In New York City, Two Versions of End-of-Life Care

 Most elderly patients in their last two years of life have more intensive treatment, more tests, more days of hospitalization — and more out-of-pocket costs — at private teaching hospitals like N.Y.U. and Lenox Hill than their counterparts at Bellevue and the city’s other municipal hospitals, which have historically served the neediest New Yorkers.

The city’s private hospitals were among the most aggressive of about 3,000 hospitals studied across the nation, ranking in the 94th percentile as a group, while the public hospitals landed in the 69th percentile, still significantly above the national average.

The rankings, compiled by Consumer Reports from a 15-year research project based at Dartmouth College, have huge implications for administrators, doctors and patients as they consider which model of care is best for those suffering from chronic, fatal illnesses like cancer, congestive heart failure, lung disease and dementia.

The study does not address the question of whether longer stays and more intervention prolong patients’ lives, and the Dartmouth researchers argue, in general, that less-aggressive treatment does not change the outcome, but spares patients the agony of unnecessary tests and reduces the risk of hospital-borne infections.

Now what I find most interesting is one of the main explanations:

Dr. Eric Manheimer, who is the medical director at Bellevue and on the faculty at N.Y.U., said that having a foot in both the public and private systems gave him a unique perspective on the discrepancies. He said that care was less aggressive at public hospitals because most of their doctors — he estimated 75 to 85 percent — were salaried physicians with little financial incentive to order tests or other interventions. At private hospitals, he said, supply can create its own demand: There is often an abundance of beds and an endless list of specialists who can be called.

“You end up with the phenomenon of specialists referring to other specialists, with nobody coordinating, which results in confused messages, more referrals, more hospitalizations, deterioration in health care and a more anxious patient,” Dr. Manheimer said.

Does this sound familiar? Yesterday I blogged about the problem of too many specialists.

New Yorkers are not getting better care, just more expensive care.  I have heard that New Yorkers tend to see a subspecialist for each problem they have.  But paradoxically, subspecialists do not provide better care unless perhaps you have one specific disease.  I would see a subspecialist for Crohn’s disease, or rheumatoid arthritis, or lymphoma.  However, the average older patient with several common chronic diseases will get better more coordinated care from one excellent internist (or subspecialist you still manages the entire patient.)  In general, too many cooks spoil the broth.  In medicine, too many physicians lead to poor coordination, increased expenses and generally more complications.

So I blame the model. 

I am currently at the Alabama ACP meeting.  (disclosure for the remainder of this rant – I am currently a member of the ACP Board of Regents)  We had an excellent presentation on the rationale for the medical home model today.  Now I do understand that the medical home at first blush sounds like a gimmick.  After today’s presentation, I believe that I can defend the ACP much better.  The intent of the medical home is to pay physicians to spend the extra time to coordinate care. 

If readers want me to write a defense of the medical home, I will oblige.  ACP is trying to address the biggest weakness in our health care – the lack of financial incentive to become an outpatient internist.  At least we are trying.

Back to the problem, subspecialists are important for many positive attributes.  They often provide expertise that patients need.  They are more likely to be aware of the most recent data and treatments.  However, as I implied yesterday, and this newspaper article implies, subspecialists who only care for their system should have generalists who care for the entire patient.  The most confusing care is uncoordinated care.  The most expensive care is uncoordinated care.  New Yorkers think they are sophisticated because the use multiple subspecialists.  In fact they are naive.

Related posts:

1. Happy Hospitalist on RVUs
2. Build it – they will come – and spend money
3. Medicare crisis – as considered 7 years ago
4. Our health care system has perverse incentives
5. Avoid becoming a partialist

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