Two Peninsula hospitals on 'aggressive' list toward Medicare patients
By Jim Casey, Peninsula Daily News
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Jefferson Healthcare hospital ranks in the second percentile of a nationwide study of how aggressively hospitals treat chronically ill Medicare patients.
Olympic Medical Center is a notch higher at the third percentile on a scale of one to 100, least to most aggressive.
Forks Community Hospital was not included in the study.
The rankings were published last week by Consumer Reports Health based on data from Dartmouth Medical School in New Hampshire.
While aggressiveness might sound desirable, medical experts say that's not necessarily so.
Aggressive care brings outcomes no better than "core measures," or best practices, as measured by the Centers for Medicare and Medicaid, the OMC chief of medical staff said.
Aggressive means more specialists, more tests, more surgeries and the possibility of more errors, misdiagnoses, infections and incompatible prescriptions, Dr. Mark Fischer said.
Fewer days in hospital
A Medicare patient with a late-in-life illness would spend an average of 13.8 days at Jefferson Healthcare and make 42.8 visits to his or her doctors, according to Consumer Reports Health.
At OMC, the hospital stay averages 14.4 days, with 47 visits to doctors.
Fischer said Friday it's also a case of less aggressiveness meaning less cost.
"There's no secret anymore that much more doesn't mean much better," he said.
"That's the consensus of the Dartmouth report."
Fischer answered, "Absolutely!" when asked by Peninsula Daily News if the practice was shared among doctors, not dictated by financial administrators.
"This has occurred without the medical community having some sort of mandatory fiscal requirement," he said.
Moreover, the protocol isn't practiced only at OMC but also by solo practitioners and group clinics in Sequim and Port Angeles, he said.
Patient can choose care
As for Jefferson Healthcare, CEO Vic Dirksen said, "I think we do a real good job, real good primary care.
"On the other hand, someone who wants an illness treated aggressively may choose to go to another hospital, such as Swedish Health Services in Seattle," which, [at the 44th percentile, was rated the most aggressive in the state.
"That's something I think our residents should feel good about."
The Dartmouth study reviewed the records of more than 4.7 million Medicare patients at hundreds of hospitals from 2001 to 2005.
Patients were 65 or older, and being treated for the top nine causes of death: congestive heart failure, chronic pulmonary disease, cancer, dementia, coronary artery disease, chronic kidney failure, peripheral vascular disease, diabetes with organ damage, and severe chronic liver disease.
U.S. regions vary widely
One of the study's salient findings was that aggressiveness varied among geographic regions of the U.S., with New York, Florida and California at the top.
Fischer cited a New York Times report that quoted Peter Orszag, director of the Congressional Budget Office.
Orszag noted that the average cost to Medicare for patients in the last six months of their lives varied from $28,763 at an affiliate of the Mayo Clinic in Minnesota to $52,911 at the UCLA Medical Center in Los Angeles.
Both are premier facilities.
"How can the best medical care in the world cost twice as much as the best medical care in the world?" Orszag asked.
Hospitals in the Pacific Northwest were among the least aggressive and least costly in the nation.
The lower cost is a blessing for patients but a curse for providers because Medicare has locked in levels of cost on which it reimburses doctors and hospitals.
Cost tied to levy lift
The result is that while Northwest medical centers range from the first to the 44th percentiles of aggressiveness, Washington state ranks 46th in reimbursements from Medicare.
The shortfall is one reason why OMC where about 70 percent of patients are insured by Medicare, Medicaid or another government insurer seeks to boost its tax levy from 11 to 44 cents per $1,000 of real property's assessed value in the election that will end Aug. 19.
Some things, said Fischer, money can't buy.
"You can draw some conclusions that emphasize teamwork, vision, communication among providers of care, quality of care, safety of care and, last but not least, economic stewardship."
OMC meeting standards
The Northwest measures well by other standards.
Fischer cited the Centers for Medicare and Medicaid Services benchmarks for treatment of heart attack, heart failure, pneumonia and surgery care.
In 29 applicable categories, OMC in March scored 100 percent in 22 measures and was at or slightly below average level in the others.
"In Port Angeles and Sequim, it's not an accident that our CMS measurements look good, that our length of stay is respectable and that we show up on these Dartmouth measurements as an efficient medical center that takes medical stewardship very seriously," Fischer said.
Aggressive care drives up costs, Fischer said.
"The insatiable appetite by patients to have everything done and a motive to do tests, that's all going to lead to incredibly higher costs and not necessarily higher quality," he said.
It's the patient's decision
However, in the end sometimes at life's end the decisions on aggressiveness of care are up to the patient, then the family and lastly the caregiver.
"Some people would say, 'I want everything done,'" Fisher said.
"Others would say, 'Never in my life would I have wanted to do that.'"
Meanwhile, OMC and Jefferson Healthcare have single-digit rankings.
Dirksen added, "I think people should feel pretty pleased that they live in Washington state.
"I'm glad to hear that the outcomes for our patients are good outcomes."
Said Fischer: "I don't have any reason to believe that we should be ashamed of a low rating.
"We're in good company."
Aggression by the numbers
North Olympic Peninsula and Puget Sound-area hospitals, ranked by percentile in the aggressiveness of care given chronically ill Medicare patients, and followed by the average patient cost for total doctor visits while in the hospital, include:
1 Whidbey General, Coupeville, $1,756.
2 Jefferson Healthcare, Port Townsend, $2,178; Mason General, Shelton, $2,754.
3 Olympic Medical Center, Port Angeles, $2,149; Tacoma General Hospital, Tacoma, $2,258.
5 Grays Harbor Community Hospital, Aberdeen, $2,442.
10 Harborview Medical Center, Seattle, $2,171.
11 Harrison Medical Center, Bremerton, $2,734.
17 St. Joseph Medical Center, Tacoma, $2,409.
29 Virginia Mason Medical Center, Seattle, $2,531.
33 UW Medical Center, Seattle, $2,809.
40 Swedish Medical Center, Seattle, $2,493.
44 Swedish Health Services, Seattle, $2,924.
Consumer Reports
What's the difference?
PORT ANGELES What's medical aggressiveness compared to conservatism?
Dr. Roger Fischer, chief of medical staff at OMC, offered this example:
A 90-year old female is diagnosed with aortic stenosis, in which a narrowing of the aortic valve prevents blood from flowing freely from the heart to the aorta, the body's main artery.
The operation will include a period of inpatient recovery, perhaps with a ventilator. plus rehabilitation for about three weeks in a nursing home.
"It's not a slam dunk as to which pathway would be better," Fischer said but added that the conservative approach does not include surgery, inpatient recovery, rehabilitation, or the risks of an infection or a post-operative stroke.
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Reporter Jim Casey can be reached at 360-417-3538 or at jim.casey@peninsuladailynews.com.
Last modified: May 31. 2008 9:00PM