Understanding Health Care
Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. “Geographic Variations in Expenditures for Physician Services in the United States” New England Journal of Medicine 1993 March 4; 328(9):621-627.
An early study that revealed the greater than two-fold differences across regions in spending – in this case for physician services. Miami, then as now, at the top.
Fisher ES, Wennberg JE, Stukel TA, Sharp S. Hospital Readmissions Rates for Cohorts of Medicare Beneficiaries in Boston and New Haven”. New England Journal of Medicine 1994 October 13; 331(15):989-995.
In the 1990s, residents of Boston spent much more time in the hospital than residents of New Haven (Were Yale physicians rationing? Or Harvard docs doing too much?). This article suggested a reason: more beds in Boston, and thus a lower threshold for admission.
Pritchard RS, Fisher ES, Teno JM, Sharp SM, Reding DJ, Knaus WA, Wennberg JE, Lynn J. “Influence of Patient Preferences and Local Health System Characteristics on the Place of Death.” Journal of the American Geriatric Society 1998 October; 46(10):1242-1250.
Millions of dollars were spent in the SUPPORT study to try to help ensure that seriously ill patients’ preferences guided end-of-life decision making. The intervention failed to change practice. This analysis showed why: the supply side is powerfully important.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. “The Implications of Regional Variations in Medicare Spending. Part 2. Health Outcomes and Satisfaction with Care. Annals Internal Medicine 2003 Feb 18; 138(4): 288-298.
These two articles — Part 1 and 2, above, were the result of a five year project that showed that Medicare enrollees in US regions with higher Medicare spending did not receive more evidence based care, but did get more “supply sensitive care” (days in the hospital, visits to docs) and that higher use of these services wasn’t associated with better care or outcomes. These papers led to visits to Congress and the White House (under Republicans and Democrats) and were used by Peter Orszag to argue that there was so much waste we could afford to cover everyone in the US
Wennberg JE, Fisher ES, Stukel TA, Skinner JS, Sharp SM, Bronner KK. Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States. BMJ. 2004 Mar 13;328(7440):607.
We used US News and World Report to choose the “best” hospitals, and showed two fold differences in how much treatment people in their last 6 months of life received between, for example NYU and Cedar-Sinai (high) vs the Cleveland Clinic and UCSF (low). The high rate places did not like getting called out. Led to invitations to speak at NYU and Cedars Sinai.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb, DJ. “Variations in the Longitudinal efficiency of Academic Medical Centers.” Health Affairs (Millwood). 2004; Suppl Web Exclusives:VAR19-32.
The 2003 Annals papers were criticized by academic medical centers on the grounds that if they got to spend more money, more would be better. It wasn’t.
Sirovich BE, Gottlieb DJ. Welch HG, Fisher ES. “Variation in the tendency of primary care physicians to intervene.” JAMA Internal Medicine. 2005 Oct 24;165(19):2252-6.
Compared to physicians in low spending regions, those in high spending regions are more likely to provide discretionary treatments – tests, referrals or admissions.
Sirovich B, Gottleib DJ, Welch HG, Fisher ES "Regional variations in health care intensity and physicians’ perceptions of care quality.” Annals of Internal Medicine. 2006 May 2; 144(9):641-9.
Did physicians think care was better in high spending regions? Nope. It was harder to refer patients and harder to admit them, even though high spending regions had more specialists and more hospital beds. A paradox! The likely explanation: if physicians are making more discretionary referrals and admissions, demand for unnecessary care can outstrip supply. Another important finding: physicians in higher spending regions were more likely to report that quality was compromised by difficult communication among physicians, also not a surprise when there are more physicians involved in each patient’s care.
Barnato A, Herndon MB, Anthony D, Gallagher PM, Skinner J, Bynum JPW, Fisher ES. “Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences?: A Study of the US Medicare Population.” Medical Care. 2007. 45(5):386-393.
Many worried that patient preferences explained our findings of regional variations in end-of-life care. This study, based on a national survey of Medicare beneficiaries, did not find that to be the case.
Sirovich, B, Gallagher, P, Wennberg, J, Fisher ES. “Discretionary decision making by primary care physicians and the cost of U.S. Health care.” Health Affairs (Millwood) 2008 May-June;27(3):813-823.
We asked physicians: “for a patient with well-controlled hypertension and no other problems, when would you schedule the next visit”. Answers varied from one month to twelve months. Put this and other such questions together, and you can predict local health care spending, as David Cutler, Ariel Stern, Jon Skinner, and David Wennberg showed here.