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Medicare: More May Not Be Better

Researchers have long known that American medical care differs dramatically from one community to another. Experts have argued endlessly about what that means. Are people better off if they live where rates of surgery or hospital use or diagnostic tests are high? Studies in this week's Annals of Internal Medicine begin to answer that question. As NPR's Richard Knox reports, the research shows that more is not better.

Dartmouth Medical School researchers started by dividing the country into a quilt with 300 patches. They looked at how much Medicare spends on average for the care of its elderly enrollees. Then the researchers zeroed in on the care of people who had three very different problems -- heart attacks, colon cancers and hip fractures -- and examined how many of these patients died over the course of a year. Levels of disability and patient satisfaction were also taken into account.

"Medicare enrollees who lived in regions with more intense practice patterns received more care, but they didn't get better care," said Dartmouth researcher Dr. Elliott Fisher, who led the five-year study. "On most measures, both the quality of care and outcomes of care were better in the more conservative regions."

The least expensive care was just as good -- even better in some respects. Medicare patients who live in the highest-spending areas got 60-percent more care, but had slightly higher mortality rates. Those in the lowest one-fifth were more likely to get preventive care, such as flu vaccine or aspirin following a heart attack.

Below is a comparison of Medicare spending and care in two Michigan cities. Grand Rapids is on the lowest end of per-capita Medicare spending nationally. Detroit is on the high end.

Average per capita Medicare spending in 1996:

• Grand Rapids: $4,004

• Detroit: $5,954

Patients receiving annual flu vaccine during first year after heart attack or colon cancer:

• Grand Rapids: 40-48%

• Detroit: 33-39%

Physician encounters per person in the first year following a heart attack:

• Office visits -- Grand Rapids: 8.7

• Office visits -- Detroit: 10.9

• In-hospital visits -- Grand Rapids: 19.1

• In-hospital visits -- Detroit: 32.7

• In-hospital specialist consultations -- Grand Rapids: 1.9

• In-hospital specialist consultations -- Detroit: 4.4

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