Are doctors what ails U.S. healthcare?

• Public Health • Nov 06, 09

Nowhere in the United States has more doctors at its beck and call than White Plains, one of the wealthiest cities in the nation.

Doctors have been flocking to the area and surrounding Westchester County since the 1970s, drawn in part by an upper-class clientele who demand top-notch medical care and have the means to pay for it. The county has one of the highest median household incomes in the nation (about $77,000 a year in 2007), and the figures soar above six digits in suburbs like Scarsdale and Chappaqua, which former President Bill Clinton calls home.

Nearly 3,000 miles (4,830 km) away, scaring up a doctor in Bakersfield, situated in California’s economically battered Central Valley, is a lot harder. In fact, White Plains has more than twice the number of doctors per capita as Bakersfield, where needy patients until recently had to take a 2-hour bus trip to Fresno to see a diabetes treatment specialist.

Two decades worth of U.S. healthcare data analyzed by Dartmouth Medical School at Reuters’ request shows that such regional disparities are increasingly creating a nation of health-care haves and have nots.

The research also suggests that the chasm between places like White Plains and Bakersfield is likely to grow - a point underscored by dozens of interviews with doctors and experts. That’s because physicians, the data shows, gravitate toward affluent locales in the United States that already have all the medical help they need.

What’s more, the Dartmouth analysis shows, clusters of doctors tend to result in higher health care costs - and, perhaps most surprisingly, outcomes aren’t any better in cities with the largest physician populations.

Congressional Democrats in late October unveiled a sweeping healthcare overhaul that would transform the insurance market, extend health insurance to 46 million additional U.S. patients and levy new taxes on the rich.

The House of Representatives could vote as early as Saturday on a bill that would launch the biggest changes to the U.S. healthcare system since the creation of the Medicare health program for the elderly in 1965. But Senate action is unlikely until next year.

President Barack Obama has made reform of the $2.5 trillion U.S. healthcare industry, which constitutes one-sixth of the economy, his top domestic priority.

Yet, even if Obama gets everything he wants in his bruising fight with Republicans, stunning imbalances will remain in how the fruits of the health care system are distributed.

Access to top doctors, cutting-edge procedures and advanced life-saving technology has less to do with need and more to do with quality of life issues that any professional would consider when deciding where to live - climate, schools, and perhaps most importantly, income.

IRRATIONAL DISTRIBUTION

Consider this fact: The number of primary care physicians per capita varies by a factor of 2.5 across U.S. hospital districts, and specialists by more than three-fold, according to Dartmouth. For every doctor who lives and practices in an underserved area, four others settle in an overserved area, the medical school’s data shows.

There’s an “irrational distribution” of the most valuable and expensive U.S. health care resources and “physicians simply do not settle in greater numbers where patient needs are greater,” said David Goodman, director of health policy research at the Dartmouth Institute for Health Policy and Clinical Practice.

Neonatologists don’t set up practice where the need is greatest, and cardiologists don’t flock to cities with high rates of acute myocardial infarction, Goodman said.

Moreover, Dartmouth’s examination of two decades of U.S. hospital admission data show that more doctors are not necessarily the solution to what ails the U.S. healthcare system. That’s because patients treated in communities with an abundance of doctors are more likely to receive unnecessary tests and procedures, the school found.

To illustrate the point, Dartmouth’s Atlas of Medical Care database compares spending on patients covered by Medicare - the U.S. government’s program to cover elderly and disabled patients - during the last two years of their life.

At Westchester Medical Center in Valhalla N.Y., near White Plains, Medicare spending was about $87,000 in the last two years of life, and during the last six months of life patients spent an average 24 days in the hospital and were seen by 53 physicians.

Meanwhile, at Mercy Hospital in Bakersfield, Medicare spending was $57,000 in the last two years, and patients spent an average 14 days in the hospital in the last six months and were seen by 40 physicians.

Westchester County hospital executives defend their specialist networks as essential to their patients.

“If you ask me if patients in this area are overserved, my answer is no,” said Michael Israel, chief executive of Westchester Medical Center, a highly specialized academic hospital that handles some of the Hudson Valley’s most complex treatment cases.

“In many areas of the country people need care that is not available to them,” Israel said. “They are not getting it.”

TWO CALIFORNIAS

In the San Joaquin Valley, an oil producing center north of Los Angeles, Stephen Schilling struggles to staff his clinics, which mostly serve low-income, Hispanic migrant workers who harvest the valley’s endless fields of cotton, almonds, pistachios and other crops.

“This is a tough place to bring professionals,” said Schilling, who offers visa assistance for foreign doctors and medical school repayments to entice doctors to practice at his clinic - Clinica Sierra Vista. “I could hire a family practitioner if they walked in here any day of the week.”

It’s no mystery why doctors avoid Bakersfield.

The summer heat is oppressive, the air quality is poor and the Valley has been pegged by congressional researchers as one of the nation’s most depressed regions, on par with the Appalachia region stretching across West Virginia and other coal-mining states.

Most of California’s wealth and medical expertise dwells in the dozen or so coastal counties like San Francisco and Los Angeles, where the weather is fine and so is the living, Schilling said. “They’re massively overserved,” he said. [20091106 130421 GMT]

“There are two Californias,” Schilling said. “It’s not northern and southern. There’s coastal California and then there’s the rest.”

