Two Hundred Years of Hospital Costs and Mortality — MGH and Four Eras of Value in Medicine

New England Journal of Medicine: Two Hundred Years of Hospital Costs and Mortality — MGH and Four Eras of Value in Medicine

Recent discussions about health care delivery have focused on value, defined as health outcomes achieved per dollar spent. One unique window into value over the past two centuries is afforded by mortality and cost data from Massachusetts General Hospital (MGH), which celebrated its 200th anniversary in 2011. These data complement the chronicles of MGH care that the Journal has been publishing since 1924 in the form of “Case Records of the Massachusetts General Hospital.” The story these sources tell has implications beyond MGH, reflecting national trends in acute care. …

The article's conclusion:

… We thus seem to have identified four eras of value in U.S. medicine, as chronicled at one academic medical center. The first was characterized by relatively high inpatient mortality but relatively low costs, with year-to-year variation probably determined by secular events and epidemics more than by the quality of care. During the second era, value increased modestly with the introduction of novel high-impact therapies, from salvarsan in 1910 to penicillin and other antibiotics; medical breakthroughs were being applied in hospitals that were caring for a wider spectrum of patients. In the third era, value increased further, as a growing research–industrial complex introduced diagnostics and therapeutics to address an expanding array of diseases. In each of these eras, challenges were encountered and gradually addressed in a manner that improved value.

The post-2000 era, however, seems to be characterized by diminishing returns, with growth in costs far outpacing reductions in inpatient mortality. Treatment of severely ill patients with increasingly complex conditions contributes to this phenomenon, but that fact does little to mitigate the reality that for the first time, improvements in inpatient mortality may be coming at unsustainable increases in cost. Close examination of our past clarifies just how daunting is the challenge we face today.

This article reminded me of the seminar I attended last summer. A doctor from John Hopkins gave the example of a low-income, middle-aged single man who weighed 380 pounds, had diabetes, mental disabilities, no support network, no transportation, and several other challenges brought on by his weight and diabetes. How is care to be efficiently and effectively delivered to such a person? All the pieces must be addressed simultaneously, but we have segmented uncoordinated services. Any one segment trying to do its part uncoordinated from the others is largely useless, yet we spend vast sums of money doing just that. These cases are by far some of the biggest drains on private practice physicians.

There is a great article in the Stanford Social Innovation Review that I think has some good insights: Collective Impact