Can you cut health care spending without undermining the quality of care? It’s a major concern as Medicare prepares to prod hospitals to provide medical care more efficiently by giving bonuses to those whose patients cost less and taking money away from places that send the government higher bills.

Last week, Kaiser Health News’ blog Capsules culled through the Medicare data to identify the hospitals whose patients cost Medicare the most, from the three days before admission to a month afterward.

Here is an admittedly unscientific first pass at how the nation’s best-regarded hospitals rate in terms of their patients’ Medicare spending.

Kaiser Health News looked at the 16 hospitals that U.S. News includes in its widely followed “Best Hospitals’ Honor Roll,” which is calculated based on a mix of quality indicators and reputation surveys.

(One hospital, Johns Hopkins in Baltimore, was omitted because Medicare didn’t provide figures for Maryland hospitals.)

As a group, the average cost to Medicare for a patient at a U.S. News top hospital was $17,808, or 1 percent below the national median spending of $17,988.

The least expensive of these hospitals had patients who, on average, cost Medicare 5 percent below the median (represented as a ratio of 0.95).

The most expensive hospital had patients who, on average, cost Medicare 3 percent above the median (1.03).

• New York-Presbyterian Hospital (New York, N.Y.): $17,089 (0.95)

• University Of Washington Medical Center (Seattle, Wash.): $17,089 (0.95)

• Mayo Clinic St. Mary’s Hospital (Rochester, Minn.): $17,269 (0.96)

• Mount Sinai Hospital (New York, N.Y.): $17,269 (0.96)

• Ronald Reagan UCLA Medical Center (Los Angeles, Calif.): $17,628 (0.98)

• UCSF Medical Center (San Francisco, Calif.): $17,628 (0.98)

• Duke University Hospital (Durham, N.C.): $17,628 (0.98)

• Cleveland Clinic (Cleveland, Ohio): $17,808 (0.99)

• Barnes Jewish Hospital (Saint Louis, Mo.): $17,808 (0.99)

• Vanderbilt University Hospital (Nashville, Tenn): $17,808 (0.99)

• Stanford Hospital (Stanford, Calif.): $17,808 (0.99)

• UPMC Presbyterian Shadyside (Pittsburgh, Penn.): $18,168 (1.01)

• University Of Michigan Health System (Ann Arbor, Mich.): $18,168 (1.01)

• Brigham And Women’s Hospital (Boston, Mass.): $18,348 (1.02)

• Hospital Of University Of Pennsylvania (Philadelphia, Penn.): $18,348 (1.02)

• Massachusetts General Hospital (Boston, Mass.): $18,528 (1.03)

None were outliers among the 3,346 hospitals that Medicare evaluated.

In fact, more than a quarter of the nation’s hospitals were more costly than all of the “honor roll” hospitals and another quarter of the hospitals were less expensive than all of the “honor roll” hospitals.

Let us know what you think about Medicare’s Spending Per Hospital Patient ratings in a comment below.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

• Lifetime Achievement Award: Rick Linneweh, CEO, Yakima Valley Memorial Hospital

• Outstanding Health Care Executive: Rick Cooper, CEO, The Everett Clinic

• Outstanding Health Care Professional: Margaret L. Hall, Northwest Hospital & Medical Center

• Innovation in Medical Devices: Physio-Control

• Innovation in Biopharmaceuticals: Seattle Genetics

• Global Health Organization: SightLife

• Community Outreach: Providence Senior and Community Services

• Wellness Program (Western Washington): Group Health Cooperative

• Wellness Program (Eastern Washington: Baker Boyer Bank

The changes, detected in white matter of the infants’  brains, were widespread and would likely have a profound effect on brain development, said Annette Estes, PhD, research associate professor of speech and hearing sciences at the UW and a co-author of the study.

The findings also suggest that autism does not develop suddenly but involves a long process that begins early in life, Estes said.

A tensor diffusion image showing the white matter tracts of the brain

Individuals with autism typically have difficulty with social interaction, interpersonal communication and may engage in repetitive behaviors. Symptoms can range from mild to severely disabling.

