A study published in the May 28 issue of JAMA discusses the results of a survey of Medicare beneficiaries and finds that more regional spending on medical care is not related to the perceived quality of the medical care that the patients receive.
In previous studies, researchers have shown that among several areas across the United States, there is wide variation in per capita expenditures for Medicare beneficiaries. These variations, however, have not been due to differences in health status. Medical and health professionals are interested in knowing if beneficiaries who reside in low-expenditure regions perceive that their care is of lower-quality than the care given to those in regions with high-expenditures.
To investigate the perceived quality of care as it relates to regional spending, Floyd J. Fowler Jr., Ph.D. (University of Massachusetts Boston) and colleagues studied a detailed survey of Medicare patients. The survey consisted of several questions that asked the patients to comment on how they perceive the quality of health care to be. Three of the questions specifically asked about perceived unmet need for care, four questions pertained to the perceived quality of ambulatory care, and three questions requested a rating on the perceived quality of overall care. To see how spending is related to patient perceptions, the investigators compared the answers to these questions with how much money is spent per person within various regions in the U.S. The survey answers – from the 2,515 patients who responded – allowed researchers to place each respondent in one of five quintiles, depending on sex, average age, and race-adjusted per capita Medicare expenditures (based on claims data from Centers for Medicare & Medicare Services).
The analysis demonstrated an association between per capita expenditures and receiving more medical care – such as the average number of ambulatory physician visits in the past year. As a specific example, 40.1% of respondents in the lowest average expenditures quintile received cardiac tests compared to 63.5% of respondents in the highest average expenditures quintile. Expenditures, however, were found to be unrelated to 7 of the 10 measures of perceived quality. Just 3.9% and 5.0% of respondents from the lowest and highest quintiles, respectively, perceived unmet needs for tests and treatment, and 88.7% and 87.0%, respectively, reported spending enough time with physicians. A key difference was noted, though, as the overall rating of perceived quality of care was higher in the lower-expenditure areas – 63.3% to 55.4%).
The authors conclude that, “On average, those in the lower-expenditure areas reported no more perceived unmet needs for care and a perceived quality of ambulatory care similar to that in high-expenditure areas; furthermore, they rated the overall quality of their health care at least as highly as those in the high-expenditure areas.”
An accompanying editorial, written by Gerard F. Anderson, Ph.D., and Kalipso Chalkidou, M.D., Ph.D. (Johns Hopkins Bloomberg School of Public Health, Baltimore), includes commentary regarding Medicare expenditures and perceived quality of care:
“The article by Fowler et al adds to the discussion concerning whether the economic principles of ‘more is better,’ diminishing returns, and comparisons with others apply in health care. When patients are able to access good-quality objective information on the risks and benefits of the various treatment alternatives, they do not necessarily choose more aggressive or more costly interventions. Currently, the United States spends more than twice as much as most other industrialized countries on health care services, some regions of the United States spend twice as much as other regions of the country, and some institutions or clinicians are twice as expensive as others. In terms of outcomes and satisfaction, the United States may have reached the position of diminishing returns for spending on medical care.”
Relationship Between Regional Per Capita Medicare Expenditures and Patient Perceptions of Quality of Care
Floyd J. Fowler Jr; Patricia M. Gallagher; Denise L. Anthony; Kirk Larsen; Jonathan S. Skinner
JAMA (2008). 299[20]:2406-2412.
Written by: Peter M Crosta