CECS in the Classroom
Kate Baicker took a year off to serve on the Presidents Council of Economic Advisers from 2001 to 2002, but now shes back in Hanover, teaching undergraduates and preparing a new study for Health Affairs with her colleague Amitabh Chandra. Both are assistant professors in Dartmouths Department of Economics. The pairs paper echoes themes familiar from previous CECS research. Using the vast Medicare database, they asked whether there is a relationship between the amount states spend on health care and the quality of care patients receive. In this case, quality was measured by determining how often doctors administered 24 procedures and treatments known to be both effective and safe for most patients. Most of these treatments and procedures, such as giving aspirin to heart attack victims, or administering yearly eye exams for diabetics and mammograms for women over 50, are simple, noninvasive and, in many cases, familiar to consumers.
To the researchers surprise, the study revealed that higher-spending states actually had lower quality care. We thought we might find that there isnt much of a correlation between spending and the use of quality care; it might be flat, it might be slightly positive, but certainly not a negative correlation, says Chandra.
Intrigued, they continued to dig. They compared the composition of the physician workforces in different regions, thinking that this factor might affect the way medicine is practiced and thus the overall quality of care. Their numbers showed that the ratio of specialists to general practitioners was higher in higher-spending regions than in lower-spending ones, where the quality of care was higher.
These findings allowed Baicker and Chandra to develop a hypothesis that explained their earlier results. Perhaps, they suggest, there is something different about the way specialized medicine is practiced that makes it more difficult to provide the high-quality, effective care that is associated with higher-quality outcomes. Take, for example, a hospital that specializes in cardiac care, says Chandra. To provide that kind of care, you need to hire a lot of cardiologists, anesthesiologists and surgeons. When you hire them, you dont get to hire internists and general practitioners. And maybe thats how we get the patterns that we discuss in this paper. These hospitals are very good at the kind of care they offer, but that in turn causes them to be less good at the less-invasive management of other conditions, he says. Thats just a hypothesis, but it has major implications for how we spend our money. When you spend on the technologically intensive procedures, you are getting something out of it, but theres also a cost that you might not totally be calculating.
Baicker, who discusses these health care issues in her undergraduate public finance seminar, warns that their study does not suggest that cutting spending will improve care. While spending more money wont ensure higher quality care, cutting funds across the board is likely to hurt the quality of care, she says.
Baicker and Chandra work closely with Professor of Economics Jonathan Skinner, a longtime researcher at the CECS. He and another CECS veteran, physician Elliott Fisher, Professor of Medicine and Community and Family Medicine, lead a research group that has asked the question, Is more health care really better? in a series of studies in the last several years. Their work has shown, among other findings, that regions that spend more on health care provide more of it, but dont have greater life expectancy or higher patient satisfaction than areas that spend less.
Though some people react negatively when health care issues are discussed in terms of numbers, Baicker argues that all sorts of decisions have to be made on the basis of quantitative information. We wouldnt have the information we have now about what treatments are most effective and what the costs and benefits and risks of those treatments are if doctors didnt already look at quantitative data.
Does Managed Care Measure Up?
Its spring break, and the tall corridors of Silsby Hall are largely abandoned. Piles of exams and papers lie on faculty desks throughout the building, waiting for grades. Denise Anthony, Assistant Professor of Sociology, is taking a break from grading to talk about the bewilderingand much malignedworld of managed care.
Even from an academic perspective, the insurance industry can appear nearly opaque. As an organizational sociologist, however, Anthony is trained to find the nuances that others might miss. In the past, her research has demonstrated a surprising amount of variability in how managed care companies structure their relationships with health care providers. Far from being an inflexible behemoth, she has found that the industry has evolved in recent years to accommodate doctors and consumers concerns.
These days, Anthony wants to know what doctors like and dislike about managed care, With the help of grant support from the Nelson A. Rockefeller Center at Dartmouth, she used a nationally representative survey of more than 12,000 physicians to analyze the way managed care affects their practices. Her results support the conventional wisdom that physicians have strong negative feelings toward managed carebut not necessarily for the reasons many people assume. For example, the oft-criticized treatment guidelines issued by managed care organizations dont appear to bother most doctors. Typically these guidelines are for evidence-based treatments which have been proven effective. It could be that doctors see them as helping in their practices by reinforcing what the standard of care is, she says.
Anthonys research on managed care builds upon the substantial body of work produced by other sociologists. But the interdisciplinary nature of the CECS also allows her to shape research projects that supplement findings by scholars in other fields. For example, in the March 2004 issue of the British Medical Journal, CECS physicians and economists demonstrated in a study of end-of-life care that the supply-driven nature of health care holds true at the level of individual hospitals as well as at the state level. The researchers limited themselves to the top teaching hospitals in the nationthe best of the bestand discovered that even within the same cities, the chance that a person nearing death would be admitted as an inpatient depended upon the hospital, not the patients wants or needs.
