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Geographic Variation & Healthcare Reform

On the heels of the American Hospital Association’s recent demonstration of gross discrepancies in the Dartmouth group’s data, MedPAC released its December 2009 report to Congress showing the same. Confirming data for 2000 (reported in their 2003 report), MedPAC demonstrated much less variation among states and metropolitan statistical areas (MSAs) than described by Dartmouth for states or hospital referral regions (HRRs). Closer scrutiny of MedPAC’s data reveals even more.

Adjustments. First, the Dartmouth group has claimed that they adjusted their measures of Medicare spending for age, sex, race, mortality, disease incidence and prices. However Dartmouth’s adjusted data are indistinguishable from MedPAC’s  unadjusted data, both among states (in 2000) and HRRs (in 2006), as shown to the left. This seems to confirm suspicions that Dartmouth’s “adjustments” are all shadows and mirrors, or simply malarkey. .

Adjusted variation. Second, as reported by MedPAC and consistent with the above, MedPAC found much less variation in Medicare spending among MSAs after adjusting for prices, health status and special payments than Dartmouth found among HRRs after supposedly adjusting for prices and a host of other factors. The two figures below demonstrate that. One need only look at the broadly dispersed bars in the illustration of Dartmouth variation and the more tightly packed ones in MedPAC’s.

Sociodemographic realities. But, despite finding much less geographic variation, MedPAC pointed out that there still was plenty. The greatest likelihood is that most of this residual variation is related to differences in income, which MedPAC does not account for (except as it correlates with health status). The final graphic supports that view. It distinguishes a cluster of eight southern states, which house 89 MSAs, from the other forty states (Alaska and Hawaii were excluded), which house 312. Compared to the other forty, the “southern eight” has a poverty rate that is 55% higher (89% higher for blacks); its rate of uninsurance is 31% higher (89% higher for blacks); and its mortality rate is 16% higher (30% higher for blacks). Excluding the “southern eight,” Medicare spending is within 10% of the mean in 87% of the MSAs in the other forty states. Only five MSAs out of 312 fall beyond +15%.

While no one would deny that the practice of medicine varies among practitioners for a host of reasons, both good and bad, such variation is not responsible for geographic variation, or at least not usually. Rather, geographic variation in health care spending reflects geographic variation in prices and variation in two patient-related factors: income and burden of disease. As I said before, the Dartmouth Atlas is the “Wrong Map for Health Care Reform.” Getting to the core of geographic variation can help us get health care reform right.

*This blog post was originally published at PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies*


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One Response to “Geographic Variation & Healthcare Reform”

  1. Arden Reynolds MD says:

    I truly enjoyed your presentation at The Spine Section Neurosurgical Meeting in Phoenix last Friday. You graciously offered to email a copy of your talk. I would be grateful for a copy.
    Your talk is so valuable I wondered if you talk to small regional groups? If you would consider it what are your fees?
    Again I can’t thank you enough for the information!
    Arden Reynolds MD

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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