The Quality Quandary: When Less Is More and More Is Less

When you think about it, quality in healthcare is all about improvement. It means improving the daily lives of patients, improving the technology to deliver care, improving communications between providers and patients, and improving chances for survival.

But should this improvement cost more—or less? As two new studies out this week show, what you pay for up front may lead to results you may not expect—depending on what you are treating.

At the national level, policymakers are giving more emphasis over how to achieve better quality at far less cost. In recent years, they are giving more attention on whether earlier discharges from hospitals could be a way of saving money—or creating more expense if the patient returns to the hospital within 30 days or six months.

Research by Lena Chen, MD, a clinical lecturer in internal medicine at the University of Michigan Health System, found that sometimes you may get better results if you pay more upfront—but at other times it may not make that much difference, especially in the area of long-term results.

In a study that appears in the Archives of Internal Medicine, she and her colleagues found different results for Medicare patients with two common hospitalized conditions: congestive heart failure (CHF) and pneumonia.

For each condition, the researchers used data from national databases (Medicare, American Hospital Association, Hospital Quality Alliance) to review the association between hospital cost of care and several variables: 30 day death rates, readmission rates, six month inpatient cost of care, and a quality score based on performance indicators for each condition.

Costs of care for each condition showed wide variation. Care for a typical Medicare inpatient with CHF ranged between $1,522 to $18,927, depending on which of the 3,146 hospitals where the patient had been hospitalized. The average cost was $7,114. Meanwhile, cost of care for a typical patient with pneumonia averaged $7,040 and varied in cost from $1,897 to $15,829 per hospitalization among 3,152 facilities.

Hospitals among the top fourth of the highest cost hospitals had higher quality of care scores and lower mortality for CHF. However, for pneumonia, the opposite was true. When compared with low cost hospitals, high cost hospitals had lower quality of care scores and higher mortality for pneumonia.

Hospitals with lower costs had similar or slightly higher 30 day readmission rates (24.7% for CHF and 17.9% for pneumonia) when compared with higher cost hospitals (22% for CHF and 17.3% for pneumonia). However, patients initially seen in lower cost hospitals still incurred lower overall costs of care over six months following their initial visits in higher cost hospitals ($12,715 vs. $18,411 for CHF and $10,143 vs. $15,138 for pneumonia).

"The quality between the high-cost and the low-cost both weren't that great," Chen says. As for why costs were higher or lower—perhaps use of health information technology, the existence of vertical integration, or a variation in the number of tests ordered—is not evident from this study. "We didn't have the data to look at the potential reasons for the differences in costs," Chen says.

In a diabetes study released by the National Minority Quality Forum, Medicare beneficiaries with the condition who consumed the least of their Medicare benefits and services ended up not saving money. Instead, they cost Medicare more money because they went to the emergency room more often and required more hospitalizations.

The study divided Medicare beneficiaries into five groups—crisis consumers, heavy consumers, moderate consumers, light consumers and low consumers—based on how much Medicare reimbursed for services in any year. The two most costly clusters were crisis consumers and heavy consumers, representing about 11% of Medicare beneficiaries—but 65% of all costs.

But these cluster groups could vary each year—particularly beneficiaries who are low consumers one year. They could be catapulted into the heavy consumers group the next year—triggered by a critical and costly health event.

"If we can identify these patients, who are under managing their chronic condition putting them at high risk for disease complications, we can intervene to help these individuals manage their disease more effectively, and, ultimately, reduce overall healthcare costs," says Gary Puckrein, PhD, a founding partner of the Diabetes Care Project and President and CEO of the National Minority Quality Forum, who spoke at a telebriefing where the study was released.

"As a practicing physician, we really need a paradigm shift—from a population-based approach to treating diabetes to developing a more personalized management and strategy," says Kenyatta Lee, MD, an assistant professor of community health and family medicine at the University of Florida.

So do these studies provide a lesson in comparing treatment and costs? Well, maybe more research is needed, Chen says. Possibly more efforts, such as comparative effectiveness research—or as it's referred to as "patient-centered research" in the latest federal budget—could lay a foundation for some better answers on how much to spend—less or more—for quality care and get the best outcomes.