WASHINGTON -- New research shows huge, unexplained variations in the amount, intensity and cost of care provided to Medicare patients with chronic illnesses at the nation's top academic medical centers, raising the possibility that the government could save large amounts of money.
In a report being issued today, Dartmouth College researchers say that total Medicare spending in the last two years of life ranges from an average of $93,842 for patients who receive most of their care at UCLA Medical Center to $53,432 at the Mayo Clinic's main teaching hospital in Rochester, Minn.
Other top-ranked hospitals fell in between. Medicare spending averaged $85,729 for those who used Johns Hopkins Hospital in Baltimore, $78,666 at Massachusetts General and $55,333 at the Cleveland Clinic.
Differences in the last six months of life were even more striking. Medicare spent an average of $52,911 for UCLA patients and $28,763 for those who used Mayo's St. Marys Hospital.
The numbers, from the 2008 edition of the Dartmouth Atlas of Health Care, have caught the eye of federal officials, who say Medicare could save billions of dollars a year if doctors and hospitals in high-spending regions were as efficient as those in low-spending regions.
"How can the best medical care in the world cost twice as much as the best medical care in the world?" asked Peter R. Orszag, director of the Congressional Budget Office.
More than 90 million Americans have chronic illnesses such as diabetes, cancer and heart disease, and seven out of 10 die from chronic diseases. Most of Medicare's spending on such patients in the last two years of life is for care in hospitals.
The chief author of the study, Dr. John E. Wennberg of Dartmouth Medical School, said doctors and hospitals that provided more care, or more intensive care, did not necessarily achieve better results for patients.
"Some chronically ill and dying Americans are receiving too much care -- more than they and their families actually want or benefit from," Wennberg said. "Contrary to popular assumptions, it's the volume of services, not the price per service, that accounts for most of the variation in Medicare spending."
The researchers analyzed data for more than 90 academic medical centers and focused on five ranked as the nation's best by U.S. News & World Report.
"The UCLA Medical Center was by far the most aggressive in managing chronic illness, as measured by the use of medical specialists and intensive care units, as well as the total number of physician visits," the Dartmouth report said.
In the last six months of life, the researchers said, chronically ill patients using the UCLA hospital spent about 50 percent more time hospitalized and had more than twice as many doctor visits as those who received most of their care at Mayo.
Hospital executives said they took the report seriously and wanted to understand the disparities.
Dr. J. Thomas Rosenthal, chief medical officer at the UCLA hospital, defended its practices. "Some of the aggressive care saves lives," Rosenthal said. "The Dartmouth study does not ferret that out in a systematic way."
Rosenthal also said that patients at UCLA might be more severely ill than those at other academic medical centers.
The Dartmouth Atlas says Medicare spending was even higher, averaging more than $105,000 per beneficiary, for those who received care in the last two years of life at several other hospitals, like Cedars-Sinai in Los Angeles and New York University Medical Center in Manhattan.
Dr. Michael L. Langberg, chief medical officer at Cedars-Sinai, cited two limits of the Dartmouth study. The researchers focused on patients who died, not those who lived, and they did not have access to laboratory results or other clinical information on patients.
Dartmouth Professor Elliott S. Fisher, a co-author of the study, said those observations were correct. But he added: "We are comparing patients with identical outcomes -- all were dead in two years -- so it's unlikely that differences in the severity of illness account for the variations we saw. In other studies, we found no evidence that a higher-intensity pattern of care leads to better survival."
Dr. Denis A. Cortese, president of the Mayo Clinic, suggested several reasons for his institution's less aggressive style of care.
"Our physicians are all salaried," Cortese said. "They have no financial incentive to do more than is necessary for the patient. In each case, multiple doctors and nurses make decisions collaboratively with the patient and family members. We really try to understand the patient's wishes for end-of-life care."
Dr. Robert A. Press, the chief medical officer at NYU Medical Center, said it was taking steps to address the findings. But he said: "It's not an easy fix. We are dealing with a culture of physicians who have been very aggressive in their care and a patient population that has desired this type of care."