U.S. is some- where in this zone Frequency of Care Life Expectancy Shape of the Benefit-Utilization Curve: Supply-Sensitive Services

i.e. The problem of unwarranted variation in treatment of chronic illness is a problem in overuse and waste, not underuse and health care rationing

What Does Greater Medicare Spending Buy? Medicare Per capita spending (306 regions: ) More than 15% Above Average 0-15% Above Average 0-15% Below Average More than 15% Below Average

What does Greater Per Capita Spending BUY? not more effective or preference-sensitive care Medicare Reimbursements Effective Care Preference-Sensitive Care (Discretionary Surgery) Ratio to Lowest Spending Region More than 15% Below Average 0-15% Below Average 0-15% Above Average More than 15% Above Average

What does Greater Per Capita Spending BUY? More Supply-Sensitive Care!! More than 15% Below Average 0-15% Below Average 0-15% Above Average More than 15% Above Average Days in Hospital Medical Specialist Visits % Seeing 10 or More Doctors End of life care Ratio to Lowest Spending regions

Reducing Overuse: supply sensitive care Major focus: At patient level, active chronic disease managementMajor focus: At patient level, active chronic disease management

Reducing Overuse: supply sensitive care Major focus: At patient level, active chronic disease managementMajor focus: At patient level, active chronic disease management Major focus: At system level, control of capacity relative to size of population servedMajor focus: At system level, control of capacity relative to size of population served

Reducing Overuse: supply sensitive care Major focus: At patient level, active chronic disease managementMajor focus: At patient level, active chronic disease management Major focus: At system level, control of capacity relative to size of population servedMajor focus: At system level, control of capacity relative to size of population served Major Impediment: adverse economic impact on providersMajor Impediment: adverse economic impact on providers

Days in Hospitals During Last Six Months of Life Among Patients with severe chronic illness who received most of their care in one of 77 “best” U.S. hospitals

Supply-Sensitive Care Days in Hospitals During Last Six Months of Life Among Patients assigned to Selected Academic Medical Centers NYU Medical Center27.1 Mount Sinai Hospital22.8 NY Presbyterian Hospital21.6 Cedars-Sinai Medical Center21.3 Mass. General Hospital16.5 UCLA Medical Center16.1 Boston Medical Center15.6 Brigham & Women's Hospital13.9 Beth Israel Deaconess12.2 UCSF Medical Center11.5 Stanford University Hospital10.1

Association Between Hospital Days for Cancer and for CHF patients during last six months of life: 77 Selected Academic Medical Centers

L6M hospital day rate: Non-Black L6M hospital day rate: Black R 2 = 0.75 Association between hospital days for black and non-black patients during last six months of life among 50 “best” hospitals

Supply-Sensitive Care Physician Visits During the Last Six Months of Life Among Patients assigned to Selected Academic Medical Centers NYU Medical Center76.2 UCLA Medical Center43.9 NY Presbyterian Hospital40.3 Mass. General Hospital38.8 Cedars-Sinai Medical Center66.2 Mount Sinai Hospital53.9 Brigham & Women's Hospital31.9 Boston Medical Center31.5 Beth Israel Deaconess29.2 UCSF Medical Center27.2 Stanford University Hospital22.6

R2R2 = Hospital Day Rate Physician Visit Rate Association Between Hospital Days and Physician Visits During the Last Six Months of Life among patients receiving most of their care in one of 77 “best” U.S. hospitals

Percent seeing 10 or more physicians during last six months of life among patients receiving most of their care in one of 77 “best” U.S. hospitals

Association Between Medicare inpatient + Part B Payments Months and 0-6 Months Before Death: 77 hospital cohorts ( ). R2R2 = ,000 10,000 15,000 20,000 25,000 30,000 35,00040,0001,5003,5005,5007,500 Payments Mos. Before Death Payments Mos. Before Death Payment in Last 6 Months Payment in Last 6 Months

NYU Medical Center24.6 Cedars-Sinai Medical Center20.7 Mount Sinai Hospital16.4 UCLA Medical Center14.6 New York Presbyterian13.8 UCSF Medical Center 9.2 Stanford University Hospital 8.7 Primary care + medical specialist S-FTE inputs per 1,000 Medicare decedents: last six months of life among selected hospitals

NYU Medical Center1.70 Cedars-Sinai Medical Center2.19 Mount Sinai Hospital1.10 UCLA Medical Center2.86 New York Presbyterian1.05 UCSF Medical Center0.67 Stanford University Hospital1.31 Ratio: medical specialist/primary care Ratio: medical specialist/primary care

Medicare reimbursements per decedent during the last six months of life among California hospitals (weighted average in parentheses) ( ) 5,000 15,000 25,000 35,000 45,000 55,00065,000 All other ($18,165) Sutter ($17,035) CHW ($16,824) Tenet ($29,003) Adven- tist ($18,422) St. Joseph ($14,691) Kaiser ($13,445) Univ. of CA ($27,218) Daughters of Charity ($23,727) HCA ($18,942) Scripps ($16,795)

Hospital days per decedent during the last six months of life among California hospitals (weighted average in parentheses) ( ) All other (13.6) Sutter (11.4) CHW (12.6) Tenet (16.9) Adven- tist (13.3) St. Joseph (12.0) Kaiser (10.1) Univ. of CA (14.2) Daughters of Charity (15.9) HCA (15.0) Scripps (13.1)

Association Between Total Medicare Payments Months and 0-6 Months Before Death: 77 hospital cohorts ( ). R2R2 = ,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 1,5003,5005,5007,500 Total Payments Mos. Before Death Total Payment in Last 6 Months

What Preferred Providers should be asked to do: Eliminate Underservice of Effective CareEliminate Underservice of Effective Care Reduce Medical MistakesReduce Medical Mistakes Learn What Works (Outcomes Research)Learn What Works (Outcomes Research) Assure Informed Patient Choice (Shared Decision Making)Assure Informed Patient Choice (Shared Decision Making) Achieve Efficient and Effective Management of Supply-Sensitive Care (Target: Chronic Disease)Achieve Efficient and Effective Management of Supply-Sensitive Care (Target: Chronic Disease) Achieve Efficient Allocation of Resources geared to Size of the Population ServedAchieve Efficient Allocation of Resources geared to Size of the Population Served

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