This story is from the archives of UCLA Today, a discontinued publication.

Los Angeles is not Minnesota when it comes to health care needs

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JTRosenthal
Dr. J. Thomas Rosenthal
Dr. Stobo is senior vice president of University of California Health Sciences and Services. Dr. Rosenthal is chief medical officer of the Ronald Reagan UCLA Medical Center and associate vice chancellor of the David Geffen School of Medicine. This op-ed originally appeared in the Los Angeles Times.
 
As the health-care debate moves into second gear, policymakers are searching for ways to increase access and reduce costs. Some believe there is a painless way to cut as much as 30 percent in spending by eliminating waste and by requiring physicians in the country's highest-cost areas to adopt the practices of the lowest-cost regions.

Many stories and the Obama administration have cited a June article by Dr. Atul Gawande in the New Yorker magazine and research done by the Dartmouth Atlas Project. Both assert that regional variations in Medicare expenditures occur, in great part, as a result of overuse of services and procedures. Legislation has been introduced in Congress that would reduce Medicare payments to places such as Los Angeles and redistribute the dollars to parts of the country that are deemed "more efficient."

We agree that every effort should be made to curtail spending that does not show a proven health benefit. However, we disagree that policymakers can extrapolate research data from one region to arrive at conclusions regarding another, very different region. This simplistic analysis could have real-world consequences, including further diminishing access for the urban poor and to those middle-class residents who live near pockets of significant poverty.

Investigators from Dartmouth used Medicare bills submitted by doctors and hospitals for patients who died and compared spending across geographies and across hospitals. The theory is that because all the patients died, any variation in spending must be waste. They then extrapolated these findings to identify high-spending geographic regions and high-spending hospitals for all Medicare costs.

Voila: a map in which Minnesota is the paragon and Miami and Los Angeles are the profligates. We dug a little deeper into relevant state health and hospital-use data for Los Angeles County. What we found was quite striking and pointed to one of the key differences in costs and outcomes for health care paid by Medicare.

The per capita income in Los Angeles County is $24,705; in Minnesota, it is $37,373. More than 38 percent of Los Angeles County citizens live below the poverty line, 57 percent are black or Hispanic, and 24 percent are uninsured. In Minnesota, 11.6 percent live at or below the poverty line, 9 percent are black or Hispanic, and only 8.8 percent are uninsured. In Los Angeles County's core — central and south Los Angeles — the differences are even more striking: 56 percent of the residents are at or below the poverty line, 80 percent are black or Hispanic, and 41 percent are uninsured.

Health care costs are significantly higher in areas of poverty. So while the hospital days per 1,000 Medicare enrollees is 2,429 in the central Los Angeles core, it is only 1,777 in the rest of Los Angeles County. Minnesota's is 1,613 days. If you eliminate the two Los Angeles core areas in a comparison, the Medicare cost in Los Angeles County looks much like Minnesota's. Also, non-Medicare hospital use in Los Angeles is significantly less than in Minnesota, hardly consistent with the theory that the medical care in Los Angeles is inefficient or wasted.

The Los Angeles core area is definitely not Minnesota, home of the Mayo Clinic, where there appears to be a surfeit of healthy and relatively wealthy patients and a vibrant, integrated health care infrastructure. In core poverty corridors, where there is not excess capacity in terms of beds, emergency departments, nurses and primary-care practitioners, patients are suffering because they have received too little care for too long and arrive at hospitals with multiple health conditions, requiring more extensive, and thus more expensive, care.

Controlling the rate of growth of health-care spending is an imperative. Unfortunately, there are no easy fixes. It will require incentives for patients and physicians to reduce unnecessary health-care use and to make prevention play a larger role. It also will require societal decisions about what constitutes value, particularly at the end of life.

Further, it means addressing the underlying causes of health care disparities — disparities that will not disappear just because health-care reform is enacted.

Controlling the rate of growth of health-care spending is an imperative. Unfortunately, there are no easy fixes. It will require incentives for patients and physicians to reduce unnecessary health-care use and to make prevention play a larger role. It also will require societal decisions about what constitutes value, particularly at the end of life.

Further, it means addressing the underlying causes of health care disparities — disparities that will not disappear just because health care reform is enacted.
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