It has become pretty much an article of faith among health policy experts that higher spending on health care doesn't always buy better outcomes.
Studies by the Dartmouth Atlas have shown that show that high-spending areas of the country often have poorer outcomes than lower spending areas, even after taking into account differences in the populations being treated. Analyses of health care in other countries suggest the same: the U.S. spends far more than other westernized countries, yet by most measures, the health of our population isn’t any better and in some cases, worse.
An ACP position paper published in the January 1, 2008 Annals of Internal Medicine put it this way:
"Health care quality and access vary widely both geographically among populations, some services are overutilized, and costs are far in excess of those in other countries. Moreover, the United States ranks lower than other industrialized countries on many of the most important measures of health. Current international comparisons of measures of health (life expectancy at birth, infant mortality, and deaths per 100 000 for diseases of the respiratory system and for diabetes) indicate that population health in the United States is not better than in other industrialized countries despite the greater U.S. expenditures."
(Full disclosure: I was a co-author of this paper, developed on behalf of ACP's Health and Public Policy Committee.)
Related, many see great promise in evidence-based medicine as being the best way to level out the variations, the idea being that if physicians and patients based treatment decisions on the best available evidence, there would be fewer differences in utilization and outcomes from area to area, and overall costs associated with over-treatment might be reduced.
The problem is that the public isn’t buying it. A new study in Health Affairs finds that much of the public holds values and beliefs that are at odds with evidence-based approach principles. Much of the public believe that all care meets minimum quality standards; that medical guidelines are inflexible; that more care, newer care, and more costly care is better. The authors write:
"For health care experts, variation - in quality among health care providers, the evidence base regarding therapies, and the effectiveness and cost-effectiveness of treatment options - is a well-established fact of the health care delivery system, documented extensively in the published literature and well understood after years of careful study. Yet such concepts are unfamiliar to many Americans and may even seem threatening, to the extent that they raise unwelcome questions about the quality of medical care that people receive."
Related, the New York Times reports today against a growing backlash against Dartmouth's study on regional variations. The reporter, after citing the arguments made by Dartmouth's critics, goes as far as to conclude that "... there is little evidence to support the widely held view, shaped by the Dartmouth researchers, that the nation's best hospitals tend to be among the least expensive."
The Dartmouth Atlas responded by saying that there were at least five factual errors, and several misrepresentations in the Times article, and that "What is truly unfortunate is that the Times missed an opportunity to help educate the American public about what our research actually shows - or about the breadth of agreement about what our findings mean for health care reform."
This brings the discussion full circle back to the public's views. I am among those of the view that the data are strong enough to suggest that higher spending doesn't always mean better quality, notwithstanding the controversy over Dartmouth's research. If we are going to as a country "bend the cost curve" - and we must - then decisions will need to be made on what treatments people will get. I would rather such decisions be made by my physicians and me - informed by the best available evidence on effectiveness, including both outcomes and cost.
But in a democratic country, such decisions can't be made without public understanding and support. As long as the public believes that more care, newer care, and more costly care is better care, then it is going to be almost impossible to get a handle on costs.
Today's question: What is your reaction to the backlash against evidence-based medicine and the studies of regional variation?