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The Care of Patients with Severe Chronic Illness: an Online Report on the Medicare Program by the Dartmouth Atlas Project

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The Care of Patients with Severe Chronic Illness: an Online Report on the Medicare Program by the Dartmouth Atlas Project Center for the Evaluative Clinical Sciences Back The Care of Patients with Severe Chronic Illness: An Online Report on the Medicare Program by the Dartmouth Atlas Project The Dartmouth Atlas of Health Care 2006 The Center for the Evaluative Clinical Sciences Dartmouth Medical School Center for the Evaluative Clinical Sciences Back Library of Congress Cataloging-in-Publication Data Dartmouth Medical School Center for the Evaluative Clinical Sciences. The Care of Patients with Severe Chronic Illness/The Center for the Evaluative Clinical Scienes, Dartmouth Medical School. ISBN 0-9785301-0-1 Medical care – United States – Marketing – Maps. 2. Health facilities – United States – Statistics. I. Title. Copyright 2006 The Trustees of Dartmouth College All rights reserved. The reproduction or use of this report in any form or in any information storage or retrieval system is forbidden without the express written permission of the publisher. DARTMOUTH ATLAS OF HEALTH CARE II Center for the Evaluative Clinical Sciences Back Principal Investigator: John E. Wennberg, M.D., M.P.H. Co-Principal Investigator: Elliott S. Fisher, M.D., M.P.H. Lead Analyst: Sandra M. Sharp, S.M. Editors: Megan McAndrew, M.B.A., M.S., and Kristen K. Bronner, M.A. and other members of the Dartmouth Atlas of Health Care Working Group Thomas A. Bubolz, Ph.D. Vincent J. Fusca III, M.M.S. David C. Goodman, M.D., M.S. Daniel J. Gottlieb, M.S. Jia Lan, M.S. Zhao Peng, M.S. Stephanie R. Raymond, B.A. Jonathan S. Skinner, Ph.D. Dean T. Stanley Dongmei Wang, M.S. Phyllis Wright-Slaughter, M.H.A. Atlas design by Jonathan Sa’adah and Elizabeth Adams Intermedia Communications DARTMOUTH ATLAS OF HEALTH CARE III Center for the Evaluative Clinical Sciences The Center for the Evaluative Clinical Sciences Dartmouth Medical School Lebanon, New Hampshire 03766 (603) 653-0826 http://www.dartmouthatlas.org DARTMOUTH ATLAS OF HEALTH CARE IV Center for the Evaluative Clinical Sciences Back This report is dedicated to James R. Knickman, Ph.D. in grateful recognition of his steadfast support and championship of the Dartmouth Atlas Project DARTMOUTH ATLAS OF HEALTH CARE V Center for the Evaluative Clinical Sciences Back The research on which the Dartmouth Atlas Project is based was made possible by grants from The Robert Wood Johnson Foundation in association with a funding consortium including The Wellpoint Foundation The Aetna Foundation The United Health Foundation The California Healthcare Foundation DARTMOUTH ATLAS OF HEALTH CARE VI Center for the Evaluative Clinical Sciences Back Table of Contents Preface ...................................................................................................................................................................x Chapter 1: Chronic Illness and the Problem of Supply-Sensitive Care ...........................................................1 Is More Better? ..................................................................................................................................................................3 Implications for Evaluating Efficiency in Managing Chronic Illness ............................................................................5 Why We Are Interested in Measuring Care at the End of Life .......................................................................................6 Chapter 2: Variations Among States in the Management of Severe Chronic Illness .....................................8 Introduction .....................................................................................................................................................................8 Part One: Care During the Last Six Months of Life ............................................................................................................9 Days Spent in Hospital per Decedent During the Last Six Months of Life ...................................................................9 Days Spent in Intensive Care Units per Decedent During the Last Six Months of Life .............................................10 Physician Visits per Decedent During the Last Six Months of Life .............................................................................11 Percent of Decedents Seeing Ten or More Physicians During the Last Six Months of Life ........................................12 Part Two: Medicare Spending and Resource Inputs During the Last Two Years of Life ................................................15 Inpatient and Part B Spending per Decedent During the Last Two Years of Life .......................................................15 Standardized FTE Physician Labor Inputs per 1,000 Decedents During the Last Two Years of Life .........................16 Comparing Labor Inputs of Primary Care Physicians and Medical Specialists..........................................................17 Associations Between Physician Labor Inputs and Hospital Use ................................................................................18 Comparing Labor Inputs of Primary Care and Medical Specialists ............................................................................19 The Primary Care - Medical Specialist Mix and Variation in Cost, Use and Quality of Care ....................................20 DARTMOUTH ATLAS OF HEALTH CARE VII Center for the Evaluative Clinical Sciences Back Chapter 3: Treatment of the Chronically Ill at Academic Medical Centers ....................................................21 Introduction ...................................................................................................................................................................21 Part One: Variations in Utilization Among COTH Integrated Academic Medical Centers ..........................................22 Average Number of Days in Hospitals ..........................................................................................................................23 Average Number of Days in Intensive Care Units ........................................................................................................24 Average Number of Physician Visits ..............................................................................................................................25 Academic Medical Centers and the Capacity Effect .....................................................................................................26 Hospital Days per Decedent with Cancer and with Congestive Heart Failure ...........................................................27 Physician Visits per Decedent with Cancer and with Congestive Heart Failure .........................................................28 Hospital Days per Decedent for Black and Non-Black Patients ..................................................................................29 The Capacity Effect During Earlier Periods of Illness ..................................................................................................30 Part Two: Variations in Medicare Spending and Resource Inputs and Benchmarking Relative Efficiency .................32 Variations in Medicare Spending and Resource Inputs ...............................................................................................32 Inpatient and Part B Medicare Spending ......................................................................................................................33 Physician Labor ..............................................................................................................................................................34 Use of Intensive Care Unit Beds ....................................................................................................................................35 Comparing UCLA to the UCSF Benchmark ................................................................................................................36 The Medical Care Cost Equation...................................................................................................................................38 Part Three: Benchmarking Physician Labor Inputs.........................................................................................................40 Allocation of Medical Specialists ...................................................................................................................................41 Allocation of Primary Care Physicians ........................................................................................................................42 Ratio of Primary Care to Medical Specialist Labor ......................................................................................................43 Benchmarking Workforce Need ...................................................................................................................................44 DARTMOUTH ATLAS OF HEALTH CARE VIII Center for the Evaluative Clinical Sciences Back Chapter 4: How to Use the Dartmouth Atlas to Compare Performance in Managing Chronic Illnesses ...46 Part One: Graphic Representation of Variation: the Distribution Graph ......................................................................47 Part Two: Hospital-Specific Performance Reports ...........................................................................................................49 Part Three: The Medical Care Cost Equation ...................................................................................................................55 Part Four: Hospital-Specific Reports
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