Carmegeddon and the Drive Towards More Access

As many of you have heard, “Carmegeddon” took place over the weekend.  A ten mile stretch of Los Angeles’ 405 Freeway was closed for a full 48 hours. Why? To make it bigger of course! After all, pushing the same amount of traffic through greater lane capacity should reduce congestion in the country’s busiest road…. right? Nope.

Notes policy analyst Steve Lafleur*: “LA drivers spend over half a billion hours per year stuck in excess traffic delays, which costs the economy roughly $12 billion dollars. Adding more freeway lanes seems like an obvious solution, except for the fact that it doesn’t work. Studies have shown that every percentage increase in roads leads to an equal percentage increase in driving. In other words, more roads mean more driving.”

Freeways aren’t the only places where traditional notions of capacity are turned upside down. Dartmouth Atlas researchers famously showed that too much of a good thing might not actually be a good thing when it comes to physician visits, procedures and days spent in the hospital. The term was “distributional inequity,” i.e., the numbers of specialists and hospitals in largely urban areas drives the quality and efficiency of patient care— but not in the direction one might expect.

A traditional view of markets would hold that having more physicians would make stuff less expensive (supply and demand) and high quality (via increased competition). But Dartmouth researchers and proponents argue that hospitals need to fill their beds and physicians need to fill their appointment books.  Supply increases demand. 

In a 2007 report on utilization and equity, Dartmouth authors identified that Miami, Los Angeles, and Manhattan have overbuilt their acute care sectors, whereas Minneapolis, Salt Lake City, and Portland, OR have been frugal, using fewer hospital beds, less physician labor, and fewer expensive technologies such as ICU beds and medical imaging. The group saw excessive utilization increase in those “overbuilt” markets, with care intensity increasing everywhere, and growth in specialist visits and ICU stays escalating rapidly in high-cost regions. What constitutes “excessive” is a subject of heated debate but the latest FFS Medicare per member per month expenditures in those markets stand out: Miami: $1,236.51; Portland, OR: $615.41.

So while too little access causes problems (the Kaiser Family Foundation estimates that 60 million Americans lack adequate access to primary care, eventually driving up unreimbursed, emergency and acute care costs), it appears too much does as well. Of course access to what matters greatly. Since the ACA passed, much has been made of the fact that so many of the reforms depend on a robust, empowered system of primary care— and it is PCPs we’re in shortest supply of.

One can’t help but think it’s the definition of “access” itself that needs a close examination. I was reminded of this quote from Don Berwick: “The greatest potential for reducing costs while maintaining and improving the lot of patients is to replace visits with better, more flexible and fine-tuned forms of care. But almost all current payment mechanisms, whether enforced by the market or mapped into organizations by internal compensation systems, use impoverished definitions of productivity that actively discourage the search for and incorporation of non-visit care.”

Maybe the best thing about non-visit care is the fact that you don’t need to get in the car to have it.

*It should be noted that Mr. LaFleur is a Canadian, which may explain his un-American views on the automobile.

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