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But not all such efforts may serve patients well. There’s concern, for example, that outpatient surgical centers don’t always have the resources and staff needed to handle potential complications of the increasingly complex operations they’re taking on. Other research suggests that hospitals that spend more and do more may have better patient outcomes and lower mortality rates.
Teaching hospitals are generally the costliest medical environments. Some have argued that only the sickest patients — for whom complex services and technologies are most likely to help — should be treated there, while relatively healthy patients should preferentially be cared for in less costly community hospitals. But do sicker patients really do better at teaching hospitals? And do healthier patients fare just as well in either setting?
The new study on Medicare hospitalizations sheds some light. (Both of us were part of the group that conducted this study.) Led by Laura Burke and Ashish Jha at Harvard, the study analyzed more than 11 million Medicare hospitalizations and found that almost all patients — whether very sick or relatively healthy — had lower mortality rates at teaching hospitals. But there are also some differences.
Among patients admitted for operations like hip replacements, the patients with the most health problems over all were the ones likeliest to benefit from a teaching hospital. On the other hand, among people admitted with conditions like pneumonia or heart failure, though all groups did better at the teaching hospitals, the difference was greatest for the relatively healthy patients.
The more advanced technologies available at teaching hospitals explained some, but not all, of the difference. Other factors like subspecialty expertise, more clinicians involved in care, and greater availability of ancillary services may also be playing a role.
Given the high — and sometimes unjustifiable — cost of some health care settings, it seems reasonable to pursue payment parity for comparable care delivered in different settings. And all other things equal, the shift toward lower-intensity, lower-cost settings is a worthy goal. But in some cases, outcomes may not be equal, and it seems we should make sure we’re not cutting quality when we’re cutting costs.
Dhruv Khullar, M.D., M.P.P., is a physician at NewYork-Presbyterian Hospital, a researcher at the Weill Cornell Department of Healthcare Policy and Research, and director of policy dissemination at the Physicians Foundation Center for Physician Practice and Leadership. Follow him on Twitter at @DhruvKhullar.
