Monday, October 4, 2010

How Statistics Lie

The New England Journal of Medicine in an article written by Thomas Bodenheimer M.D., Ph.D., And David West M.D analyze  Medicare statistics from the beloved Dartmouth Study. The Dartmouth Atlas of Health Care study reveals a wide disparity in the number of coronary bypass procedures in Golden Colorado compared to other areas.

The report reveals a 60% reduction in the number of procedures as compared to Miami, Florida.  The Dartmouth Atlas Study has been used to justify changes in payment systems by Medicare. The study has previously criticized for a number of flaws.

One factor which may  explain the disparity regarding numbers of cardiac cases is Golden Colorado’s proximity to a major heart center in Denver, Colorado.  A quick google map search will reveal that is is a short 15  minute ride to the outskirts of Denver, and a 25 minute ride to downtown Denver and the University of Colorado.

This is a very important factor in the numbers differences.

“Centers of Excellence”  became a buzzword about ten years ago for cardiac, orthopedic, and other specialties.

The typical scenario for a patient with cardiac problems would be to travel and  seek out the best experts in a region for a cardiac problem.

Would you seek out a surgeon or cardiologist in Golden if you could drive down the road for fifteen or twenty minutes to have a cardiac surgery at a university center? 

The article attempts to justify the differences in cost as a result of managed care organizations with primary care as the ‘gatekeepers’. They attribute risk management coupled with witholds of physician payments, rewarding groups that manage costs well with a financial reward and a form of rebates.

In my opinion there were some very good observations that might be transferrrable to other communities, regardless of reimbursement algorithms.

1.Rocky and Grand Junction’s family physicians made another unusual decision: to pay physicians Medicaid fees equal to those for other patients. As a result, Medicaid patients gained access to private primary and specialty care — and became less likely to utilize expensive care in emergency departments. This policy is probably responsible for the low per-enrollee cost for Medicaid acute care

2.The most important event in Grand Junction’s health care history was the assumption of leadership by family physicians.4 In the early 1970s, a group of primary care physicians and specialists founded the physician-run Rocky Mountain Health Plans (“Rocky”) and the Mesa County Physicians Independent Practice Association (MCPIPA). Family physicians gained substantial control of these organizations and fostered a culture of incentives for cost control and cost transparency. In 2006, Grand Junction had 85% more family doctors per capita than the national average.

3.Many medical communities have two or more hospitals with cardiac-surgery units and other expensive services. To compete for cardiologists and cardiac surgeons, such hospitals create more cardiac-catheterization facilities and perform more coronary angiography and revascularization procedures. In Grand Junction and its surrounding hospital referral region, there is only one tertiary care hospital, St. Mary’s, providing interventional cardiac care, neurosurgery, and other subspecialized services. St. Mary’s is fed by smaller secondary care hospitals that do not offer expensive interventional services. Moreover, thanks in part to the control of the primary care community over Rocky, St. Mary’s has kept its number of beds and amount of expensive equipment at reasonable levels. Because only one hospital can offer interventional cardiac procedures, there isn’t room for many cardiologists in Grand Junction; with such limits on facilities and workforce, the rates of such procedures remain low.

4.Finally, with the encouragement of family physicians, low-cost end-of-life care became a prominent part of the region’s health care system. Thanks to the area’s single nonprofit hospice, which also offers palliative care, physicians are educated about initiating discussions with elderly patients about advance directives, and the public is informed about end-of-life choices. As a result, Grand Junction’s population spends 40% fewer days in the hospital during the last 6 months of life and 74% more days in hospice than the national averages, and 50% fewer deaths than average occur in the hospital.

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