It's Volume, Stupid

The new Dartmouth Atlas of Health features a careful mapping of differences in treatment of elderly Medicare patients with chronic disease in the last two years of life. Why do such patients in Los Angles who wind up UCLA's Cedar-Sinai Hospital cost more than twice as much as patients in Minnesota who wind up at the Mayo Clinic? As I noted in this space a few weeks ago, it's not just prices (and in some cases, it's not prices at all), it's the quantity of services consumed, which, according to the Atlas, is largely driven by the quantity of hospital beds, physicians and other "inputs" available. In health care, it would seem, supply creates its own demand.

Sadly, there was zero attention given to this insightful report in this morning's national press. The best comment I've seen so far came from Rob Cunningham on Health Affairs blog. (That journal is where much of Atlas architect Jack Wennberg's work has appeared over the years). Cunningham pulls from the report the lesson that beefing up primary care is not a magic bullet for holding down costs.

“Simply increasing the number of primary care physicians alone will not improve coordination. Spending on ambulatory visits, many of them to primary care physicians, is positively correlated with (hospital) inpatient days and inpatient physician visits,” Cunningham quotes the authors. “There are no tradeoffs.” Yet the study strongly endorsed the movement toward giving primary care physicians "medical home" responsibilities for coordinating chronic disease care. Cunningham concludes: "Perhaps the next step is to understand how primary care works in low-spending areas."

Anyone seriously interested in health care reform ought to read this year's Atlas, entitled "Tracking the Care of Patients With Severe Chronic Illness." That's what I intend to do over the next few days. That task should be made easier by the fact that Shannon Brownlee of the New America Foundation provided editorial assistance to its authors. She drew heavily from Wennberg and his colleagues' work in her new book, "Overtreated," available from fine bookstores everywhere.

(A personal note: I will be largely offline for the next week due to a death in the family.)