birth-weight
babies actually had fewer specialists.
But even though babies in areas with more neonatologists
and more neonatal intensive care beds were more likely to
spend time in the care of those specialists and to be
admitted to those hospital units, their mortality rates
were no better than those in any but the lowest 20 percent
in terms of supply.
From the second to the fifth quintile, there was a fourfold
increase in the numbers of newborn intensive care beds and
newborn intensive care specialists, Dr. Fisher said. The
more beds available, he said, the more likely it was that
babies of low to moderate risk spent time in one of these
hospital units, he said.
"But we didn't see any benefit," he added.
Commenting in
an editorial that accompanied the researchers' article in
the journal, Dr. Kevin Grumbach of the University of
California at San Francisco wrote: "The saga of neonatology
is emblematic of how a market-driven health care system
with inadequate public planning produces too much of a good
thing."
The question of how much medical care is enough "is a major
issue that we need to start addressing head on," Dr.
Grumbach said in a recent interview.
The accumulating data, he said, "makes you question what
we're getting for this phenomenal investment in health
care."
Complements of The New York Times 2002/07/21