The Overuse, Underuse, and Misuse of Health Care


geographic variation in spending for health care

perhaps the most compelling evidence suggesting inefficiency in the health sector is that per capita health care spending varies widely within the medicare program, and yet that variation is not correlated with measures of the quality of care or health outcomes overall. in 2004, for example, medicare spending per beneficiary ranged from about $5,600 in south dakota to about $8,700 in louisiana. yet a comparison of composite quality scores for medical centers and average medicare spending per beneficiary shows that facilities in states with high average costs are no more likely to provide recommended care for some common health problems than are facilities in states with lower costs (see figure 1); if anything, it would appear that the opposite might be true. (for the country generally, health care spending per capita also varies widely, ranging from roughly $4,000 in utah to $6,700 in massachusetts in 2004, but the connection between that variation and health outcomes has not been examined as closely. in addition, medicaid spending per enrollee also varies considerably among states.)



interesting testimony....

Chico David, BSN, RN

1 Article; 624 Posts

Much of this has been known for a long time, so I've had some chance to think about it. The map tends to make it easier to draw some inferences.

My not-too-systematic thoughts:

1. I see a high relationship between cost and doctor density. Could it be that in areas with low numbers of physicians the docs tend to do just what is needed, but in areas with higher numbers, they try to get the maximum financial mileage out of each patient by ordering a lot of tests and procedures?

2. I see also some correlation with income levels - do richer patients and families ask for/demand more tests and procedures while lower income folks just take what the doctor orders?

3. We know from other research that much of practice patterns are influenced by the habits of other doctors in the same area. Could better disemination of info on optimal practices help even things out?

4. We know that Medicare costs are heavily weighted to end of life - that a very large part of the money is spent on people in the last six months of life. Might it be that social attitudes toward end of life care vary widely by region? Maybe some areas people are more amenabelot a hospice type approach, while in other areas people want ICU care to the very end?

One might think that all of those questions would yield opportunites for researching further. Interesting to think about


328 Posts


There are socio-economic disparities to be sure, in the access to and distribution of health care resources and services. Quite honestly, my cynic's antennae went up just reading the title of the thread. I can't quite put my finger on it, but I don't think the provision of basic, medically necessary "health care" is what the author of the report is really talking about. Alarm bells really started going off in my head when I realized that the report is quite possibly a precursor that's setting the stage for the dismantling of MediCare. After reading it, I can just invision the insurers lining up and casting lots for the last remnants of this popular, socialized, single-payer health care program for our seniors.

Yeah, I realize that it's testimony by Director Peter Orszag of the Congressional Budget Office (CBO) to the Senate Finance Committee. But wait? Just who are they representing and serving? Overuse, underuse, and misuse? Alcohol, tobacco, firearms, automobiles, health the saying goes, "one of these things is not like the others...!" Commodity versus service?

Orszag told lawmakers that federal subsidies for health IT typically only help physicians who already are close to adopting the technology and do little to encourage physicians who are unsure about investing in the technology. According to Orszag, tying Medicare reimbursement to health IT use would result in higher rates of physician IT adoption. He said, "You could very quickly get to universal health IT if you say to doctors that you have a certain amount of time to adopt such systems or "you would not be reimbursed under Medicare."

How about reimbursing physicians at higher rates for providing actual care rather than buying expensive technology? How about universal health CARE, as opposed to universal health IT? Technology for data collection that predatory insurers will use to weed out expensive customers no doubt. The introduction and framing of the report really lays the groundwork for what this particular audience might want to hear, considering that they get the majority of their campaign funding from insurers, drug companies, hospital associations, IT firms, and medical device manufacturers. Never mind that we the people pay their salaries and provide them with generous health care benefits.

We have to be watchdogs when these folks talk about cost and quality. Sounds good at first, nothing wrong with that, and then it hits you. So, what do you think the chances are for an endorsement of a single-payer system that would extend MediCare to all would be, in the wake of this so-called Senate Finance Committee, "Prepare for Launch," HEALTH REFORM SUMMIT?

Here's a link so you can identify the Senate Finance Committee Members:

And, a great "follow the money" tool from open secrets:

Max Baucus, Chairman D/Mont

Chuck Grassley, Ranking Member R/IA

Regarding MediCare costs during the last two years of life? A word of caution here and it has to do with lowering the public's expectations and redefining individual responsibility and collective burden. To me, there's a very onerous, subliminal message embedded in this discussion. And it is the message that it may be a waste of public money to pay for the care of our elderly, especially if they're only going to live another two years. Although know one really knows when those "last two years" will commence, it occurs to me that if care is limited (conservative?) in scope, and treatments are delayed or denied, those last two years of life may sneak up on a patient sooner, rather than later. Don't tell that to the SiCKO "golden ticket" holders, (a.k.a. corporate servants), in Congress who are out to privatize health care for the benefit of the insurers. They might get the idea that they can balance the budget by slashing funds for public health entitlement programs, such as Medicare. Ooops, guess that one's out of the bag already!

I think I read somewhere that 20% of the population accounts for 80% of the expenditures for care. If we put everyone in one risk pool, in a publicly accountable, single-payer system, we can provide better care, control costs, and equitably distribute resources.

Go back and read the report...thanks for the link, Viking!

Do you see what I see? Mandates, incentives, tax credits, insurance coverage, and Bush appointee Ben Bernanke...need I say more?

"Rising health care costs represent the central fiscal challenge facing the country..."

"Expanded use of health information technology (IT) has the potential to improve the quality and efficiency..."

" addition to financial incentives, norms and default options can exert a strong influence on individuals’ choices..."

"Bringing about those changes would probably require action by public and private insurers to incorporate the results into their coverage and payment policies in order to affect the incentives for doctors and patients."

"One proposal that has received attention recently would create some type of federal health board; for example, Senator Baucus and Federal Reserve Board Chairman Bernanke expressed interest in that idea during the Finance Committee’s recent summit on health care reform."

Health care is not a vacation destination or a commodity. People generally seek it when they need it unless there are barriers to access. One barrier is blame and shame. Others include copays, deductibles, exclusions, and recissions. Yet another is incentivizing privatization of a public resource, like MediCare part D: it's costing us more, and we're getting less! Right off the top 31% or more of each dollar paid to insurers goes toward administrative overhead, marketing, and inflated executive bonuses.

Follow the money, and put it back into public health care. HR 676, expanded MediCare for All. :up:


328 Posts

Has 15 years experience.

RN4Mercy ,

Those were some awesome links. Thanks ! I bookmarked them so I won't lose them.

Follow the money is always a good plan to use to try to figure out the motive behind things.

In the words of some famous sociologist (name escapes me)

Two important questions to ask . 1) who benefits ?

2) who is disadvantaged ?

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