Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.

Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care. Efforts to reduce spending should proceed with caution, but policies to better manage further spending growth are warranted.

N THE FACE OF THE FINANCIAL, practical, and ethical challenges inherent in undertaking randomized clinical trials (RCTs), investigators often use observational data to compare the outcomes of different therapies. These comparisons may be biased due to prognostically important baseline differences among patients, often as a result of unobserved treatment selection biases. Unmeasurable clinical and social interactions in the diagnostic-treatment pathway, and physicians' knowledge of unmeasured prognostic variables, may affect treatment decisions and outcomes. Physicians are frequently risk averse in case selection, performing interventions on lower-risk patients despite greater clinical benefit to higher-risk patients. [1][2][3] In some cases, especially when data are collected on detailed clinical risk factors, these differences can be controlled using standard statistical methods. In other cases, when unmeasured patients characteristics affect both the decision to treat and the outcome, these For editorial comment see p 314.

Many current policies and approaches to performance measurement and payment reform focus on individual providers; they risk reinforcing the fragmented care and lack of coordination experienced by patients with serious illness. In this paper we show that Medicare beneficiaries receive most of their care from relatively coherent local delivery systems comprising physicians and the hospitals where they work or admit their patients. Efforts to create accountable care organizations at this level -the extended hospital medical staff-deserve consideration as a potential means of improving the quality and lowering the cost of care.Recognition that the U.S. health care system suffers from serious gaps in quality and widespread waste has stimulated a broad array of public-and private-sector initiatives to improve performance. These include not only public reporting, pay-for-performance (P4P), and quality improvement programs but also major initiatives by the organizations responsible for institutional accreditation and professional certification. 1 The underlying goal of these efforts is to improve the quality and lower the cost of care by fostering greater accountability on the part of providers for their performance.A distinguishing feature of many of these efforts, however, is their focus on the individual provider as the locus of both performance assessment and accountability. This focus reflects the historical development, oversight mechanisms, and payment systems that prevail in the U.S. health care system and the interest of providers to be held accountable only for care that is within their direct control. The limitations of this approach are increasingly apparent. The provision of high-quality care for any serious illness requires coordinated, longitudinal care and the engagement of multiple professionals across different institutional settings. Also, many of the most serious gaps in quality can be attributed to poor coordination and faulty transitions. 2 For these reasons, a recent Institute of Medicine (IOM) report called for efforts to foster shared accountability among all providers for the quality and cost of care. 3Although it is attractive in theory, many practical challenges exist in identifying an appropriate locus for shared accountability in the current environment. Some have focused on physician groups, largely based on evidence suggesting that large physician groups achieve better performance. 4 However, the physician organizations most capable of integrating and coordinating care-traditional health maintenance organizations (HMOs) and multispecialty group practices-represent only a tiny share of the current market, and most physicians still practice in small groups. 5 Health plans are present in all U.S. markets but have largely focused NIH Public Access Author ManuscriptHealth Aff (Millwood) In this paper we explore an alternative approach: fostering the development of accountable care organizations comprising local hospitals and the physicians who work within and around them. 7 We build on...

Introduction-The long-term excess mortality associated with hip fracture remains controversial.

Per capita Medicare spending is more than twice as high in New York City and Miami than in places like Salem, Oregon. How much of these differences can be explained by Medicare's paying more to compensate for the higher cost of goods and services in such areas? To answer this question, we analyzed Medicare spending after adjusting for local price differences in 306 Hospital Referral Regions. The price-adjustment analysis resulted in less variation in what Medicare pays regionally, but not much. The findings suggest that utilization—not local price differences—drives Medicare regional payment variations, along with special payments for medical education and care for the poor.

No abstract

Recent studies have revealed dramatic differences among academic medical centers (AMCs) in the quantity of care provided to their patients. The implications, however, depend upon whether the additional resources provided by some centers lead to better results. This study describes the content, quality, and outcomes of care across AMCs that differ by up to 60 percent in the overall intensity of medical services delivered to patients with serious chronic illnesses. Efforts to reduce costs will require attention to supply-sensitive services (the frequency of hospital stays, physician visits, specialist consultations, diagnostic tests, and minor procedures) and should include a focus on the longitudinal efficiency of hospitals and medical staffs.