As for Bakersfield, “We’re at the mercy of the medical community and what they are willing to contribute,” said Carol Sorrell, chief executive of Kern Health Systems, a state-run health insurance program that caters to the area’s needy patients. “We’re really at our wit’s end.”

The need is greatest for specialists like orthopods, urologists and dermatologists, Sorrell said.

Kern Health Systems recently spent $1 million to help the area’s “safety net” hospital - Kern Medical Center - open a clinic to care for patients with diabetes, which is more prevalent in Hispanics due to their high-protein diet and other lifestyle factors.

“It’s not cheap, but in the long run it’s a lot cheaper than amputated feet,” Sorrell said, referring to the likely outcome if diabetes is not treated.

Kern Medical Center’s emergency room is often the only resort for many of Bakersfield’s low-income patients. The hospital spent about $65 million caring for indigent and uninsured patients in 2008.

“This hospital saved my life many times,” said Maung Thettin, an uninsured Burmese man who recently came to the hospital seeking relief for joint pain.

IS MORE BETTER?

Outside of Bakersfield and other underserved cities - such as McAllen, Texas, and Tupelo, Mississippi - the case for more doctors is far less clear.

For many U.S. cities, Dartmouth Atlas data shows that more doctors are associated with higher costs of care and more procedures that have dubious benefits for patients.

States like Minnesota, Wisconsin and North Dakota have maintained low costs by relying on primary care doctors to keep patients healthy and out of hospitals, while in high-cost states like New York, patients are more likely to get admitted to hospitals and receive a battery of tests and treatment.

One reason is the “fee-for-service” structure of the U.S. healthcare system, which rewards specialists for performing complex procedures but offers scant rewards for primary care physicians who practice preventive medicine.

Primary care doctors must see about 35 patients a day - which works out to less than 15 minutes per visit - to make $150,000 a year, if they rely on the U.S. government’s Medicare system fees.

Meanwhile, a brain or heart specialist can easily make four times that salary for performing complex procedures. “You get paid enough for one case to make a down payment on a car,” said Guy Clifton, professor of neurosurgery at the University of Texas Health Science Center in Houston.

SHOW ME THE MONEY

For government officials looking to pay the bill for health care reform, the Dartmouth data could offer an enticing map for cutting costs.

After all, the U.S. healthcare system wastes between $505 billion and $850 billion every year, according to a report from Robert Kelley, vice president of healthcare analytics at Thomson Reuters .

The United States spends more of its gross domestic product on health care than any other developed nation at 15 percent - versus 11.3 percent in Switzerland, 10 percent in Canada and 8.1 percent in Japan, according to the Kaiser Family Foundation.

If it’s true that about one in three U.S. health care dollars is wasted, then billions of dollars in costs can be eliminated through improved efficiency, rather than through more government spending that would widen the $1.4 trillion U.S. budget deficit.

But some experts say that there could be unexpected consequences in any attempt to reform how health care is distributed.

“This idea that it’s all waste and we don’t have to invest in more doctors or additional costs to actually cover these people, that’s about as seductive as anything you could possibly imagine,” said Thomas Rosenthal, chief medical officer at the UCLA Medical Center in Los Angeles. “But you’d better be careful.”

Allocating funds away from high-cost cities like Los Angeles toward under-served cities could leave urban hospitals struggling to care for the high percentages of uninsured patients they have historically treated, Rosenthal said.

“If you do some of these things willy-nilly, you’re going to cause more harm,” he said.

For now, the main thrust of health care reform is more about expanding benefits to uninsured patients than cutting costs, Clifton said.

Obama administration officials made a calculated decision to concentrate on access to avoid alienating key industry allies that could have stopped their efforts cold, Clifton said.

One telling fact in the health care debate to date is that public outcry from major health industry associations like the American Medical Association and the pharmaceutical industry has been largely absent. “You’ve seen no attack ads from any industry group,” he said.

If Obama administration officials had “waded into the really nasty politics of pulling a third of the money out of the health care system, they would have lost the support of the industries they needed,” he said. “This is the politics of the possible.”

Dartmouth’s Goodman agreed that insurance reform being pushed in Washington is unlikely to have an impact on the problem of soaring costs and uneven quality of care in the United States.

“Just increasing insurance coverage by itself won’t address the dilemma that nearly 50 million people face,” Goodman said. “It’s not going to lead us to a sustainable healthcare system from a financing standpoint.”

But marginal improvements in health care efficiency and quality could yield appreciable results, while large changes could trigger a wave of hospital bankruptcies, Goodman said.

“If the hospitals in White Plains started practicing like the Mayo Clinic tomorrow, they would look like General Motors,” he said. “They would go bankrupt.”

Still, a deep-rooted system of incentives for health care providers must change, Goodman said. “We should be paying for high-quality care and outcomes and not just for more care,” he said.

For a graphic related to this story see: http://graphics.thomsonreuters.com/119/US_HEALTH1109.gif

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By Chris Baltimore

WHITE PLAINS, N.Y. (Reuters)