In New York City, Two Versions of End-of-Life Care

By ANEMONA HARTOCOLLIS
01 jun 2008--There are two starkly different paths toward death in New York City’s hospitals, one for patients at elite private institutions, another for those at public hospitals, according to new data compiled as part of a consumer rating system.
Most elderly patients in their last two years of life have more intensive treatment, more tests, more days of hospitalization — and more out-of-pocket costs — at private teaching hospitals like N.Y.U. and Lenox Hill than their counterparts at Bellevue and the city’s other municipal hospitals, which have historically served the neediest New Yorkers.
The city’s private hospitals were among the most aggressive of about 3,000 hospitals studied across the nation, ranking in the 94th percentile as a group, while the public hospitals landed in the 69th percentile, still significantly above the national average.
The rankings, compiled by Consumer Reports from a 15-year research project based at Dartmouth College, have huge implications for administrators, doctors and patients as they consider which model of care is best for those suffering from chronic, fatal illnesses like cancer, congestive heart failure, lung disease and dementia.
The study does not address the question of whether longer stays and more intervention prolong patients’ lives, and the Dartmouth researchers argue, in general, that less-aggressive treatment does not change the outcome, but spares patients the agony of unnecessary tests and reduces the risk of hospital-borne infections.
“The general principle is that greater intensity of care is not better, and at the high end can actually be harmful,” Dr. David Goodman, a co-author of the Dartmouth Atlas of Health Care, as the database is called, said in an interview on Thursday. Saying that New York’s healthcare system was “full of ironies,” Dr. Goodman suggested that the dichotomy of treatment might illustrate how a city with an abundance of sophisticated doctors and wide disparities in patients’ income and education could result in unfair distribution of resources.
“You have some of the most expensive and high-intensive care in the nation, and yet we know that there are populations that are not getting the care that they need,” Dr. Goodman said. “So this robs it, drains resources from places where it’s really necessary.”
The level of care was most intensive at New York University Medical Center, on First Avenue in the 30s in Manhattan, where 65 percent of patients saw 10 or more physicians in their last six months of life and paid an average of $5,500 beyond what Medicare — the federal insurance program for the elderly — pays for in the last two years of life. N.Y.U. ranked in the 99th percentile nationally.
In contrast, at Bellevue Hospital Center, on First Avenue in the 20s, 7 percent of patients saw 10 or more physicians, and patients averaged $1,380 in out-of-pocket expenses.
Dr. Elliott Fisher, another co-author of the Dartmouth Atlas, said that some people, but not all, were eager for every possible intervention to delay death. “Many patients say, ‘If I’m 85 and this is a choice between being in the hospital and being at home, I’d rather be home,’” he explained.
Kenneth Raske, president of the Greater New York Hospital Association, which includes public and private institutions, said the data was flawed because it worked backward from patients who died, rather than looking at the outcomes for patients who had the same treatment but survived.
He attributed the aggressiveness of private hospitals in New York simply to the sophistication of the patients and their families and the desire of doctors to give them the best possible care.
“The patients and physicians and their families, of course, are trying to live longer and beat whatever malady they have,” Mr. Raske said, “and that’s a reflection of the New York culture that we have.”
Dr. Eric Manheimer, who is the medical director at Bellevue and on the faculty at N.Y.U., said that having a foot in both the public and private systems gave him a unique perspective on the discrepancies. He said that care was less aggressive at public hospitals because most of their doctors — he estimated 75 to 85 percent — were salaried physicians with little financial incentive to order tests or other interventions. At private hospitals, he said, supply can create its own demand: There is often an abundance of beds and an endless list of specialists who can be called.
“You end up with the phenomenon of specialists referring to other specialists, with nobody coordinating, which results in confused messages, more referrals, more hospitalizations, deterioration in health care and a more anxious patient,” Dr. Manheimer said.
The city’s public hospitals, he said, offered a more collegial, intimate culture of care because many of their staff members came from the same community as their patients.
“We’re not smarter or better than the private doctors,” Dr. Manheimer said. “But when you have a salaried physician staff that’s cohesive, that works together, with no incentive to do additional health care, that’s a different mental model.”
He noted that the Mayo Clinic in Rochester, Minn., a prestigious private hospital where doctors also work on salary, ranked in the 28th percentile for aggressiveness of care.
The Dartmouth Atlas, from which the data is drawn, includes 46 New York City hospitals: 8 public and 38 private.
The Consumer Reports rankings allow consumers to look at data from hospitals across the country, and examine the intensity of care during the last two years of life. Intensity is measured by how many days the average patient spent in the hospital, how many times a doctor visited that patient and how much the patient or private insurer spent for doctors beyond what Medicare covered.
Patients in the city’s private hospitals averaged 54 visits from doctors, while those in public hospitals averaged 24 visits during the final six months. In private hospitals, 56 percent of patients saw 10 or more physicians, compared with 32 percent in public hospitals.
And private patients paid an average of $4,000 out-of-pocket over two years, nearly double the $2,200 per patient at the city-run institutions. But in terms of the ultimate outcome, there was little difference.
The Dartmouth Atlas showed that 58 percent of the public-hospital patients died in the hospital as opposed to at home or in hospice care, compared with 57 percent for private hospitals. Thirty percent of patients in public hospitals had been admitted to intensive care units before their death, compared with 27 percent in private hospitals.
Many fewer patients from public hospitals — 7 percent — were enrolled in a hospice than patients from private hospitals, where the rate was 12 percent, according to the Dartmouth data.