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A couple of weeks back two New York Times reporters (Abelson & Harris) decided to take on the orthodoxy of the Dartmouth school. Frankly their efforts reminded me of England’s performance in the world cup so far—abject and inept and leaving the fans hoping for much better. Within a few hours the mainstays of Dartmouth (Fisher & Skinner) responded correctly accusing Gardiner and Harris of shaky reporting. Although that original article was particularly muddled, there are indeed legitimate questions about some of the Dartmouth research, raised by serious academics (including on the august pages of THCB), but few of those made their way into the hodgepodge that was that original article. And now in their response to the response, Abelson & Harris have descended further into the mire.
The new argument is basically this. Yes, the Dartmouth academics have done all the corrections to regional data that the NYTimes duo accuse them of not having done. But they’re not available on the website within a click, not always portrayed in the maps in the Atlas, and (horror of horrors) you’d have to read Health Affairs to find out what they’d done. And that some of the academics who read Health Affairs hadn’t carefully looked at the maps which showed unadjusted data.
So now it’s not an academic issue or a misstatement. It’s an issue of poor user interface design! Well I guess we’re used to that in health care!
But let’s not have the Dartmouth researchers respond. There’s no need because the response comes inadvertently in the New York Times this very same weekend. Abelson & Harris in their article ask the key question, “Does higher medical spending lead to worse care?” Precisely, the Dartmouth gang say unproven, but they clearly believe it to be the case. And Harris & Abelson try to hang them with that distinction.
But the punishment that should be meted out to Harris & Abelson is to read a wonderful article by guest author Katy Butler in the Sunday NYT Magazine. It’s titled What Broke My Father’s Heart. Please read it fully.
It’s a fabulous article about the real life over-treatment of the author’s father, and the havoc and devastation that caused on the author’s family—especially her wonderful mother. And it’s an inadvertent and fabulous answer to Harris & Abelson’s question.
Yes, more care, incented by the system and profitable to far too many actors within it, is worse care.
Categories: Matthew Holt
If anyone is still following this thread, I’m the author of “My Father’s Broken Heart” and going back to an early comment that my mother and I could have paid the beloved family physician out-of-pocket for a longer consult before the fateful decision was made. It was Dr. Fales’s understand, which I have not double-checked, that Medicare regulations did not permit him to accept a side payment from us, when the purpose of the meeting would be to discuss the care of a Medicare patient. If this is accurate, it is one of many examples of how Medicare under-pays for physician time (and limits palliative care and hospice services) while reimbursing freely for expensive and sometimes harmful procedures.
MG, You are absolutely correct. Both health reporting and financial reporting are a travesty, and primarily for the reasons Matt points out above. The relevant information is all kept in the proverbial black box, shielded from disclosure as being the proprietary property of private enterprises.
Conversely, you get lots of very good reporting about government because everything that involves public tax dollars is subject to freedom-of-information and other sunshine laws, with a few reasonable exceptions.
Matt’s right, having regular disclosure of and/or access to claims information in the private, commercial sector of the insurance industry would be a total game-changer.
From a strictly journalistic point of view, regardless of whether their reporting and analysis proves accurate, Abelson and Harris’ story selection was stupid from the get-go: you take the one segment of the insurance industry that DOESN’T operate in a black box, i.e. Medicare, and smear the best research being done on it with thin reporting. If a reporter wants to burn his best, or in this case only, source, the evidence had better be bulletproof.
And for the record, I don’t think Abelson and Harris are stupid. So the only other logical conclusion is that they were spurred on to this story by someone with something to gain from the outcome.
This whole episode just generally reinforces my notion of how lousy & incomplete the general level of reporting is in his country on healthcare issues even at the bastions of journalism like the NYT. It is only slighly better than financial reporting but not by much.
The Dartmouth data showing significant spending differences across regions, even after adjustment for differences in medical input costs, leads some to conclude that there are significant savings to be had from eliminating “waste.” However, so-called waste at the population level is not so easy to identify at the individual patient level before services are rendered. I said before that doctors and hospitals that treat aggressively do so because of a combination of culture, defensive medicine, and financial incentives to do more rather than less. I think the more accurate term for this “waste” is unnecessary and/or inappropriate care.
This is actually an area where I would like to see us become more like Europe. We need a more conservative definition of what constitutes good, sound medical practice, especially as it relates to end of life care, surgical interventions and cancer treatment. Shared decision making and palliative care consults need to become routine. The litigation system needs to be changed to provide doctors with robust, safe harbor protection if they follow evidence based guidelines where they exist and the sound medical practice guidelines developed by each specialty society. The safe harbor protections could also be extremely helpful in reducing the amount of diagnostic testing, especially imaging, that takes place in ER’s and elsewhere.