The U.S. Centers for Disease Control and Prevention estimates that 1 in 110 U.S. children is affected by the disorder. The condition is usually detected in the second year of life after a seemingly normal infancy.

Although the cause of autism is unknown, recent research suggests that abnormalities in the brain’s white matter are involved.

White matter: the brain’s wiring

White matter is made up of bundles of millions of nerve fibers that create the “wiring” through which nerve cells communicate with each other. These nerve fibers are sheathed in a fatty insulating material, called myelin, that gives these areas of the brain a whitish appearance.

It is thought that abnormalities in white matter not only disrupt communication within the brain but also impair normal brain development, Estes said.

In the study, the UW researchers, working with collaborators from across the country, studied the brains 92 infants with a technique called diffusion tensor imaging that allowed them to track the development of the infants’ white matter,

The infants all came from families that already had one child with autism, which meant the infants were at high-risk of developing the condition as well.

Each infant had diffusion tensor imaging study at six months followed by a behavioral assessment at the age of two. Most also had follow-up scans at at one and two years of age.

The  researchers found that at the age of two, 28, or 30 percent, of the children had symptoms of autism while 64, or 70 percent, did not.

Comparing the brain imaging studies of the two groups revealed significant differences in the development of 12 of the brain’s 15 major white matter tracts.

That so many white matter tracks are involved suggests that at this stage autism is a “a whole-brain phenomenon not isolated to any particular brain region at this early stage of development,” said said Dr. Stephen R. Dager, M.D., UW professor of radiology and principal investigator of the University of Washington team.

The study’s findings are preliminary and diffusion tensor imaging is not ready to be used to diagnose autism in infants, Estes said, but the technique should help researchers better understand the cause of the condition and hopefully develop better interventions.

Autism and childrearing

In the past, it was commonly held that autism was the result of the failure on the part of parents to be sufficiently nurturing to their infants,  but the findings of this study suggest autism involves abnormal brain development that begins very early in life, Estes said.

Many parents wrongly blame themselves when their child develops autism, Estes said, but these findings indicate they “did nothing wrong” to cause the condition.

Future research will include looking at changes in the white matter development in infants younger than six months of age and tracking those changes as children age, Estes said.

The study, published online by the American Journal of Psychiatry, was the result of a collaboration with the Infant Brain Imaging Study (IBIS) Network funded by the National Institutes of Health and headquartered at the University of North Carolina at Chapel Hill.

Dr. Joseph Piven, professor of psychiatry at University of North Carolina at Chapel Hill and director of UNC’s Carolina Institute for Developmental Disabilities, was the senior author of the study.

Other institutions that took part in the study include the University of Utah, Washington University in St. Louis, McGill University, Children’s Hospital of Philadelphia and the University of Alberta.

To learn more:

• Visit the Infant Brain Imaging Study (IBIS) website: www.ibisnetwork.org

• UW Autism Center’s IBIS page.

• Seattle Children’s Autism Center.

By Phil Galewitz

The Obama administration launched a $40 million effort Wednesday to reduce premature births, especially early elective deliveries, but it has no plans to stop Medicaid from paying for those deliveries.

About 10 percent of all deliveries are scheduled — either as induced or Cesarean-section –before 39 weeks and are not medically indicated, according to the Department of Health and Human Services.

Preterm babies, those born before 39 weeks, are at increased risk for death, low birth weight, lung disorders, feeding problems and blood infections, according to the American College of Obstetricians and Gynecologists.

Medicaid, the state-federal health insurance program for the poor, pays for about 40 percent of all deliveries in the United States each year. Medicaid last year stopped paying for several so called “never” events such as preventable complications or wrong site surgery.

But on Wednesday, Medicaid chief Cindy Mann said it has no plans to stop paying for elective deliveries before 39 weeks. “This is not a payment strategy,” Mann said when asked whether Medicaid would keep paying for elective preterm deliveries.

