Some folks from Nevada asked me why the Dartmouth group says that their state has excess expenditures when it doesn’t feel that way. In fact, it’s so bad that 60 Minutes did a special about it on April 5th. So I took a look at it, and here is what I found. There are two Nevadas, the Dartmouth group’s and the real one.
According to Dartmouth logic, Nevada ranks
#16 from the top for Medicare per enrollee (high spending)
#2 from the top for specialists per capita (among the most)
#35 for Quality (near the bottom third)
#44 for Mammography among Medicare beneficiaries (near the bottom)
The Dartmouth group would conclude that Medicare spending is high because Nevada has too many specialists who use too many “supply sensitive services,” yet outcomes (quality, mammography rates) are poor. The solution would be to create practice incentives so that those surplus specialists in Nevada would stop churning the system and give good care for less, instead.
But in reality, although Nevada rank #16 for Medicare spending, it ranks
#43 for specialists per capita (among the fewest in the nation, not the most)
#43 for total spending per capita (among the lowest spending in the nation)
#50 for health care workers per capita (the fewest in the nation)
#44 for Mammography among Medicare beneficiaries (very low)
#38 for Mammography among women 40-65 (also very low)
Everything except Medicare spending ranks low—low physician supply, few health care workers, low total spending and poor outcomes. Outcomes, such as quality rankings and mammography rates, depend on total revenues (Medicare plus everything else), not just Medicare. The strongest correlate of mammography screening among Medicare patients is the rate of mammography screening younger women in the same community. Mark Pauly calls this “spillover” If efforts are made to reduce the number of specialists and reduce the amount of Medicare (and other) spending through practice incentives, Nevada’s health care will crumble.