In the end, I don’t think tinkering with payment models will be as helpful as some think. Capitation might work for primary care but it could also create a financial incentive to withhold necessary care. Bundled payments probably make sense for surgical procedures like CABG and hip replacements but are not as useful elsewhere. Patients are likely to resist getting all of their care from an Accountable Care Organization because if they develop a rare or complex condition or need an organ transplant, they are probably going to want access to a regional center of excellence and not be tied to their ACO or the hospital to which it is prepared to refer the patient if it cannot handle the procedure in house. It is also probably not practical for insurance to pay for a given procedure under some circumstances but not others. For example, will we pay for a pacemaker for an elderly patient whose mind is still sharp but not for someone with advanced Alzheimer’s? What about a patient with early stage Alzheimer’s?
Finally, there is also an issue regarding how we define quality. Suppose, for example, that conservative treatment causes patients with Alzheimer’s, dementia or advanced cancer to die sooner than those who get aggressive treatment but the former suffer less. Family care givers also suffer less and for a shorter period than those caring for family members receiving aggressive treatment. I would argue that the patient getting the more conservative treatment, as well as his or her family is net better off. At the very least, shared decision making and palliative care consults need to part of the treatment protocol in all of these cases.
As I said before I don’t think I know enough to agree or disagree with the Dartmouth research and I am no journalist, but I do know a thing or two about scientific research and I don’t see why this particular research project cannot be scrutinized without it being considered sacrilegious. If the research is good and sound, it should be able to stand on its own merits, so why all the personal stuff?
Also, when the first article came out and the rebuttals too, I clicked on every link posted and I searched the Dartmouth site the best I could and I still couldn’t find anything about hospital outcomes. I assumed that the ambulatory Diabetes management map was a link posted in error.
Does anyone have a link for hospital outcomes?
Truth Seeker, MD– The whole point of healthcare reform is to rob physicians of their autonomy and pay them less not more.
The savings that you are describing would be coming out of the pockets of those who control the flow of healthcare dollars right now.
Healthcare is a business and the less money doctors make, the more business interests get. Patients are not even part of the equation. All the talk about P4P for example is not really to improve quality of care but to squeeze more out of doctors and start to control their behavior. Little do most know the real reasons behind over-utilization of care (defensive medicine, fragmentation of care, patient expectations, etc)
By the way, (and it said this in my first piece about the new controversy) I agree with Rose & I am actually working with HHS and others to try to get those data flowing from private sectors too. Of course it would be best to get a complete view of what’s really happening in each segment e.g. price (real costs) & volume for both Medicare & Private payers. And err..real outcomes too.
Wouldnt it be nice if all that was routinely reported from all sources?
Otherwise, we’re going to be having these pro v con arguments all the time….and there’ll always be an excuse to say “data’s wrong, need more research, do nothing in the meantime”
This argument over cost could be a lot simpler if insurers, hospitals, etc, would only make their data public, instead of claiming it’s proprietary.
Then there’d be little need for the kinds of inferences the Dartmouth folks have to make because they can only get their hands on Medicare (public, government) data.
Correction: “their” findings, not “there” findings. I am slipping. (:
I agree with Brad. This controversy seems to be similar to the “Don Berwick is going to convert us all to the National Health Service” bad-mouthing going around. All 3 of these people are respected scientists with a lot to say, if people would just listen. Too bad the ideologues are trying to subvert there findings to political hack purposes.
For professional reasons, I too have followed the Dartmouth work closely for the last 6-7 years — alongside other valuable research, including my company’s own.
As a former journalist, I find Gardner Harris’ defense of his work unconvincing. My own experience (23 years as a writer and editor) leads me to believe that when he remarks that “they have repeatedly exaggerated and mischaracterized their own work in public settings to suggest it can be prescriptive” and “that the data are simply not good enough to guide spending decisions in the government’s $484 billion Medicare program” it sounds an awful lot like these are conclusions the authors arrived at, or were guiding towards, BEFORE they embarked on their work. If my suspicions are true, it’s a fair bet that these are not conclusions that the authors arrived at by happenstance, in the normal conduct of their beats as writers, but were guided to by others — others who presumably have an axe to grind with the Dartmouth researchers, or at the very least, those who might listen to them.
All journalists consider prior restraint a vice. But its complete opposite — no restraint at all — can hardly be considered a virtue.
I found their response interesting, and there are some truths there. However, it would have been more instructive if they wrote their original piece critiquing Dartmouth’s landmark 2003 Annals paper and the legitimate shortcomings of their publicly available map (which seems to be their fixation). Rather they parse, what appears to me, nuanced and complicated conclusions in the academic world vs those in the lay press–differences, IMHO, that are honest but consistent, and not all that newsworthy.
