Hospitals in Los Angeles County spend more on often-futile care for elderly patients at the end of life than medical centers elsewhere in California, according to a groundbreaking study to be released today.
Chronically ill Medicare patients stayed in the hospital longer, saw more doctors and received more intensive-care treatment in Los Angeles than in other metropolitan regions, including Sacramento, San Francisco and San Diego, according to research by Dartmouth Medical School. There was no evidence that the care prolonged patients' lives.
Indeed, the aggressive care in hospitals might actually have hastened their deaths, the authors said, based on previous studies showing that hospitalizations can lead to infections and other deadly complications.
"It is at least equally plausible that people are being harmed by overuse than that they're benefiting ... and we know that they're spending a lot more money," said Dr. Elliott S. Fisher, a Dartmouth professor and one of the study's authors.
The reason for the disparity: The Los Angeles region has more doctors and hospital beds for its population than other parts of the state, according to the study published in the journal Health Affairs.
The supply generates its own demand.
"Once you put something in -- MRI machines, surgical suites, ICU beds -- they'll fill it," said Laurence Baker, an associate professor at Stanford University and a co-author of the study. "Doctors by nature like to deliver care."
The research, the first of its kind to allow broad comparisons among individual hospitals, could cause insurers and policymakers to rethink how medical centers are compensated. It could also add fuel to the debate over the costs of end-of-life care, which is contributing to soaring national healthcare costs.
"This is the first ray of light on a very important facet of healthcare delivery performance," said Dr. Arnold Milstein, medical director of the Pacific Business Group on Health, a coalition of employers interested in improving quality and lowering health costs.
The study, which covers 1999 to 2003, addresses the treatment of patients on Medicare, the government health insurance program for the elderly and disabled. The patients studied suffered from one of a dozen chronic illnesses whose prognoses are grim, including metastatic cancer, AIDS and end-stage diabetes.
The researchers looked at medical costs in patients' last two years of life and the intensity of treatment provided in their last six months.
On average, Medicare spent $58,480 for each chronically ill patient in Los Angeles County in the last two years of life, according to the data. That compares with $34,659 in Sacramento, the region considered a benchmark by the researchers, $45,672 in San Francisco and $41,319 in San Diego. (The data were adjusted for race, sex, age and the frequency of chronic conditions.)
Among facilities driving the high costs in the Los Angeles region were those formerly owned by Tenet Healthcare Corp.
The nation's second-largest hospital chain had used a questionable scheme to boost Medicare billings for its sickest patients, but abandoned the controversial billing practice in December 2002.
The highest costs for care in the last two years of life were reported at Garfield Medical Center in Monterey Park, Centinela Hospital Medical Center in Inglewood, Brotman Medical Center in Culver City and Hollywood Presbyterian Medical Center in Los Angeles. All of the hospitals have been sold by Tenet since November 2004 to other operators.
"For us, this is old news," Tenet spokesman David Langness said. "Our rates were higher until 2002, when Tenet's new management disavowed the old, failed pricing strategy and changed many things."
UCLA Medical Center and Cedars-Sinai Medical Center, leading names in Southern California healthcare, also ranked near the top of the list in spending. UCLA spent far more than any of the other four UC hospitals, including UC San Francisco.
While not questioning the study, leaders at Los Angeles hospitals urged caution in interpreting it. In particular, they warned health insurers and the Medicare program against hasty cuts.
"Is the medical use in Los Angeles higher than it is in Sacramento? The answer is yes," said Dr. J. Thomas Rosenthal, associate vice chancellor of the David Geffen School of Medicine at UCLA and chief medical officer of UCLA Medical Center.
"Do we think there's substantially better healthcare in Los Angeles that would justify all that extra use? The answer is no."
However, he said, "When you get it down to individual hospitals, it's a much tougher call."
Rosenthal said 96% of the chronically ill people who came to UCLA in the last year did not die, and it's not always possible to know which patients are going to die.
"They expect that when they come to UCLA, we're going to use our resources fully to save their lives," he said.