Healthcare reform was a frontline topic during the recent presidential elections. The political warfare and misleading information around the Patient Protection and Affordable Care Act (PPACA), also known as Obamacare, has prevented the public from understanding its intended purpose, and has left many skeptical about its benefits. It is safe to say the general public has little to no idea about the quality of healthcare delivery in their respective regions.
In fact, it is not a far cry to claim that even healthcare professionals might not truly understand the issues facing American healthcare. Thus, most of the public is generally uninformed or misinformed about the population level problems facing the healthcare system. Therefore, it is quite simple for political parties to misguide the public and capitalize on their uninformed perceptions. If the public knew more about the flaws present in the healthcare system, perhaps they would better realize the PPACA is a reasonable start at addressing the failings of our system.
The Dartmouth Atlas Project is an online database which collects Medicare spending and utilization data from around the country. Information gathered from the database has shown immense variation in the way medical resources are utilized by even similar regions, communities, and health care organization. Evidence has repeatedly shown that, from a population perspective, areas that spend more on medical care do not consistently benefit from increased quality of care or patient wellbeing. Variation in the type of care delivered can be attributed to diverse incidence and prevalence of disease severity or the type of care a well- informed patient chooses. Variation in health care delivery is thus omnipresent and expected, because every patient is unique and medical innovation presents a growing number of care options to choose from.
However, much of the variation in healthcare practice is “unwarranted” because it cannot be explained by the degree of illness or patient preference. In fact, the two main drivers of unwarranted variation are the capacity of the local health care system to provide growing number of expensive services that must be utilized, and the physician’s practice habits that may not be evidenced based or patient preferred. The current healthcare reimbursement model propagates variation in care delivery due to the financial incentive of providing more service even when little benefit exists for the patient.
Analyzing Medicare data in a political context, the table below displays spending and service utilization data for the top ten Republican and Democratic states, based on the elections polls that tracked the popularity of each presidential candidate during the race (election polls).
These data tells a clear and simple story. The top ten Republican states have higher Medicare spending than the top ten Democratic states. The rate of hospitalization and surgical procedures are also higher for Republican states. If we investigate a procedure like percutaneous coronary interventions (PCI), the Republican states are performing more PCI procedures with equal mortality benefit compared to Democratic states. The evidence of variation in cost and utilization is a strong indication of inconsistency and inefficiency in the care delivery process. Are the Republican states providing better care by providing more care? We cannot find evidence of for such an assertion. Nor do we find evidence of harm occurring from a lack of utilization to individuals residing in democratic states.
Six of the ten Republican states sued the federal government over the individual mandate and Medicaid expansion earlier this year (Utah, Alabama, Louisiana, Texas, Georgia, and Nebraska), compared to only one democratic majority state (Maine). Yet the Republican states have a higher average of uninsured people, thus inhibiting a greater percentage of their citizens from accessing preventive healthcare. It is possible to draw many conclusions from these data, however it is intriguing that the states that have higher spending and resource utilization supported a Republican candidate who was not a supporter of the PPACA. The intrinsic values of the reform act are to cut down on waste, ensure access to preventive care, pay providers for quality rather than quantity, and reduce unwarranted practice variation and disparities by promoting accountable models of care delivery. Regardless of political stance, minimizing unwarranted variation is an ethical priority and a solution to decelerating the growing of healthcare spending in the United States. Hopefully, the continuing implementation of Obamacare over the next four years will prove to be beneficial.
Dr. Anubhav Kaul is a recent medical graduate from Ross University School of Medicine, and he is pursuing a Masters in Public Health at The Dartmouth Institute of Health Policy and Clinical Practice. Thom earned his PhD from The Dartmouth Institute for Health Policy and Clinical Practice where his dissertation focused on understanding variation in the costs and utilization of care within and between hospitals.