Promoting Excellence : Forum Summary : The Mismatch Between Quality and Cost

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John Wennberg, M.D., director of the Center for the Evaluative Clinical Sciences at Dartmouth Medical School and a nationally recognized expert in health care usage and spending patterns, presented evidence to illustrate that when it comes to Medicare spending for end-of-life care, more is not necessarily better. The data he used, based on nationwide Medicare data from the early to mid-1990s, revealed great variations in and systematic overuse of hospitalization, stays in intensive care units (ICUs) and physician visits—particularly at the end of life—and with no measurable evidence on patient outcomes. Instead, he said, it appears the more that services are available, the more they are used.

For example, between 1995 and 1996 in Miami, Florida, and in the borough of Manhattan in New York City, more than 30 percent of patients saw 10 or more physicians in their last six months of life. For equivalent groups of Medicare patients in their last six months of life in Missoula, Montana, Iowa City, Iowa, and Portland, Oregon, the rate was barely 7 percent. In the same period, the average number of visits to medical specialists for Medicare enrollees during their last six months also varied tremendously—from 25 visits per patient in Miami to fewer than four in Portland. Furthermore, the percentage of Medicare enrollees who were admitted to an ICU during their last six months of life ranged from nearly 50 percent in Miami, to less than 23 percent in Minneapolis, Missoula and Portland. Yet, according to Wennberg, the number of ICU visits had no impact on life expectancy.

In terms of Medicare costs in 1996, spending per enrollee ranged from $8,414 in Miami to $3,431 in Minneapolis. “On an age/sex/race and illness-adjusted basis,” Wennberg said, “total Medicare-program spending would be reduced by 33 percent if the benchmarks for the efficient areas [such as Missoula and Minneapolis] were the national norm.”

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Promoting Excellence in End of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit for more resources.

Promoting Excellence