In the last two years of life, patients at some top academic medical centers spent more time in the hospital, had more doctors' visits and cost Medicare way more money than patients at equally esteemed top medical centers. But the higher bills didn't bring them longer life. In fact, patients with the more intensive and expensive treatment tended to die slightly sooner, according to the latest research on chronic disease and end of life spending from the Dartmouth Atlas.

The Dartmouth Atlas now has published huge amounts of data pounding home the message that more isn't always better. Doctors and patients haven't yet gotten the message across the board, and the way our health care system (Medicare and much of the private sector) pays doctors and hospitals encourages more and more volume.

"Higher spending doesn't lead to better quality or outcomes," Dr. Elliott Fisher, director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practices told a teleconference. "We continue to be surprised by the differences in practice." But if the most intensive and expensive hospitals adopted the practices of the high-quality but lower-spending centers, Medicare could save some $50 billion a year.

The Dartmouth team, for instance, compared UCLA and the Mayo Clinic, both excellent centers with sterling reputations. Four salient points:

Spending—UCLA spent more than $93,000 per patient over the last two years of life. The Mayo Clinic, by contrast, spent $53,432-a little more than half the amount of UCLA on similar patients during the same period of time.

Utilization—Chronically ill patients in their last six months of life had more than twice as many physician visits at UCLA compared with Mayo, and they spent almost 50 percent more days in the hospital.

Resource Use—Compared to the Mayo Clinic, UCLA uses one-and-a-half times the number of hospital beds, and almost twice as many physicians to manage similar patients.

Medicare—indeed, much of our health care system is designed for a bygone era. People had acute diseases, and then they died. Now people live for years with chronic disease or diseases. More than 90 million Americans live with at least one chronic disease, and seven out of 10 Americans will die from one.

The folks at Dartmouth aren't just pointing to statistics. They have an action agenda. Here are a few of their ideas:

• Science aimed at establishing the best treatments, settings and use of resources for the chronically ill, and then payment systems to bring behavior in line with those findings. "The nation needs a crash program to transform the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient's wishes, and where resource allocation and Medicare spending can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care."
• More organized integrated systems of care, like the Mayo model which uses fewer resources to achieve high quality care.
• Medical homes—where a team of primary care practioners manage chronically ill patients—have promise but they need to have good and efficient collaboration with specialists.
• Shared savings. Transforming the payment system away from volume and toward quality and outcomes could take a decade or more. In the meantime, providers (doctors or hospitals) should be able to share the savings if they improve coordination and reduce overuse. That way efficent doctors are rewarded.
• Given that they've been issuing similar reports for years without seeing enough ripples through the system, the Dartmout team was upbeat. "We may be near a tipping point," they concluded in their report. From their vantage point in Hanover, and ours here in Washington, we can see policy makers beginning to think about how to link smart spending with quality care.

The Atlas's discussion about primary care and medical homes has already prompted some discussion. The Health Affairs Blog, for instance, Rob Cunningham sees the Atlas report as "a roadmap to medical homes." He notes that not everyone has the same definition of what a medical home is or should be, whether it should encompass all general practioners who take on care coordination or a more sophisticated capacity targeted at the patients who use the most medical services. He writes,

"The Dartmouth finding that 'simply increasing the number of primary care physicians alone will not improve coordination' is an important contribution to a growing policy debate about medical homes. If a new national policy conversation about health reform does in fact occur in the wake of next November’s elections, there may be an opportunity to consider delivery system organization as a basic element, along with cost and coverage. A magical, payment-driven transformation of the delivery system into integrated entities cannot be assumed to be inevitable, as it was in the early 1990s. If there’s going to be real change, it will have to be organized from the ground up. The new Atlas ought to be an invaluable navigation aid to the next wave of pioneers. Perhaps the next step is to understand how primary care works in low-spending areas."

We've been posting quite a bit about chronic disease management lately, and we asked The Urban Institute's Robert Berenson to chime in. We'll post his thoughts here on Tuesday.