Uncategorized

Dartmouth Analysis Again In the Cross Hairs

Reed Abelson and Gardiner Harris in the New York Times are questioning some of the key assumptions behind the Dartmouth Atlas of Health, which for twenty years has documented wide variations in Medicare utilization rates across the country and used that to claim huge savings could be obtained by rooting out waste in high-spending regions. In February, Harris reported on a commentary by Sloan-Kettering’s Peter Bach in the New England Journal of Medicine that argued the Dartmouth analysis failed to adjust for illness severity. I reported on the Medicare Payments Advisory Commission’s similar analysis here.

This time, the Times’ two most thoughtful health care reporters bring quality into the discussion. After describing a map in Office of Management and Budget director Peter Oszag’s office that divided the nation into low-spending beige regions and high-spending brown regions, they write:

For all anyone knows, patients could be dying in far greater numbers in hospitals in the beige regions than hospitals in the brown ones, and Dartmouth’s maps would not pick up that difference. As any shopper knows, cheaper does not always mean better. . . The debate about the Dartmouth work is important because a growing number of health policy researchers are finding that overhauling the nation’s health care system will be far harder and more painful than the Dartmouth work has long suggested. Cuts, if not made carefully, could cost lives.

For documentation, the reporters used quality data generated by the Wisconsin Collaborative on Healthcare Quality, which I wrote about a month ago for The Fiscal Times.

This is an important debate. But as is often the case in journalism, the attempt to reduce complex realities into a single-factor analysis that can be summarized in a headline or a single “why this story is important” paragraph can leave a mistaken impression. Regional variation in Medicare spending is one indicator of gross overutilization. Something is happening when a hospital in McAllen, Texas does twice as many knee implants per Medicare beneficiary as a hospital in Baton Rouge, Louisiana. (An earlier version of this post compared McAllen to Rochester, MN, which actually has a slightly higher rate of knee implants per 1,000 Medicare enrollees.)

But that by itself tells us nothing about why that overutilization occurs. Greedy doctors or hospitals working in a fee-for-service system are part of the problem. Cost shifting due to high levels of uninsurance and illness severity also may account for some or even much of those differences. And, as the Times report points out, quality differentials have to be taken into account.

The pushback by Dartmouth Atlas proponents has already begun. The Atlas website carries a five-page rebuttal of the Times story. Meanwhile, Columbia University professor Andrew Gelman on his blog suggests the reporters could have used some help from experts in statistics to help them focus their analysis. My complaint with today’s story comes from an entirely different angle. Higher quality care lowers costs, it doesn’t raise costs.

Take a few additional steps to keep operating rooms germ free and rates of hospital-acquired infections and their attendant higher costs plummet. Do a knee implant right the first time and you don’t have a patient back within a year for a revision. A careful mapping of quality has never been done by Medicare or anyone else since good data isn’t available. The Wisconsin Collaborative is one of the nation’s few efforts to create such a database. The reform law will generate much better data, but that is years away. But when it is done, comparing those maps to spending patterns may provide researchers with crucial clues for determining what accounts for variations in spending across the U.S.

One thing is for certain. Quality data will provide patients-as-consumers with information about what hospitals and physicians to avoid — something that spending patterns by themselves can never do.

(An earlier version of this blog post incorrectly called Professor Andrew Gelman of Columbia University a defender of the Dartmouth Atlas analysis. His blog’s critiquefocused on the methdology of the Times reporters. I regret the error.)

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at  GoozNews, where this post first appeared.

Livongo’s Post Ad Banner 728*90

22
Leave a Reply

22 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
18 Comment authors
rihanagorgesmart patientDr. Sekersewa mobiltsuris Recent comment authors
newest oldest most voted
rihanagorge
Member

Nice

Vikram C
Guest
Vikram C

smart patient- you raised interesting point of detachment from personal and financial concerns.
My own observation is that doctors who have financial worries or dissatisfaction do not tend to be most effective.

smart patient
Guest
smart patient

I never saw a definition before. However, I suggest the utmost concern about the first component: “I want the doctor to treat me as though I am a member of his/her own family and he/she is paying the bill out of his/her own pocket.” Uh oh, bad idea. Detachment from relations and financial concerns is the best policy. I think that most doctors know how to practice cost effectively. The price freezes and inane demands by payors corrupt and generate potent inflationary forces. Thus, considering that each US doctor controls about $3.5 million in spending by his/her pen or clicker,… Read more »

