A key to health care: same cost everywhere

During the final two years of his life, the typical senior in Miami sees doctors 106 times. He receives an astonishing array of lab tests, MRIs and medical procedures, and spends a month in hospital beds.

The bill for all that care adds up. Medicare, the federal health program for seniors, spends a staggering $16,351 a year per Miami patient, more than anywhere else in the nation, and roughly double the 2006 national average.

That distinction places Miami at the center of the nation's debate over health costs, and has people everywhere asking the same question: What's going on in Miami?

Just a few hundred miles away in Tampa, Medicare spends $8,991 per enrollee. Sarasota provides care for $7,467 per senior, less than the national average.

But Miamians on the whole don't appear to live longer than their fellow Floridians. Nor do they seem to have more medical problems that call for so much more expensive care.

In fact, there's little evidence that patients get much benefit from such huge regional disparities in Medicare spending. What the cost divides do reveal are local differences in how medicine is practiced, disparities that affect taxpayers and patients of all ages.

But while the numbers are black-and-white, how to address them is the real debate.

"There's no question there's a significant variation across the country and in Florida in cost of care, and actually in the way we go about rending care to patients," said Dr, Michael Wasylik, a Tampa orthopaedic surgeon who chairs the Florida Medical Association's managed care committee.

But he said the numbers don't show doctors what kind of care is safe to stop. Nor do they show consumers' role in escalating costs. "Imaging is demanded by patients when it often isn't necessary,'' he noted.

The White House contends that excessive spending isn't just wasteful — it actually hurts the most vulnerable Americans.

Here's what White House budget director Peter Orszag wrote about regional cost disparities in a recent blog post: "The result is an estimated $700 billion a year spent on health care that does nothing to improve patient health, but subjects you and me to tests and procedures that aren't necessary and are potentially harmful — not to mention wasteful."

History lesson

This spring, Linda Quick, president of the South Florida Hospital and Healthcare Association, saw Florida Sen. Bill Nelson in a visit the Capitol. He quipped that she needed to give him some excuses to explain to his colleagues why the region spends so much.

"He could probably defend the area by saying everyone should get as much medicine as the people in South Florida," she said. But "the outcome data doesn't indicate that our older people are any healthier because of all this excess service."

Could it be all the retirees living in South Florida?

"We don't have more than you all do on the west coast, as a percentage of the population," she said.

Differences in health levels? Cost of living?

None of these, she acknowledged, can explain away the huge divide in what Miami spends on health care compared to the rest of the state.

To start looking for the answer, Quick said, you have to go back to the early days of Medicare, the 1965 federal program providing health coverage to senior citizens.

It was a heady time for Miami's medical community. The program paid doctors and hospitals well. There seemed no end in sight to the region's influx of snow birds and retirees.

This was before the government strictly controlled the number of hospital beds built in a community. Every neighborhood wanted its own medical center, and some rose within walking distance of each other.

In a decade, Quick's association grew from representing some two dozen hospitals to about 70 institutions.

More facilities and more doctors mean more medical services.

"In the areas where you have more health care providers, people consume more health care," said Holly Benson, secretary of the Florida Agency for Health Care Administration.

"And Miami is one of them."

Studying patterns

Miami's costs are exceptional, but the trend is not. St. Petersburg spends over 20 percent more per Medicare patient than Sarasota, a half-hour's drive south. Sarasota is more costly than Atlanta.

For over two decades, a team of Dartmouth researchers has studied the patterns nationally. Higher-spending regions tend to have more hospital beds, more physicians, more specialists, and deliver more care per capita.

The catch: More is not necessarily better.

"It's often not the spending lots of money on procedures that gets you the benefit, but it's getting things right the first time around," said Jonathan Skinner, an economics professor and co-author of the Dartmouth Atlas of Health Care, which details the spending differences.

He said hospitals that use low-cost but effective measures, such as giving aspirin to heart-attack patients, do so much better by their patients that the results swamp the spending differences.

In fact, quality of care is sometimes lower in high-spending areas, the Dartmouth researchers say. Excessive procedures and tests can expose patients to more risk of hospital infection and medical error.

And yet, the health care system keeps expanding.

Jay Wolfson served for a dozen years on the Tampa General Hospital board, and heard talk about the need to fill beds and build new facilities.

A professor of public health and medicine at the University of South Florida, Wolfson argued Tampa needed better preventive services and higher quality school lunches more than it needed to fill hospital beds.

"It's not as sexy as building," he said. "That stuff is soft and squishy. You can't see it. And you can't put your name on it."

Reining in care

This year, health spending in the United States is expected to total $2.5 trillion. At this rate of growth, it will consume one out of every $5 Americans earn in the next decade.

President Barack Obama calls this "a ticking time bomb for the federal budget."

Dr. Joel Strom, a USF professor and cardiologist, saw a microcosm of the American health care crisis in one patient.

His father-in-law, a Florida resident nearing age 90, had multiple problems and doctors for each. A urologist for prostate issues. A dermatologist for melanoma. An internist for hypertension. A psychiatrist and a psychologist for Alzheimer's.

In all, there were 10 doctors, all writing prescriptions.

His next stop was hospice, where he went for end-of-life care. He was taken off the medications. His condition improved dramatically.

"He was a poster child for overutilization of health care," said Strom, who spent much of his career in New York. Strom has observed in Florida a culture of referring patients to multiple specialists.

But as politicians seek to rein in decades of established practices, they know patients accustomed to that culture — to say nothing of some medical providers — won't easily let it go.

Nelson, Florida's senior senator, says he wants to make the system more efficient. But he opposes across-the-board cuts for high-spending areas, a step that he says could deny people care they truly need.

Kathy Castor, a U.S. representative from Tampa, also acknowledges the complexity of cutting costs and care. She sees oversight groups, led by medical professionals, as a way to bring spending under control.

To reinforce how complex the situation is, she points out that Miami also has the distinction of being one of the nation's hot spots for Medicare fraud. The contested issue of medical malpractice is often cited as another factor.

And the mood in Miami?

Cost-control measures have been tried before, said Quick, the president of the local hospital and health care association. She says the system needs to be "right-sized," but given its long history doubts that change can happen overnight.

"There are a lot of people,'' she said, "that are wishing the Congress and the administration well."

Times researchers Carolyn Edds and John Martin contributed to this report. Letitia Stein can be reached at lstein@sptimes.com or (813) 226-3322. For more health news, visit www.tampabay.com/health.

WHO SPENDS WHAT

Per person health care spending, measured by 2006 Medicare reimbursements:

FLORIDA

Statewide average $9,379

Miami $16,351

Fort Lauderdale $9,816

St. Petersburg$9,103

Tampa $8,991

Clearwater $8,697

Orlando$8,588

Sarasota$7,467

UNITED STATES

National average $8,304

McAllen, Texas$14,946

Manhattan$12,114

Boston $9,526

San Francisco $8,331

Charlotte $7,742

Atlanta$7,363

Green Bay, Wis. $6,810


WHAT THEY SPENT

Here's a comparison between Miami, Tampa and St. Petersburg showing Medicare reimbursements, per Medicare recipient, in the last two years of life.

Total physician visits:

Miami 106

St. Petersburg 77.5

Tampa 78

Hospital days:

Miami 29

St. Petersburg 20

Tampa 20

Days in hospital intensive care units:

Miami 13

St. Petersburg 9

Tampa 7.5

Source: Dartmouth Atlas Project

A key to health care: same cost everywhere 06/20/09 [Last modified: Wednesday, June 22, 2011 9:10am]

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