What if Where You Live Determines Your Health Care?

Sorry....it's a trick question. Your care is already determined by where you live and by which hospital you choose for your care. Anyone who wants to discuss health care policy intelligently should be familiar with the Dartmouth Atlas. The Atlas started more than 10 years ago, and became famous for discovering that geography determined rates of procedures such as heart bypass surgery and mastectomy for cancer.

Their most recent report (PDF) looks at Medicare spending and care provided to patients with severe chronic illnesses in the final two years of life. This is particularly important, given the debates about rationing and "death panels." New Jersey, California and New York spend more than 20% more than the national average. On the other hand, North Dakota, Iowa and South Dakota spend more than 25% less than the national average.

Further analysis shows it is the volume of services, not the cost per service that kicks the price up. So, it's not explained away because New York and California are expensive places to do business. UCLA Medical Center spent an average of $93.8K, had 18.5 days of hospitalization, and 38% of deaths associated with intensive care. Massachusetts General spent $78.7K on 17.3 days and 22.5% associated deaths and the Mayo Clinic $53.4K with 12 hospital days and 23% associated deaths. If you don't want to spend your final days as a senior connected to machines, don't go to California. Are people running away from the Mayo Clinic? Not that I've heard.

The single most important factor determining whether a community or a given care system and its associated physicians overtreats the chronically ill is the size of its acute care sector relative to the number of chronically ill patients who need treatment. In high-cost regions and health systems, providers have overbuilt their acute care sectors [hospital beds].

Remember, we are looking at the Medicare population where patients have the same reimbursement rules wherever they live. Comparing high spending regions to lower spending regions, the high-spenders have:

• 32% more hospital beds
• 31% more physicians
• Lower quality measures
• Little difference in major elective surgery
• Slightly higher death rate after heart attack, hip fracture and colorectal cancer diagnosis
• More likely to report poor communication among physicians
• Worse access to care and greater waiting times

The Dartmouth Atlas is important because it uses existing Medicare data to demonstrate where the opportunities are for savings in the system. Clearly, spending more does not mean better care.