The passage of the Affordable Care Act of 2010 has created a real opportunity to advance delivery and payment system reform in the United States. The need for reform is widely recognized, not only because of the now well-established consensus that uneven quality and poorly coordinated care are endemic (IOM 2001) but also because of the growing concern that continued health care spending growth will exacerbate the federal deficit, potentially reducing U.S. Treasuries to junk bond status.
The article by Jeffrey Silber et al. (2010) in this issue of Health Services Research can contribute to a better understanding of how to improve quality and reduce costs in U.S. health care. They use data on Medicare beneficiaries undergoing major vascular, orthopedic, and general surgical procedures at U.S. acute care hospitals. Their primary results are that when a Dartmouth measure of end-of-life hospital resource use—or as they call it, “aggressiveness”—is higher, 30-day surgical mortality rates and the relative risk of failure to rescue (having a complication and dying) were lower. In other words, hospitals spending more on their chronically ill patients near death also experienced better outcomes among surgical patients.
There is much to admire in the study. The quality of the statistical analysis is very high and they do a commendable job of risk adjustment at the individual level. The failure-to-rescue quality measure is clinically meaningful and well validated. And we certainly approve of their using the Dartmouth end-of-life hospital measures.
Our major concern is that the study's results will be interpreted incorrectly. For example, their finding of a modest positive correlation between end-of-life health care intensity and surgical outcomes could be viewed—wrongly—as meaning that any cuts in health care costs must inevitably lead to worse outcomes, or that these results are somehow inconsistent with those found in earlier Dartmouth research. Instead, the conclusions we draw from this and other studies is (a) it is not how much you spend that is important, but how you spend it; (b) overall spending alone explains remarkably little in health outcomes, implying that most hospitals can cut costs without any loss in quality of care; and (c) there is a tremendous degree of inefficiency, in terms of lost lives and wasted dollars, in the U.S. health care system. We believe that these three messages in turn hold important lessons for designing and implementing real health care reform in the United States.