But why should the supply of health care resources be such a factor in how much theyre used? In a proposed study, Anthony, along with fellow researchers Dr. Elliott Fisher at DHMC and Dr. Amber Barnato at the University of Pittsburgh Medical Center, will go into hospitals in regions previous CECS studies have identified as providing high-intensity and low-intensity medical care to explore differences in the way medicine is practiced. Within hospitals, there are organizational rules and practices in place that make certain kinds of behavior more likely and other kinds of behavior less likely. Those are the formal practices. Then there are social norms, the informal practices, the how we do things here. And that all influences and interacts with the supply of beds and the doctors, she says.
Researchers at the CECS have found that the supply of health care resources appears to drive the demand for them. This graph illustrates the trend among the population of patients with congestive heart failure. As the number of available beds rises, so does the number of people admitted as inpatients.
An example might be a hospital that imposes sanctions on doctors when a patient dies. On the one hand, this policy could be an incentive for physicians to do everything possible to save a patients life. On the other hand, it could have unintended consequences, like encouraging providers to admit dying patients to the intensive care unit, regardless of whether it is in their best interests.
Bringing Everyone Together in One Place
Ann Floods day is full: After meeting with a graduate student and a candidate for admission to one of the CECS masters programs, she is grabbing a bite to eat at Café North, Dartmouth Medical Schools dining hall, en route to an off-campus meeting. Classes arent in session, but as chair of CECSs doctoral and postdoctoral programs and the Centers Policy Studies Program, Flood, a Professor of Community and Family Medicine, has a lot of administrative responsibilities in addition to her own research.
When she joined Dartmouth in 1991, the degree programs at the CECS were just beginning to coalesce. Today, the Centers two masters programs and one doctoral program attract students of all backgrounds and levels of life experiences. In CECS classes, its not uncommon for a freshly minted bachelors degree student to be sitting in the same classroom with an emergency room physician.
The faculty similarly reflects diverse backgrounds and expertise. There are many physician researchers. Some, like Goodman, still see patients; others devote their time to research and teaching. In addition to the doctors, there are statisticians, epidemiologists, economists, sociologists, and more, all interested in how to measure, document and reproduce high-quality health care outcomes. The result is an organization that is multi- and interdisciplinary, Flood says.
Thats why I was drawn to the CECS and was so glad when Jack Wennberg asked me to join the faculty here, Flood says. In her past experience, doing interdisciplinary work often meant splitting her time between several different departments. But Jack brought everyone together in one place, she says.
Getting Clear: The Outcomes Group Works on Medical Communication
The Outcomes Group at the Veterans Administration Hospital in White River Junction, Vt., is a large and lively group of a dozen or so physicians and research fellows. They joke and laugh as they pull up to the long conference table for their weekly meeting. But once the groups cochair, Dr. Gilbert Welch, a Professor of Medicine and Community and Family Medicine, starts the meeting, everyone falls silent and turns his or her attention to the first task: absorbing and reacting to a diagram created by one of the group members to show treatment options for a gastro-intestinal condition.
Does the differential weighting of the arrows have any significance? one person asks the chart's creator, noting that the arrows leading to one outcome in particulardeathare much larger and more pronounced than the others.
What follows is an animated discussion in which the group prods the researcher about the message he wants to convey with the chart. Eventually the group will turn its attention to another schematic, this one on coronary heart disease, and then to the wording of an abstract for a forthcoming study. In medicine, misunderstandings can have fatal results; communication skills are crucial, and experienced CECS researchers like Welch and cochair Dr. Elliott Fisher, know that how findings are presented can have a major impact on how they are received. Throughout the meeting, the pair push group members to refine and restate the messages they want to communicate and their goals for communicating them.
The labels on these categories of risk are inconsistent. I think we're running the risk of confusing people unless we come up with more descriptive terms, says one young woman about the heart disease chart. At one point, the group takes a few minutes to brainstorm and then vote on alternate wording for a key concept.
This threshold language is hard to interpret, but its not politically smart to talk about aggressive care; people will read that as pejorative, one person says.
When the meeting adjourns, there still is no final resolution on the wording issue. All of the researchers whose projects were discussed today are sent back by their peers to rethink at least some aspect of their presentations. There are multiple communications priorities: precision, conciseness, transparency of meaning. And, where findings might be critical of the status quo, theres also a need to be assertive without provoking defensiveness.
Complex Questions, Multidimensional Answers
Thats been the struggle for the CECS from the beginning: how to bring attention to areas in need of improvement without alienating the people and institutions capable of bringing about that improvement. There are also questions about who should be responsible for change. Almost everyone agrees that public policy must play some role, but, as Kate Baicker points out, theres still a lot that must be learned before responsible policy can be drafted.
Were certainly not making the case that any of this is easy or simple. This is just another small piece to add to our understanding of how the whole system works, she says. One implication is that being an informed patient matters. Its understanding not only your own preferences and concerns as a patient, but the way the medical system works so you can influence your care and manage your needs the best way possible.
In the end, the answers, like the questions, must be multidimensional, Denise Anthony says. The problems and solutions in health care are almost always directed at doctors, but theyre just one part of an overall system. Maybe they shouldnt have to be the only people to bear that responsibility, she says.