In a new paper in Medical Care Research and Review, Reschovsky, Hadley and Romano have shown quite conclusively that geographic variation in health care spending is related to the burden of illness and little else. Of course, the burden of illness is greatest among the poor, and the two are strongly correlated, so, indirectly, they also showed that geographic variation is related to poverty and little else.
The graph below summarizes the data. Medicare expenditures varied widely, as had been observed in studies using the Dartmouth Atlas. Dartmouth’s earlier studies (not shown) corrected for age, gender and black race but nothing more, believing that there was no need to correct for illness levels because the expenditures that Dartmouth studied were in the last two years of life, and since everyone was similarly dead, they all must have been similarly ill, a conclusion which, aside from being absurd, has been shown to be false, most completely in the Reschovsky study. Sutherland and coworkers from Dartmouth approached the question by studying patients in the Medicare Current Beneficiary Survey. After the standard adjustment for demographic factors, they adjusted the data using five disease parameters and found that such as adjustment explained 18% of the variation between the extremes of expenditure quintiles. Zuckerman and colleagues carried out an identical study but applied 12 disease parameters, and they explained 29% of the variation. Reschovsky et al utilized 70 disease parameters within the hierarchical condition category (HCC) model developed for the Centers for Medicaid and Medicare Services (CMS) and found that illness levels explained 93% of the variation. Even using a modified version to remove observer bias in charting illness, disease burden accounted for 85% of the variation.
Isn’t it time to stop this foolishness about geographic variation being a manifestation of variation in practice? Wouldn’t it have been wonderful if that could have occurred before all of the foolish incentives and penalties were written into Obama-care? Shouldn’t someone be held accountable for deceiving congress, distorting the practice of medicine and bilking the profession? Isn’t it time that the high health care costs of poverty became a focus of national attention? Don’t we owe our children a health care system that they can sustain? Won’t it take honest, critical research (like Reschovsky’s) to get us there?