State Ranks Near Bottom in Medicare Study

By JULIE MARQUIS and ROBERT A. ROSENBLATT

Oct. 4, 2000 12 AM PT

TIMES STAFF WRITERS

WASHINGTON — In the first study of its kind, federal researchers have found that California’s doctors and hospitals rank near the bottom nationally in the quality of care provided to most Medicare beneficiaries.

The quality provided by the state’s health system ranks 41st among the 50 states, Puerto Rico and the District of Columbia, according to the research published today in the Journal of the American Medical Assn. It falls just between Florida and Oklahoma but a few notches ahead of Texas, which ranked 45th.

Rather than focusing on the differences among states, the researchers said their findings highlight “substantial opportunities to improve the care delivered to Medicare beneficiaries” nationwide.

“I think this reinforces that we [as a nation] do a little less well in preventive than curative care, but we’re not doing that well in either,” said Dr. Stephen F. Jencks, director of the Quality Improvement group at the U.S. Health Care Financing Administration, which did the study.

Still, many California health care officials were dismayed by the state’s poor standing--which the state’s leading physician group attributed to general underfunding of health care.

“It is unacceptable,” said Jo Ellen Ross, president of CMRI, the federally funded organization charged with improving quality of care for the state’s Medicare beneficiaries.

The study focused on proven quality indicators, including prevention and treatment of heart attacks, heart failure, stroke, pneumonia, breast cancer and diabetes.

“These indicators are very straightforward, noncontroversial, and scientifically accepted,” Ross said. “We would have expected to see higher rates than we did. . . . We hope [the study] will serve as a catalyst for physicians and hospitals to focus on improving care.”

The study reviewed the nation’s traditional Medicare program for the elderly and disabled. It did not examine Medicare managed-care plans, although researchers said they have no reason to believe quality is significantly different under managed care.

Nearly 4 million Californians are enrolled in Medicare, of whom 1.6 million--or 39%--are enrolled in managed care plans. Forty million people are enrolled in the Medicare program nationwide.

The unprecedented Medicare research is based on a scientific sampling of patient records. In the past, there have been surveys of patient satisfaction, studies of how doctors deal with particular medical problems and audits of health maintenance organizations.

But the ongoing federal study, expected to cost more than $200 million over three years, is the first national look at how well doctors deliver care to Medicare recipients.

Some experts also consider it a fair indication of basic shortcomings in the health system overall--or at least a first step toward assessing medical quality on a national basis.

California fell below the median in 16 of 24 areas, including the percentage of hospital patients who received flu and pneumonia screening; beta blockers within 24 hours of admission and upon discharge for heart attacks; ACE inhibitors, a heart medication, upon discharge for certain cardiac problems; and anticlotting medication upon discharge for stroke. The state also lagged in the percentage of diabetics who received annual hemoglobin tests.

Illinois, New Jersey, West Virginia, Puerto Rico and most of the Southern states, including Texas, joined California in the bottom ranks.

Jencks cautioned that the variation among the states was relatively modest. The most remarkable finding, he said, was how much room for improvement existed across the board.

“We published the state numbers because we felt if we did not, people [in individual states] would have said, ‘That’s the national performance but we’re better than that.’ . . . In every state, there are significant opportunities to improve.”

Asked to explain regional and state variations, Jencks said, “We don’t know the answers. . . . We have to do further studies to understand that. But it would be terrible to get wrapped up in a debate about which one does a bit worse and which does a bit better.”

Nonetheless, some variations among states are striking. For example, it is universally agreed that a heart attack victim should be given a prescription for beta blockers to prevent a second heart attack upon hospital discharge. However, the compliance with this rule of good medicine ranged from 47% of patients in Mississippi to 93% in Massachusetts, according to the study. The California figure was 68%. The median state performance was 72%.

The state’s hospital and physician groups pledged this week to work together to improve California’s performance.

Yet officials at the California Medical Assn. said the state’s health system has been hampered by chronic underfunding. They blamed “spillover” from the world of for-profit managed care, which they said has squeezed medical groups, overtaxed emergency rooms and threatened the solvency of hospitals statewide.

“Medicare patients don’t go to a separate doctor’s office,” said Dr. Marie G. Kuffner, president of the California Medical Assn. “They’re mixed up with the whole population. Their care is going to reflect . . . the general environment.”

Dr. Jack Lewin, the agency’s chief executive officer, acknowledged that there are other pressures on health care in this state as well, including the large number of uninsured immigrants. But he, too, named for-profit managed care as the chief culprit in quality lapses.

Bobby Pena, vice president of communications for the California Assn. of Health Plans, an HMO trade group, responded: “I think the connection that the CMA is trying to make is a reach.” To blame managed-care plans for problems with care it is not involved in is, he said, “illogical.”

A trade group representing more than 450 of the state’s hospitals had a more subdued reaction to the federal study than the CMA. Dorel Harms, vice president of professional services for the California Healthcare Assn., called the findings “very useful.”

“I would imagine we’ll be discussing what we can do to make it look better three years from now,” she said.

Marquis reported from Los Angeles and Rosenblatt from Washington.

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Medicare Across the Map

In a state-by-state comparison, elderly Medicare patients were more likely to receive widely accepted treatments for heart failure, stroke and other life-threatening diseases in Northern and less-populated states than in Southern and more-populated states.

TOP 10

1. New Hampshire

2. Vermont

3. Maine

4. Minnesota

5. Massachusetts

6. Connecticut

7. North Dakota

8. Iowa

9. Colorado

10. Oregon

BOTTOM 12