Barry Carol
Guest
Barry Carol

Dr. Seker — I think care quality has several aspects to it. From a patient’s perspective, here are my thoughts. 1. The care should be necessary and appropriate. Tests and procedures should not be ordered just to generate revenue or to protect against a potential lawsuit. I want the doctor to treat me as though I am a member of his/her own family and he/she is paying the bill out of his/her own pocket. 2. In the case of surgical procedures and cancer treatments, I want the risks and benefits clearly explained to me. What is the range of potential… Read more »

Dr. Seker
Guest
Dr. Seker

Maggie and Barry,
How do you define the quality medical care? Is there a definition for cost effectiveness?
Thank you for answering.

maggiemahar
Guest

Barry– As I think you know, the Dartmouth research adjusts for the variables you talk about, including differences in local prices. David Cutler tells me that he explained this, very, very clearly, to the reporters. But they ignored him. The Dartmouth reserach also looks at use of resources–how many specialsts a hospital patient sees, how many tests he undergoes, how many procedures, how many days he spends in the hospital, what % of patients are readmitted– quite apart from how much all of this costs. When you look at use of resource, you don’t have to adjust for differences in… Read more »

sewa mobil
Guest

nice article, thanks

tsuris
Guest
tsuris

Barry Carol, why do you say this. Doctors are not executioners. Are you??
“This mentality needs to change. Shared decision making, with help from palliative care teams, can play an important role in helping patients to make an informed choice that is consistent with his or her wishes and value system.”
Hospitals’ use palliative care teams to bury their mistakes facilitated by CPOE and other ill designed HIT equipment.

Barry Carol
Guest
Barry Carol

I don’t think there is any question that medical spending per person varies significantly by region. There are lots of reasons depending on the type of care and different approaches are called for, in my opinion. First, prices vary a lot even within the same city. Since Medicare dictates the prices it pays, this is more of an issue for commercial insurers. I would like to see disclosure of contract reimbursement rates and tiered insurance products that require higher co-pays if patients want to use more expensive hospitals for procedures that virtually all providers can do well. There is no… Read more »

Vikram C
Guest
Vikram C

I tried finding physician density map but couldn’t. So I looked at population density map, to see if there is any correlation with Medicare pay rates. Generally high density places also have higher pay rates though Western TX is big exception to that. Another theory I have is that physicians being better paid tend to gravitate to areas that are more expensive for ordinary folks such as SoCal. Though once at that place they find a lot of competition. How do doctors decide to where to practice? How do they decide to move? What is their strategy to maximize revenue… Read more »

Monkeyseemonkeydo
Guest
Monkeyseemonkeydo

Dartmouth validates the ages old adage of human behavior: Monkey See, Monkey Do! Regions have doctors that trained in the regions, having learned from the senior physicians and faculty. As the wage and price freeze gripped medical care in an ill conceived effort to control inflation, Monkey Saw the Monkey Do the procedures in high volume to thwart the price freeze. That is all, no more no less. To think that you can explain the complex inner workings of medical care systems on Dartmouth’s simplistic research model is folly. Maggie should know this, but chooses to ignore it. Quality is… Read more »

J.S.
Guest
J.S.

Anyone who has seriously published in NYT knows, they triple-check something this big.
This is just the tip of the iceberg.

Bart
Guest

Anyone who has seriously published in NYT knows, they triple-check something this big.
This is just the tip of the iceberg.

Nate
Guest
Nate

“And hosptials spending less–like Mayo or the Cleveland Clinic– often have clearly better outcomes measured in many different ways.” Great example of why people should be questioing Dartmouth, why is Cleveland Clinic held up as a great example of cost efficient care? They are the highest priced system in the area. Actually look at some CC bills then tell me the rest of the county should be modeling them. Overall they provide some incredible miracles but they have issues with infections, overcharge like you woulodn’t beleive, and don’t deliver any better care then UH. I know this because I see… Read more »

Bill
Guest
Bill

There is tremendous opportunity in our field to improve upon how we measure and compare quality and outcomes.
The only issue I have with the Dartmouth work is that it can’t use quality and outcomes data sets which don’t exist as of this time.