Last week’s Cavalcade of Risk (the fifth anniversary edition!) included a very interesting article by one of my favorite health care bloggers, Jaan Sidorov. Jaan wrote about a recent Dartmouth study published in the JAMA that analyzed health care costs, death rates, and preventable hospitalizations for Medicare beneficiaries in 2007, and also took into account how many doctors were providing primary care (including self-identified PCPs and “full time equivalents”, or FTEs) in each patient’s zip code.
For people who believe that increasing the number of PCPs would be a panacea for our healthcare system, the results of the Dartmouth study are likely to be surprising. The researchers found that if all areas in the US were to have a PCP density as high as the areas in the study with the most PCPs (and FTEs), we could expect 48,398 fewer deaths and 436,002 fewer hospitalizations. But total health care spending would increase by $13.8 billion, even with the fewer hospitalizations. That’s because although there would be lower overall hospital costs, there would be increased doctor fees that would more than offset the savings in hospital costs.
I’ve written about how the PCP shortage is likely to be more of an issue for people who have Medicaid then for those with private health insurance. And for people in communities with very few PCPs, it can also be inconvenient to try to schedule an appointment with a PCP, especially as a new patient. The 48 thousand fewer deaths that could be achieved among Medicare beneficiaries if all areas of the country had high PCP densities is compelling, but the $13.8 billion in additional spending is a bit sobering. Healthcare costs have been increasing rather quickly for years now, and a “solution” that would further increase them isn’t likely to work well.
The Dartmouth study results might seem counter-intuitive, since we often assume that as long as people are getting regular care by a PCP, they will be more able to avoid expensive hospitalizations. That appears to be true, but the lower cost office visits and outpatient treatments add up faster than one might expect, and would actually exceed the cost of the hospitalizations that they would prevent. Of course, another way of looking at the picture is in terms of human outcome. I think most people would rather avoid a hospitalization or preventable death by having more visits with a PCP. For the 48,398 people who died and the 436,002 people who have a preventable hospitalization, my guess is that they would much rather have had a higher PCP density in their area, despite elevated costs associated with more PCP care.