Medicare Patients' Care Is Generally Good, but Varies Widely

From the WebMD Archives

Oct. 3, 2000 -- The quality of medical care received by Medicare beneficiaries nationwide is generally good, but varies greatly from patient to patient and could be improved significantly, according to a new study published in the Journal of the American Medical Association.

The study found that nationally, an average of 69% of the patients in the Medicare fee-for-service program got the recommended care, as determined by 24 specific measures related to the prevention or treatment of six medical conditions (heart attack, breast cancer, diabetes, heart failure, pneumonia, and stroke).

But it also found that the quality of care varies considerably from state to state and region to region, as well as among different health care services. For instance, 95% of all the Medicare beneficiaries with acute stroke nationwide were appropriately treated on at least one measure of care -- they were not given a medication that can be dangerous in stroke patients -- but only 11% of those with pneumonia were appropriately screened to see if they had received the pneumococcal vaccine.

There also was wide variation in the quality of care within states. For instance, Ohio ranked as high as seventh among the states in administering aspirin to heart-attack patients upon their admission to a hospital, but it ranked 47th in the percentage of patients receiving a pneumococcal vaccination.

"There is a significant national opportunity to improve care, although it is important to note that the care that is being delivered is pretty good," Stephen F. Jencks, MD, MPH, director of the quality improvement group at the Health Care Financing Administration (HCFA), and lead author of the study, tells WebMD.

John Eisenberg, MD, director of the federal Agency for Healthcare Research and Quality, hailed the report. "This is the first time a national study has looked at evidence-based measures and provided us with an opportunity to [measure] our performance for services that ought to be provided to Medicare beneficiaries," Eisenberg tells WebMD.

The report shows that while many beneficiaries are being well-served, others are not, he says. "If anything resonates throughout our health care system, it is that some Americans are being left out," he says.

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The report indicates that less populous states and those in the Northeast tended to score better on the various measures than more populous states and those in the Southeast.

The 10 states with the highest average scores across all measures were, in order, New Hampshire, Vermont, Maine, Minnesota, Massachusetts, Connecticut, North Dakota, Iowa, Colorado, and Oregon.

The areas with the lowest average scores, in order, were Puerto Rico, Arkansas, Mississippi, Louisiana, New Jersey, Georgia, Illinois, Texas, Alabama, and West Virginia.

In an interview with WebMD, Jencks says that the development of performance measures for a range of medical services is at least as important as the researchers' actual results. The measures, derived from widely accepted practice guidelines, will be used by the HCFA to help improve care through the agency's national network of Peer-Review Organizations. The mission of each state or territorial Peer Review Organization is to ensure the quality, effectiveness, and efficiency of services for Medicare beneficiaries.

In the past, Jencks says, HCFA has sought to improve care by hunting for "bad apples" among physicians through audits of patients' charts. The new report represents an effort to instead use population-based performance measures to gauge the quality of care across the entire Medicare system.

"We think that a great deal of the gap between what could be done and what is happening is attributable to systems failures," Jencks tells WebMD. "We think the health care system could be engineered so that these things happen as a matter of course, rather than depending on very busy individual physicians to make them happen."

For example, Jencks says, screening for patients' immunization status would improve if doctors' office systems were designed -- through computerization and other mechanisms -- to ensure patients were screened routinely. Now, many offices simply rely on the doctor to ask during checkups. "It is likely the immunization rates under these two scenarios are going to be profoundly different," he says.

In an independent assessment of the study, Elliott Fisher, MD, MPH, professor of medicine at Dartmouth Medical School and a researcher involved in the Dartmouth Atlas Study Series, says the study underscores the inconsistency found in American medical practice. The Dartmouth Atlas series has found wide variation in the utilization of services in the Medicare program.

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"I think this drives home the message that for a variety of very well-measured attributes of medical care, there are substantial differences across states," says Fisher, who also is co-director of the VA Outcomes Group, a research group based at the Veterans Affairs Hospital in White River Junction, Vt., "Even the best states could do much better. There is lots of room for improvement."

The challenge, Fisher cautions, will be to use the information to improve overall systems of care, rather than focusing on specific measures on which states fared poorly. "There will be a temptation to look at these results in the same way that physicians look at report cards," he says. "We need take what we learn from these measures of variation and modify the systems to achieve the results we know we can achieve."

But some medical societies in states that did not score well suggest that the study does not necessarily tell the entire story. Leroy Sprang, MD, president of the Illinois State Medical Society, acknowledged there are areas of care that can be improved, but said the report's focus on performance measures may not indicate how the patients actually fared in treatment.

Jencks says that doctors and others who react defensively to the report, and patients who react with fright, risk missing the potential inherent in its findings.

"The point is that there is an opportunity to improve care, and the opportunity is best realized through systems change," Jencks says. "These figures are not about what has gone wrong. We have a system that is getting better."

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