I have followed this literature and the work of Dartmouth closely, and have communicated with some of the investigators, and at no time have I ever found them to be intellectually dishonest or seeming to promote their work for “fame and glory” over factual truth.
My take: Dartmouth 1, NYT 0.
Matthew
Brilliant– Yes, Katy’s story is the perfect response to Harris & Abelson.
In case people don’t have access to the NYT online, and live someplace where it;s not easy to go out and buy the Times, I excerpted parts of her story on healthbeat here. http://www.healthbeatblog.com/2010/06/one-familys-story.html
But I’d urge everyone to read the whole story if they possibly can. It’s beautifully written.
I am saddened by the comments by Gardiner Harris, as they seem to have descended into personal attack on my and Elliott Fisher’s integrity. We are currently preparing a response to the most recent posting from Mr. Harris and Ms. Abelson, and will be posting it shortly on the Dartmouth Atlas website.
Barry–
My oldest friend was a close friend and neighbor of the Butler’s throughout the time that Kay writes about.
There was no question about paying the primary care physician to consult. He was not that kind of doctor. He would have been very happy to talk to them– at no charge.
As Katy says, he loved them.
I guess you’ve never had a doctor who would talk to you on the phone for half an hour without charging you? I am happy to say I have.
In a situtation like this, neither the family nor the doctor were thinking about money. And the Butlers never blamed insurers or others for not paying bills.
But Mr. Butler was in pain; his wife was exhausted; the surgeon withheld the information about an external pacemaker. (This seems, to me, pretty close to malpractice.) Pressured, Mrs. Butler was made to feel that there was no point in consulting with the PCP.
She was bullied– as patients and relatives too often are. Mr. Butler, who had stood up to this same surgeon in the past, was too stroke-damaged to do it again.
After having a heart attack, my friend was referred ot this same cardiologist. He tried to pressure her into an invasive procedure. She fired him.
About 10 years later, she has not had another heart attack, never had an invasive procedure, and is doing fine on medication.
Part of the issue here, it seems to me, is that patients are being asked to make critical decisions without having enough information – indeed, without even knowing the right questions to ask. And they’re being forced to make these decisions within an environment that subtly reinforces the message of “do everything you can.” If this can happen to a savvy, literate family like Butler’s, where is the hope for everyone else?
The main point of Reed’s and my pieces about the Dartmouth work is that the data are simply not good enough to guide spending decisions in the government’s $484 billion Medicare program. If the Dartmouth researchers had acknowledged this point, our story would not have been all that interesting. But they cannot bring themselves to do this, and in fact they have repeatedly exaggerated and mischaracterized their own work in public settings to suggest it can be prescriptive.
An ancillary point was to warn those on capitol hill, the administration and journalists to be wary of those highly popular maps from the Atlas. You have scoffed that it’s a small thing that the Dartmouth researchers fail to adjust their online data for price and illness. But misunderstandings about this are widespread. That landmark piece by Dr. Gawande that you cited used the Atlas’s unadjusted data. Dozens of stories in newspapers and magazines around the country have used the unadjusted data to criticize health institutions. Even David Cutler, among the top health economists in the country, was unaware that the atlas offered largely unadjusted data.
Accuracy may seem a small point to you. It is not to us.
Our Friday piece also pointed out that Dr. Elliott Fisher and Mr. Jon Skinner claimed that their 2003 Annals pieces had found a negative correlation between spending and outcomes. In fact, the pieces found no correlation between spending and outcomes. This is not a small distinction. If there’s a negative correlation, cuts in spending will actually improve health. If no correlation has been found, then cuts become far harder and perhaps more painful. We cannot go into reforms of our healthcare system believing that the work will be easy. But that is what the Dartmouth researchers have suggested, and this siren song has had an enormous impact on Capitol Hill.
In an aside, when was the last time you saw researchers so profoundly mischaracterize their own work? How is it possible that they could claim their annals pieces concluded something when they didn’t? I can’t remember ever seeing that happen.
–Gardiner Harris
There was not any indication for a pacemaker. She also did not report which medications he was taking prior to the pacer advice, and whether he was on aspirin prior to the stroke. The cardiologist was an idiot for recommending a permanent pacemaker for asymptomatic sinus bradycardia, and the surgeon was an idiot for not discussing the case and consulting with the patient’s revered internist.
There has got to be more to this story and it by no means refutes the critical analysis of the Dartmouth Atlas data.
This is simply consistent with the fact that the less doctors are paid, the more inappropriate work is done.
This country would be better off paying each doctor a one quarter to half million $ per year and enable them to practice medicine as it should be, taking good care of the patients and not gaming the system. If each doctor saved $50,000 (very easy to do) of the $3.5 million each (on average) their pens and clickers control, that would be a savings of $40 billion per year.
