The publishers of the Dartmouth Atlas have seized upon an important insight: The cost of health care varies widely from region to region across the country, and higher costs are not always associated with superior outcomes. In its most recent report, the Dartmouth Institute plumbs one of the more vexing problems facing health care policymakers: the outlandish cost of caring for patients during the last few months of their lives.
In “Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness,” the authors suggest that thanks to the spread of the hospice movement, fewer Medicare patients across the country are dying in hospitals and they are spending fewer days in hospitals in the last six months of their lives. Hospice care is beneficial to the patients and their families, and it eases the fiscal stress on the Medicare system.
However, the intensity of medical care rose for those Americans who did wind up in hospitals. Increases were particularly sharp in two measures: the amount of physician labor per patient and in the number of patients who saw 10 or more physicians.
The broad trends are interesting in themselves, but it is crucial to delve into the details for actionable insight. As the authors point out:
Widespread regional variation persists in measures of end-of-life care. In 2007, the percentage of deaths in hospital varied by a factor of almost four across hospital referral regions, and the average number of hospice days per patient in the last six months of life varied by a factor of more than six.
So, how do we stack up in Virginia? First let’s look at the national map that shows the percentage of chronically ill patents who were treated by 10 or more physicians during the last six months of life:
A quick glimpse shows that Virginia Medicare patients tend to use health care services somewhat more intensively than in other parts of the country. But there is variation within Virginia, too, as seen below. The two largest metro areas, Northern Virginia and Hampton Roads, are the most resource intensive, followed by the Richmond and Charlottesville hospital service areas, and lower rates in the less populated areas. The percentage of Virginians dying in hospitals likewise is higher than the national norm.
Yet another map shows the variation in the average number of days spent in hospice care during the last six months of life. (Click on the map below to view a more legible image.) You’ll see that outside of Northern Virginia, hospice care has not made great inroads in Virginia compared to other parts of the country — although in another map, not shown here, Dartmouth shows that hospice care is clearly on the rise, though from a low base, in hospital service areas in the western part of the state.
What are the barriers to hospice care in Virginia? Legal restrictions? Cultural resistance? Disinterest on the part of the medical community? The Dartmouth Atlas doesn’t answer those questions. But the project has done its job if it stimulates Virginians to do so.
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