The elusive connection between health care spending and quality

Health Affairs

Volumn 28, Issue 1, 2009, Pages

  Skinner, Jonathan ^a   Chandra, Amitabh ^b   Goodman, David ^c,d   Fisher, Elliott S ^d,e  

^a Lamont Doherty Earth Observatory   (United States)

^b HARVARD UNIVERSITY   (United States)

^c DARTMOUTH MEDICAL SCHOOL   (United States)

^d Center for Health Policy Research

^e DARTMOUTH INSTITUTE FOR HEALTH POLICY AND CLINICAL PRACTICE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL PRACTICE; HEALTH CARE COST; HEALTH CARE QUALITY; HOSPITAL BED CAPACITY; HUMAN; PRIMARY MEDICAL CARE; REVIEW; SOCIAL CAPITAL; TOTAL QUALITY MANAGEMENT;

HEALTH EXPENDITURES; QUALITY OF HEALTH CARE; UNITED STATES;

EID: 59449089456     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.28.1.w119     Document Type: Review

References (22)

1. R.A Cooper, "States with More Physicians Have Better-Quality Health Care," Health Affairs 28, no. 1 (2009): w91-w102 (published online 4 December 2008; 10.1377/hlthaff.28.1.w91);
2. R.A. Cooper, "States with More Health Care Spending Have Better-Quality Health Care: Lessons about Medicare," Health Affairs 28, no. 1 (2009): w103-w115 (published online 4 December 2008; 10.1377/hlthaff.28.1.w103);
3. and K. Baicker and A. Chandra, "Medicare Spending, the Physician Workforce, and Beneficiaries' Quality of Care," Health Affairs 23 (2004): w184-w197 (published online 7 April 2004; 10.1377/hlthaff.w4.184).
4. J. Skinner and D. Staiger, "Technological Diffusion from Hybrid Corn to Beta Blockers" in Hard-to-Measure Goods and Services: Essays in Honor of Zvi Griliches, ed. E. Berndt and C.M. Hulten (Chicago and Cambridge, Mass.: University of Chicago Press and National Bureau of Economic Research, 2007).
5. A.B. Martin et al., "Health Spending by State of Residence, 1991-2004," Health Affairs 26, no. 6 (2007): w651-w663 (published online 18 September 2007; 10.1377/hlthaff.26.6.w651).
6. Commonwealth Fund, Table 6.1 (Healthy Living: Dimension Ranking), in "State Scorecard Data Tables, 2007," Supplement to Aiming Higher: Results from a State Scorecard on Health System Performance (New York: Commonwealth Fund, 2007).
7. M. Steifel, P. Feigenbaum, and E.S. Fisher, "The Dartmouth Atlas Applied to Kaiser Permanente: Analysis of Variation in Care at the End of Life," Permanente Journal 12, no. 1 (2008): 4-9;
8. and L.C. Baker, E.S. Fisher, and J.E. Wennberg, "Variations in Hospital Resource Use for Medicare and Privately Insured Populations in California," Health Affairs 27, no. 2 (2008): w123-w134 (published online 12 February 2008; 10.1377/hlthaff.27.2.w123).
9. B. Sirovich et al., "Discretionary Decision Making by Primary Care Physicians and the Cost of U.S. Health Care," Health Affairs 27, no. 3 (2008): 813-823.
10. See the discussion on page 123 in A. Martin et al., "Health Care Spending during 1991-1998: A Fifty-State Review," Health Affairs 21, no. 4 (2002): 112-126.
11. We don't take this negation very seriously, however, as one should only trust individual-level adjustments for individual-level confounders. To do otherwise runs the risk of reporting spurious correlations. Dartmouth studies, by contrast, adjust for individual-level covariates such as age and race at the individual level, and socioeconomic status measures at either the individual or ZIP code level. Other variables, however, such as system-level effects (for example, a region may have a surplus of specialists or ICU beds) should be specified at the aggregated level of a region or hospital. Some of the confusion in Cooper's analysis arises from a misunderstanding of this distinction.
12. Skinner and Staiger, "Technological Diffusion." For the classic discussion of social capital, see R. Putnam, Bowling Alone: America's Declining Social Capital (New York: Simon and Schuster, 2000).
13. E.G. Campbell et al., "Professionalism in Medicine: Results of a National Survey of Physicians," Annals of Internal Medicine 147, no. 11 (2007): 795-802.
14. S.F. Jencks, E.D. Huff, and T. Cuerdon, "Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998-1999 to 2000-2001," Journal of the American Medical Association 289, no. 3 (2003): 305-312;
15. and Skinner and Staiger, "Technological Diffusion." Because of a lack of data, Alaska, Hawaii, and the District of Columbia were excluded. There are newer data series on social capital; see http://www.bowlingalone.com/ data.htm (accessed 27 October 2008).
16. Skinner and Staiger, "Technological Diffusion."
17. These studies have relied on hierarchical modeling methods to adjust for comorbidities at the individual level as well as "system" effects at the hospital or Hospital Referral Region (HRR) level. See E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 273-287;
18. and E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-298. Additionally, semi-parametric instrumental variables techniques, analyses focusing on changes over time in region-specific spending and survival rates for AMI patients, and studies of low-birthweight babies yield similar conclusions.
19. See also J. Skinner, E. Fisher, and J. Wennberg, "The Efficiency of Medicare," in Analyses in the Economics of Aging, ed. D. Wise (Chicago and Cambridge, Mass.: University of Chicago Press and NBER, 2005), 129-157;
20. J.S. Skinner, D.O. Staiger, and E.S. Fisher, "Is Technological Change in Medicine Always Worth It? The Case of Acute Myocardial Infarction," Health Affairs 25, no. 2 (2006): w34-w47 (published online 7 February 2006; 10.1377/hlthaff.25.w34);
21. and D. Goodman et al., "The Relation between the Availability of Neonatal Intensive Care and Neonatal Mortality," New England Journal of Medicine 346, no. 20 (2002): 1538-1544.
22. Cooper, "States with More Health Care Spending," 111.