When a patient arrives at one of the two Mayo Clinic hospitals in Rochester, Minn., a team of doctors and nurses immedidately begins an evaluation. Decisions are made as to whether the patient needs tests, what specialists they may need to see, and whether the patient needs to be in the hospital at all.
"I think the way that we are structured ... it's a patient-centered structure, and it's focused on providing quick, efficient care to the patients," said Michael Osborn, chairman of the quality oversight committee and medical director of quality at the Mayo Clinic.
Hospitals around the country may soon be pressured to imitate Mayo's standard of patient care, based on a group of studies released last week. The studies, prepared by Dartmouth Medical School and published in the online edition of the journal Health Affairs, took issue with the notion that quality healthcare results from more dollars spent and more care given. The Mayo Clinic, the data suggested, has shown success at providing high-quality care while keeping quantity in check. Other hospitals that were ranked among the nation's best by U.S. News & World Report in 2001 did not fare as well.
As the CMS marches forward with pay-for-performance initiatives, and politicians, patient advocates and providers call for improved quality of care, the studies put hospitals on alert about the efficiency of care delivery in their own facilities and may raise the volume of the debate over linking reimbursements to quality and efficiency standards.
Built on earlier studies looking at variations among hospitals in different regions, last week's studies went a step further, examining Medicare data for some of the so-called top hospitals in the country. The results showed wide variations among those hospitals in the amount of care given as measured by physician visits and days spent in the hospital, and showed that patients treated at hospitals that provided large amounts of care fared no better than those who went to those that provided less.
"It is clear that quality is inversely correlated with the intensity of care and that the better hospitals are using fewer resources and providing fewer hospitalizations and physician visits," said John Wennberg, lead researcher and director of the Center for Evaluative Clinical Sciences at Dartmouth Medical School.
The ramifications of the results could be significant for hospitals, payers and patients. In addition to recommending that providers be paid bonuses for giving more efficient and higher quality care, the studies, totaling 20 articles and analyses, for the first time showed that Medicare data can be used as a measure of quality and to identify better-performing hospitals, the studies' authors said.
"Now it is possible to show these data to hospital managers and ask, `Why are your costs so high and your outcomes so average?' " said James Knickman, vice president of the Robert Wood Johnson Foundation, which sponsored the studies.
Leonard Schaeffer, chairman and chief executive officer of insurer WellPoint Health Networks, said the studies prompt questions about whether health plans should pay hospitals with high use of services more when their outcomes are no better than those of hospitals with less use.
The hospital community responded that while important, the studies still don't connect the dots to answer questions about the association between variability of care and quality provided. "Variability is a fact," said Diane Meier, director of the Center to Advance Palliative Care at 905-bed Mount Sinai Medical Center in New York. "What its relationship to quality is is a much tougher question."
The main article examined the care received by 90,616 Medicare patients in the last six months of their lives. The patients had solid cancer tumors, congestive heart failure and chronic obstructive pulmonary disease and were treated at 77 of the top hospitals, according to 2001 rankings by U.S. News & World Report. Another looked at the top seven teaching hospitals and the quality of care given to Medicare patients who were hospitalized for acute myocardial infarction, colorectal cancer or hip fracture.
Stays were twice as long at Mount Sinai
Among the variations found: Patients at Mount Sinai had hospital stays almost twice as long as similar patients at the Mayo Clinic's hospitals; and patients at the University of California Los Angeles Medical Center spent three times as many days in the intensive-care unit as their counterparts at Massachusetts General Hospital, Boston. Facilities that ordered more tests, provided more doctor visits or hospitalized patients for longer periods did not provide higher-quality care, and in some cases, high-intensity care for patients with certain terminal conditions may have hastened death.
Variations in the amount of care given by facilities are well-documented. Many attribute those variations to the way in which doctors are trained, which is influenced by the regions in which they are trained, Meier said. Differences in opinion about how much care is appropriate also exist simply because there is debate over what constitutes best practices. Variability in the amount of care is also affected by factors that may be out of a doctor's control, such as the availability of nursing homes and hospice care in a community, as well as patient preferences, said Nancy Foster, senior associate director of policy at the American Hospital Association.
But in an effort to improve patient care and the efficiency of care delivery, both the public and private sector are increasingly linking payments to quality outcomes. The CMS, in particular, has several pay-for-performance initiatives in the works, including new regulations that pay hospitals that report data on 10 quality measures higher reimbursement rates than those that do not report the data.
Several health plans also have their own pay-for-performance initiatives, including efforts to steer patients to doctors who they believe deliver better care. Some insurers are also making consumers pay more in copayments and deductibles to go to a costlier hospital.
The long-term effects of such nascent programs are unclear, however, especially as providers have been reluctant to participate in them. The resistance is rooted in the fact that defining quality in healthcare remains elusive. CMS Administrator Mark McClellan acknowledged as much when he said that despite the CMS' aggressive implementation of pay-for-performance initiatives, they "are not the end-all and be-all of healthcare."
Reacting to last week's studies, Mount Sinai's Meier said differences in the amount of care given to patients will continue until more research is done to determine what levels of care are the most appropriate. In the meantime, defining quality is a subjective exercise. "We don't have studies that say, for instance, that `this many specialists but not one more' is the right level," she said.
At the Mayo Clinic, administrators and providers have the advantage of drawing on a long history of research done at the clinic examining best practices in medicine, but Osborn said trying to define what constitutes best care is much more difficult than it sounds. Trying to boost efficiency further complicates matters.
"For providers, we come from it as the most effective care and hopefully it will be the most efficient. From the payers' perspective, (the focus) is on the most efficient care and hopefully it will be effective," Osborn said.
While respectful of the work done by the authors of last week's studies, doctors and hospital administrators said the results may not paint an accurate picture of the quality of care delivered at specific hospitals, partly because they relied on Medicare claims data.
"Here's the conundrum," said Greg Meyer, medical director of the physicians' group at 875-bed Massachusetts General Hospital. "To really answer (what is the best and most efficient care), we need more robust data that includes clinical data," which he said is limited with Medicare claims data.
Meanwhile, hospital administrators said they did not expect widespread change. Mount Sinai's Meier, who has been critical of studies like those released last week, nevertheless said she plans to speak with doctors at the hospital about their practice patterns. But if the point of the Dartmouth studies is to get hospital CEOs to curb their physicians' behavior, "Good luck," she said. "That is highly unlikely."
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