Under the four year initiative called Strong Start announced Wednesday, the federal Center for Medicare and Medicaid Innovation will seek to reduce preterm births by giving money to hospitals and other health providers and community coalitions to improve prenatal care and test new approaches such as group visits for pregnant women and offer case management services at birth centers.

Local Resources: Read LocalHealthGuide’s story about the Seattle-based Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), an initiative launched by Seattle Children’s in 2007.

“Preterm births are a growing public health problem that has significant consequences for families well into a child’s life,” said HHS Secretary Kathleen Sebelius said.

Medicaid spends $20,000 a year on babies born premature in their first year, almost 10 times that of infants born at full term.

More than 500,000 infants are born prematurely in the United States each year, an increase of 36 percent in the past two decades, Sebelius said.

A recent study by the Leapfrog Group, an employer health coalition, showed huge variation in hospitals performing elective preterm deliveries. Rates ranged from less than 5 percent at some hospitals to more than 40 percent, according to Leapfrog’s 2011 data.

Leapfrog CEO Leah Binder said Medicaid and employers should consider stopping coverage for elective preterm births. “We fully support changes in payment to disincentivize the practice,” she said.

Doctor groups often say early deliveries are done at the request of pregnant women. “Women ask for it,” said Dr. Hal Lawrence, executive vice president of the American College of Obstetricians and Gynecologists.

Scott Berns, senior vice president for the March of Dimes, said doctors also need to be educated about the risks of early deliveries.

“More education is needed for doctors and patients,” Berns said.

HHS is working with both ACOG and March of Dimes to reduce the incidence of early elective births.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

“It is time to sound the alarm,” said Dr. Judy Wasserheit, vice chair of the Department of Global Health at the University of Washington, who wrote the article with Dr. Gail Bolan of the U.S. Centers for Disease Control and Prevention and Dr. P. Frederick Sparling of the University of North Carolina School of Medicine, Chapel Hill.

Gonorrhea bacteria - Photo CDC

Gonorrhea is a sexually transmitted disease that can infect the genital tract, throat and anus.

There are more than 600,000 cases of gonorrhea a year in the U.S., making it one of the most common reportable infections in the country.

Untreated, gonorrhea can cause a number of serous complications, including infertility, a chronic painful pelvic condition in women called pelvic inflammatory disease, and ectopic pregnancy, a serious complication in which the fetus develops in the fallopian tube instead of the uterus.

In rare cases, the bacteria can travel through the bloodstream and infect joints, heart valves and the brain.

The bacteria that causes gonorrhea, Neisseria gonorrhoeae, has a history of quickly acquiring the ability to resist antibiotics. In the 1940s it became resistant to sulfa drugs, in the 1980s to penicillins and tetracyclines, and by 2007 to flouroquinolones.

Today, treatment with a class of antibiotics called cephalosporins is considered the most reliable option, but resistance to this class of drugs is on the rise both abroad and in the U.S., raising concerns that doctors here will soon begin seeing cases they cannot cure.

Untreatable cases have not yet been reported in the U.S., but they have appeared in Asia and Europe and a worrying number of strains in the U.S. are showing signs of resistance to cephalosporins.

Resistance to one of the cephalosporins has risen 17-fold in the U.S. over the past few years, Dr. Wasserheit and her colleagues write, increasing from just 0.1 percent of cases in 2006 to 1.7 percent in the first part of last year.

Resistance has been increasing even faster in the western U.S., reaching 3.6 percent of all cases last year and 4.7 percent of cases among men who have sex with men.

Although higher doses may overcome the ability of these strains to resist cephalosporins for a time, Dr. Wasserheit and her colleagues write, urgent action is needed now to prevent the spread of these strains and to develop new treatments.

“There is much to do, and the threat of untreatable gonorrhea is emerging rapidly,” they conclude.

 To learn more:

• Visit the National Library of Medicine’s Medline Plus information page on gonorrhea.

• Visit the Public Health – Seattle & King County’s page on Sexually Transmitted Infections.