Part of the politics here is that New York and Boston, the twin capitals of academic medicine in the US, look terrible in Wennberg’s data. They aren’t as bad on per capita Medicare spending as the “feral” physician markets like McAllen, TX, which Atul Gawande pilloried, but bad enough.
For the venerable “my patients are sicker” explanation to exculpate these lofty places and their unbalanced health systems would be, to put it mildly, most ironic!
One thing that seems to have gotten lost in this “is more care worse care” debate is that the Dartmouth research looks only at spending in the US. Our average level of care is quite aggressive and not-coordinated very well for reasons others have discussed. So, in the American context, less care than average can often be optimal care.
I don’t think it would surprise anyone if in many other nations (say, Somalia or India) areas that deliver more, and more expensive, care than the national average also deliver care that tends to be better than average.
I think we developed a medical culture in the U.S. that is heavily biased toward aggressive treatment. Part of it probably relates to training received in medical school. Don’t just stand there, do something if there is a reasonable chance that it could extend the patient’s life. Defensive medicine is also part of the equation as is the fee for service reimbursement system. If the option in question is whether or not to perform a well reimbursed procedure or to administer an expensive, lucrative specialty cancer drug, the more care is better care mentality is likely to prevail, especially if the patient is uneducated or passive and the PCP has no involvement.
Personally, it’s hard for me to envision a circumstance where a surgical intervention for an elderly patient with advanced Alzheimer’s or dementia can be justified. The same goes for aggressive chemo if these patients develop a late stage cancer. I think we need to pay for palliative care consults and/or an extended consult with a PCP, especially when the quality of life has already been compromised for the patient or family member.
The equation is different in the case of premature babies and people who develop a life threatening disease or condition at a relatively young age. The bottom line, however, is that shared decision making needs to become an integral, universal and routine part of our medical culture whether surgeons, interventional cardiologists and oncologists like it or not.
It is good to see how the issue of quality of medical care is brought into open, inadvertently though. It is high time the sustainable reforms are brought to healthcare and made not only affordable, but also adequately reliable.
I forgot to mention above, as another example of physician tunnel vision, the time a cardiologist wanted to put my father, who was at home dying of cancer invading his brain, on Coumadin for an unrelated condition – which not only was totally pointless, but would have required regular blood tests for monitoring – adding yet another burden to my grieving mother. I firmly refused. I should have written the cardiologist a letter and educated him in no uncertain terms, but I didn’t. Today, I would.
There are so many difficult issues on the part of both patients/families and physicians in this article, I don’t know where to start. Suffice it to say that I do not read this article as about money. I read it as about defensive medicine (1st Dr. who wouldn’t give surgical clearance without a pacemaker) and a sort of tunnel vision that specialists, particularly cardiologists, develop where they blindly concentrate only on their own body system and ultimately end up ignoring common sense.
As for the patients/families, they respond to the unspoken guilt trip from the specialists that they are neglecting their family member if they do not consent to every treatment.
Last, in the “old days” a consultant used to be just that – he consulted on the patient for the PCP, and NEVER failed to share his recommendations with the primary as well as the family, BEFORE any treatment was contemplated. Simply returning to that simple practice could have averted this tragedy,couldn’t it?
Margalit, all I can say in general about “more care” is that every bit of care administered has its risks and side effects as well as its benefits. Neither physicians nor families keep this in mind as much as they should, mostly physicians.
Barry, I think the author acknowledged that the mom in the story made a mistake when she made that faithful decision. I think the cardiologist may have erred as well, since I find it hard to believe that $461 would induce anybody, particularly a physician, to knowingly inflict years of suffering on another human being.
I don’t feel qualified to comment on the quality of the Dartmouth research, but I am having a serious problem with blanket statements like “more care is worse care”. The examples are always very elderly, usually demented, patients who should be allowed to die with dignity.
But how about young folks and children and brand new babies? Is more care always worse care for them too?
When does appropriate care become “more” care? When do heroic efforts turn into “worse” care? When they fail? I guess if you don’t try, you never fail, but you also never succeed. Should we stop trying?
I agree that it was a wonderful article. One thing I wondered about in reflecting on the article later, though, is this: It would have been well within the means of this family and millions of others to offer to pay the primary care doctor $250 or $300 or more, if necessary, for an hour of his time to help the family sort through the issues and questions surrounding whether or not the heart device should have been implanted after the stroke. No claim would be filed with Medicare or private insurance. We are so conditioned to expect a third party to pay for virtually all of our healthcare costs, that when it won’t, can’t or doesn’t, we wring our hands and complain rather than work around the problem by offering to pay ourselves. Yes, I know there are poor people who can’t afford to pay $250 or $300 for a consult like this, but a huge chunk of the population can afford it. This is especially the case when there is a long established relationship with a PCP who knows the family and their values, hopes, fears and concerns well.