The common retort when confronted with the escalating cost of care and unexplained variation is: "But, my patients are sicker!

Southerland, Fisher and Skinner in "Getting Past Denial — The High Cost of Health Care in the United States," are again observing their mentor, Jack Wennberg's dictum, written about extensively at the end of the last century and earlier, that the cost differences between regions and practices may be unwarranted.

The authors say that "substantial savings can be achieved without rationing beneficial care" as they observe that "patient outcomes are no worse in low-utilization regions,⁴ nor do elderly people who live there feel as if they’re being denied necessary care.⁵"  Indeed, "The key to attaining these cost-saving goals comes from getting the same (or better) outcome at a lower cost." They provide two classic, win-win, managed care industry examples of cost-efficient and otherwise better outcomes:

• The outpatient, rather than the revolving door of inpatient management of congestive heart failure (CHF).
• The conservative management of lower back pain (without neuropathy), especially by not jumping the gun on MRIs that can have a 50% or more false positive rate.

But they complain—"These are all good ideas, but they suffer from a common shortcoming: they require more time on the part of the primary care physician, the nurse, or the specialist — time that is not currently reimbursed [emphasis, jgk]. Eliminating unnecessary care therefore requires reorganizing the delivery system to ensure that providers aren’t penalized for providing what is often the better alternative for their patients."

And that's the rub.... There is "so much discretionary care.... provided in the United States that we could easily afford to expand coverage without increasing taxes — or rationing care — as long as we couple coverage expansion with a commitment to rapidly test and broadly implement successful reforms in payment and delivery systems. After all, many U.S. regions have already shown that they can slow the growth of spending while providing high-quality care."

Source:

Sutherland JM, Fisher ES, Skinner JS.* "Getting Past Denial — The High Cost of Health Care in the United States" Eng J Med. September 9^th, 2009, posted at NEJM.org.: 10.1056/NEJMp0907172)  [Available as a PDF]

* Dartmouth Institute for Health Policy and Clinical Practice (J.M.S., J.S.S.) and Dartmouth Medical School (E.S.F.) — both in Lebanon, NH; and Dartmouth College (J.S.S.), Hanover, NH.

See also,

• "One Cannot Measure What One Does Not Manage": Managed Care 101 in 2010 (Part XIII)
• "Inaugurating Health Care Reform: Cause and Effect Techniques" in Managed Care in 2010 (Part I-e)