The Care of Patients with Severe Chronic Illness: An Online Report on the Medicare Program

This edition of the Dartmouth Atlas reports on the last two years of life among Medicare enrollees with severe chronic illnesses the services received by Medicare enrollees who died between 1999 and 2003 and who had at least one of 12 common chronic conditions. The most prevalent conditions in this cohort were congestive heart failure, chronic obstructive pulmonary disease, and cancer. It concentrates on inpatient acute care hospitals and physician services under Medicare Part A and B. Other services provided under traditional Medicare will be reported in upcoming editions of the Atlas. Medicare Part C data are not available.  The first section shows that, contrary to a common assumption, variation in overall Medicare spending per beneficiary is not driven by variation in the prevalence of chronic illness.

Chapter one provides an overview of the problem of 'supply-sensitive? care. It first reviews the evidence that the supply of resources is closely associated with the frequency of use of physician visits, hospital admissions, and diagnostic tests. Chapter two looks at variations among the states and the District of Columbia and examines important relationships among resources, utilization, and quality. States that rely more on primary care physicians than on medical specialists in managing chronic illness tend to have lower Medicare spending and use fewer hospital beds, less physician labor, and fewer referrals to multiple specialists' and have better quality scores (measured by CMS's Hospital Compare database).

Chapter three reports on the remarkable variation in managing chronic illnesses among prominent academic medical centers. It illustrates the use of best practice benchmarking in evaluating the performance of the University of California Medical Center Los Angeles and the University of California Medical Center San Francisco, two academic medical centers that belong to the University of California Hospital System. The two medical centers differ substantially in per decedent spending, resource inputs, and utilization. Chapter four introduces the tools available on the Dartmouth Atlas web site to graphically display variation and generate reports comparing hospital, regional, and state performance. The chapter provides an example that describes variation in performance among hospitals located in the Fort Myers, Florida hospital referral region. Chapter five focuses on the problem of overuse of supply-sensitive care during the last two years of life.

Excerpt