L.A. Leads in Costly Care for the Dying
Hospitals in Los Angeles County spend more on often-futile care for elderly patients at the end of life than medical centers elsewhere in California, according to a groundbreaking study to be released today.
Chronically ill Medicare patients stayed in the hospital longer, saw more doctors and received more intensive-care treatment in Los Angeles than in other metropolitan regions, including Sacramento, San Francisco and San Diego, according to research by Dartmouth Medical School. There was no evidence that the care prolonged patients’ lives.
Indeed, the aggressive care in hospitals might actually have hastened their deaths, the authors said, based on previous studies showing that hospitalizations can lead to infections and other deadly complications.
“It is at least equally plausible that people are being harmed by overuse than that they’re benefiting ... and we know that they’re spending a lot more money,” said Dr. Elliott S. Fisher, a Dartmouth professor and one of the study’s authors.
The reason for the disparity: The Los Angeles region has more doctors and hospital beds for its population than other parts of the state, according to the study published in the journal Health Affairs.
The supply generates its own demand.
“Once you put something in -- MRI machines, surgical suites, ICU beds -- they’ll fill it,” said Laurence Baker, an associate professor at Stanford University and a co-author of the study. “Doctors by nature like to deliver care.”
The research, the first of its kind to allow broad comparisons among individual hospitals, could cause insurers and policymakers to rethink how medical centers are compensated. It could also add fuel to the debate over the costs of end-of-life care, which is contributing to soaring national healthcare costs.
“This is the first ray of light on a very important facet of healthcare delivery performance,” said Dr. Arnold Milstein, medical director of the Pacific Business Group on Health, a coalition of employers interested in improving quality and lowering health costs.
The study, which covers 1999 to 2003, addresses the treatment of patients on Medicare, the government health insurance program for the elderly and disabled. The patients studied suffered from one of a dozen chronic illnesses whose prognoses are grim, including metastatic cancer, AIDS and end-stage diabetes.
The researchers looked at medical costs in patients’ last two years of life and the intensity of treatment provided in their last six months.
On average, Medicare spent $58,480 for each chronically ill patient in Los Angeles County in the last two years of life, according to the data. That compares with $34,659 in Sacramento, the region considered a benchmark by the researchers, $45,672 in San Francisco and $41,319 in San Diego. (The data were adjusted for race, sex, age and the frequency of chronic conditions.)
Among facilities driving the high costs in the Los Angeles region were those formerly owned by Tenet Healthcare Corp.
The nation’s second-largest hospital chain had used a questionable scheme to boost Medicare billings for its sickest patients, but abandoned the controversial billing practice in December 2002.
The highest costs for care in the last two years of life were reported at Garfield Medical Center in Monterey Park, Centinela Hospital Medical Center in Inglewood, Brotman Medical Center in Culver City and Hollywood Presbyterian Medical Center in Los Angeles. All of the hospitals have been sold by Tenet since November 2004 to other operators.
“For us, this is old news,” Tenet spokesman David Langness said. “Our rates were higher until 2002, when Tenet’s new management disavowed the old, failed pricing strategy and changed many things.”
UCLA Medical Center and Cedars-Sinai Medical Center, leading names in Southern California healthcare, also ranked near the top of the list in spending. UCLA spent far more than any of the other four UC hospitals, including UC San Francisco.
While not questioning the study, leaders at Los Angeles hospitals urged caution in interpreting it. In particular, they warned health insurers and the Medicare program against hasty cuts.
“Is the medical use in Los Angeles higher than it is in Sacramento? The answer is yes,” said Dr. J. Thomas Rosenthal, associate vice chancellor of the David Geffen School of Medicine at UCLA and chief medical officer of UCLA Medical Center.
“Do we think there’s substantially better healthcare in Los Angeles that would justify all that extra use? The answer is no.”
However, he said, “When you get it down to individual hospitals, it’s a much tougher call.”
Rosenthal said 96% of the chronically ill people who came to UCLA in the last year did not die, and it’s not always possible to know which patients are going to die.
“They expect that when they come to UCLA, we’re going to use our resources fully to save their lives,” he said.
Even so, Rosenthal said, UCLA is committed to studying its figures and trying to figure out how it can reduce costs for end-of-life care.
Cedars-Sinai Chief Executive Thomas M. Priselac said he sees value in the study but believes his hospital is providing appropriate care.
He said there are already systems in place to ensure that patients admitted to the hospital stay only as long as is necessary.
The findings about the Los Angeles region rang true for some doctors unaffiliated with the study.
“There’s always one more treatment, there’s always one more, ‘Why don’t we try that?’ ” said Dr. Sandeep Kapoor, who directs the palliative care program at Providence St. Joseph Medical Center in Burbank. “But we have to realize what the goals of that patient are, which is not to be in an intensive-care unit attached to tubes with no chance of really recovering.”
Some people say that aggressive care in one’s final days can be an ordeal for patients and their families.
Barbara Benaron said her 76-year-old husband, Theodore, spent nearly four weeks in an intensive-care unit attached to a ventilator before his recent death.
He couldn’t eat, drink, stand, walk or speak. He pulled out the feeding tube in his throat when he regained consciousness, and a doctor had to insert the tube directly into his stomach. Ultimately, he was sent to a nursing home and died a few days later, after being transferred back to a hospital.
“I’m not so sure that keeping him all that time [in the intensive-care unit] did him any good because the outcome was still the same,” Benaron said. “Maybe his journey wouldn’t have been so hard.”
The study’s authors say extra spending in general does not seem to buy better care or more patient satisfaction. Surveys and quality ratings actually show that Los Angeles hospitals fare worse than their counterparts across the state.
For instance, satisfaction surveys compiled a year ago on behalf of the California HealthCare Foundation found that 57% of participating hospitals in Los Angeles had below average ratings, compared with 3% of hospitals in Sacramento and 9% in San Francisco.
Los Angeles hospitals also fared worse on treating congestive heart failure, heart attacks and pneumonia as measured by data the hospitals submitted to the Medicare agency.
Dr. John E. Wennberg, the lead author and the director of the Center for the Evaluative Clinical Sciences at Dartmouth, said he hopes employers and insurers will begin directing patients away from high-cost, inefficient hospitals. Patients can also play a role in choosing lower-cost facilities. The data are online at www.dartmouthatlas.org.
There have been “a lot of false starts and a lot of failed efforts to bring more rationality” to the healthcare system, said Dr. Lance Lang, vice president and senior medical director with Health Net of California. The latest research offers “some hope in the face of reasonable cynicism.”
The study was funded by the Robert Wood Johnson Foundation and the California HealthCare Foundation, both healthcare philanthropies.
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Medicare spending
The federal Medicare program pays Los Angeles-area hospitals more for end-of-life care than it does medical centers in other California metropolitan areas. L.A. patients have longer stays in hospital and ICU rooms and see more doctors. Yet overall, patient satisfaction is lower in Los Angeles than other regions.
*--* Los Angeles San Francisco San Diego Sacramento Medicare spending per decedent, last two years of life (inpatient and $58,480 $45,672 $41,319 $34,659 Part B) Hospital use per decedent, last 6 months of life Hospital days 17.9 13.2 13.1 11.1 ICU days 7.8 3.9 5.7 3.4 Physician visits 61.4 35.6 35.5 26.2 Percent seeing 10 or more physicians 43.1% 34.0% 36.7% 26.4% Percent of deaths with ICU admission 33.1% 22.8% 22.7% 19.2% Patient rating of hospital quality Below average 57% 9% N/A 13% Above average 7% 32% N/A 25%
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Source: Health Affairs
