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End-Care Sticker Shock

If your aging parents are thinking of moving to Florida, you might want to suggest Fort Myers, not Miami-Fort Lauderdale. They'll live just as long there, but the healthcare will be less intense and less expensive. And when they die, they'll be less likely to do so in what one researcher calls ''a therapeutic frenzy,'' hooked up to tubes and machines.

That's one of the conclusions in a new study by Dartmouth Atlas, an organization whose analyses showing widely divergent healthcare costs around the United States have for years shaped the healthcare debate.

Previous Dartmouth studies have revealed South Florida's healthcare to be among the nation's most costly, and that trend continues.

In Miami-Dade and Broward counties, 16 hospitals rank among the top 5 percent in the country in healthcare costs for patients in their last two years of life. All 33 are in the top 20 percent.

Peter Orszag, director of the Congressional Budget Office, said the Dartmouth research has ``unbelievable value.''

Orszag told a Senate committee that by reducing expenses in high-cost areas like South Florida could result in as much as $600 billion in savings on a national basis.

Dartmouth studies indicate that can be done without reducing quality of care.

In fact, the latest study says, the more money spent and the more care provided, the higher the risk of dying: ``Your chances of dying increase in regions where the healthcare system delivers more care.''


The reason is that some people ''will be harmed'' by having too many procedures done, said Elliott Fisher, the Dartmouth report's co-author. ''On average, there is no survival benefit'' from more aggressive care.

Dartmouth's data can be read as a blueprint for building a better, cheaper healthcare system that can cover more people, Fisher believes.

''There are huge opportunities to improve the efficiency of care,'' he said.

South Florida healthcare providers had better get more efficient, or they risk Congress stepping in and lowering Medicare reimbursements, warns Becky Cherney, president of the Florida Health Care Coalition, an organization of major corporations dedicated to improving quality and lowering cost of care.

''It's really time for the South Florida medical community to react,'' she said.

Dartmouth researchers believe the way to do that is by getting doctors to focus on what's called evidence-based care, following proven treatments -- for example, always give an aspirin to a heart attack patient -- rather than ordering multiple tests to see what they find.

The problem is that, at present, the system rewards providers each time more care is ordered, but not for being efficient, says Fisher.

The result is that there are wide discrepancies even within the expensive South Florida region. Among the Dartmouth report's findings:

 In Broward and Miami-Dade counties, Mount Sinai in Miami Beach ranks near the top for the amount of care. For the last two years of life, its average patient will cost Medicare $52,650 for in-patient services. In the patient's last six months, she will spend 25 days in the hospital and be subjected to 74 doctor visits. That's far more than the $28,148 spent at Imperial Point in North Broward, where the patient will spend 14 days in the hospital and have 48 doctor visits.

 In Miami, patients associated with Pan American Hospital (now Metropolitan Hospital) are the most likely to die in the hospital -- 50 percent. That's more than double the 23 percent rate at Florida Medical Center in Lauderdale Lakes.

Carlos Garcia, chief compliance officer for Metropolitan Hospital, said the new owners have not had a chance to study the complicated data. ''We are reviewing this report now, so I can't comment,'' he said.

 In west Miami-Dade, two-thirds of the patients at Westchester General will bounce between 10 or more specialists in their last six months of life. At Homestead, only a third will do that. Westchester General did not respond to two requests for comment.

The hospitals with high costs insist they shouldn't be criticized.

''Mount Sinai is going to do everything it can to follow the wishes of our physicians, patients and their families as cost effectively as possible,'' spokeswoman Pamela Gadinsky said in an e-mail.

``According to the report, Mount Sinai's aggressive score (99.3) costs Medicare approximately $82,816. However, Jackson Memorial's less aggressive score (88.3) costs Medicare only 1 percent less at $81,695.''

The research by Dartmouth Atlas, which is affiliated with Dartmouth College and its medical school, has consistently found that high-cost areas are invariably those with high numbers of hospital beds and specialists relative to patient population.

That's certainly true in South Florida, which has high rates of empty beds and many specialists.

The new data cover 2001 through 2005, and are adjusted for sex, race, age and severity of illness for Medicare, the federal health insurance for the elderly.


The report focuses on patients with at least one of nine chronic conditions so that the researchers can measure comparable populations. Much of the information concerns Dartmouth's Hospital Care Intensity index, which measures the number of days patients spend in hospitals and the number of doctors they see as in-patients.

One section of the report considers how a son might advise parents thinking of moving to Florida.

By going to and using the HCI index, ``he notes that the east coast regions in southern Florida -- Miami and Fort Lauderdale -- rank high on the HCI index, while Fort Myers ranks slightly below the 50th percentile among all U.S. hospitals.''

The report contrasts that with one hospital in Miami-Dade. ``For patients . . . who want everything possible done to rescue them no matter how ill or near to death they may be, Westchester General Hospital stands out.''

A third of all deaths there are in intensive care, ''placing it in the 99th percentile in the country for aggressive end-of-life care,'' the report says. The high number of physician visits connected with such care -- 85 -- means the average physician co-payments for a Westchester patient are $6,000 -- about 50 percent more than the co-pays a similar patient could expect at Holy Cross.

Dartmouth's Fisher notes there can be serious quality of life concerns for those who end their days in intensive care, hooked up to machines and monitors.

''This is a very important issue for patients and their families to consider,'' he said.


The report compares three Miami-Dade hospitals with high HCI scores -- Westchester, Mount Sinai and Hialeah -- with three that have much lower scores -- South Miami, Baptist and Jackson Memorial. Of these, Baptist has the lowest percentage of intensive care unit care during a final illness (25 percent) and the highest percentage admitted to hospice (46 percent), where treatment concentrates on comfort and alleviating pain.

''For those for whom the most important factor is low use of intensive care during the terminal phase of illness, Baptist Hospital may be a better choice,'' the report states.

Mount Sinai's spokeswoman said the hospital provides ``a level of treatment appropriate for each individual that is sensitive to their personal and religious requirements. . . . Mount Sinai accommodates all of its patients who seek hospice care.''

At Baptist Health South Florida, Chief Quality Officer Thinh Tran said he looks ''in depth'' at the Dartmouth data and that the five hospitals in the Baptist system work hard to practice evidence-based medicine. ''We work very closely with the families and patients'' to explain options for end-of-life care, he said, ``to provide the best outcome for the patient and also consider low costs.''

The Baptist chain includes Homestead, a hospital in which dying patients see a comparatively low number of specialists. ``We have [staff] coordinating care and, collaborating with patients, we try to bring in just the right patients at the right time.''

At the other end of the spectrum is South Beach Community Hospital, which ranked at 100 on the HCI index, putting it in the top rank nationally for intensity of care.

The hospital closed in February 2006 after running into repeated problems with Medicare over billing issues. After it filed for bankruptcy, federal officials took the extraordinary step of banning it from receiving Medicare payments for five years.

The record is more complicated at Jackson Memorial, where most services are provided by faculty of the UM medical school. Its intensity of care index ranks it near the very top of the nation's academic medical centers, next to programs such as UCLA Medical Center and New York-Presbyterian, and far above Johns Hopkins, Yale University and the Mayo Clinic's St. Mary's Hospital.

But within South Florida, Jackson ranks 26th of 33 hospitals listed by healthcare costs.

Pascal Goldschmidt, dean of the UM medical school, says he's paying special attention to the Dartmouth study and how UM's doctors practice.


When he arrived in Miami two years ago, Goldschmidt said he noted that evidence-based care was ''definitely not as advanced here'' as at his previous school, Duke University, but he has been working hard to change that.

Dartmouth's Fisher believes medical schools and their teaching hospitals can lead the way in establishing evidence-based care, but he believes that there's a basic flaw with the nation's present healthcare system. ''The current system fosters entrepreneurial behavior,'' meaning the more procedures doctors and hospitals do, the more they get paid and that ''can be harmful to patients,'' he said.


Linda Quick, president of the South Florida Hospital and Healthcare Association, has been a longtime supporter of the Dartmouth work, but she notes the data is based on what Medicare paid out, which might be different than services rendered.

That could be significant because federal investigators have long considered South Florida a top spot for Medicare fraud, particularly in areas like durable medical equipment (DME).

Although Dartmouth doesn't attempt to analyze for fraud, the patients with the highest DME expenditures in South Florida were connected with Larkin ($8,081) and Westchester ($7,862), far above the two hospitals with the lowest DME expenses -- Holy Cross ($1,498) and Imperial Point ($1,472).

Jack Michel, chief executive of Larkin, said DME expenditures are ordered by doctors, not hospitals: ``Larkin doesn't have anything to do with that.''

Still, healthcare costs in South Florida continue to be undeniably high, and UM's Goldschmidt says that needs to change.

''The overuse of specialty care and procedures is in no way good for health. There is clearly no link between the cost of healthcare and the quality of healthcare,'' he said.

Changing physician practice habits won't be easy.

''I think it's going to take about 10 years to make a difference in healthcare in Miami,'' said Goldschmidt, ``but I'm very committed.''