Matthew Holt

A NY Times guest (inadvertently) spanks its professionals

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.

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Katy ButlerMGRealityMatthew HoltRose Hoban, BSN, MPH, Health Reporter Recent comment authors
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Katy Butler
Guest

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… Read more »

Rick
Guest
Rick

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.… Read more »

MG
Guest
MG

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.

Barry Carol
Guest
Barry Carol

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… Read more »

Margalit Gur-Arie
Guest

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… Read more »

Reality
Guest
Reality

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… Read more »

Matthew Holt
Guest

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… Read more »

Rose Hoban, BSN, MPH, Health Reporter
Guest
Rose Hoban, BSN, MPH, Health Reporter

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.

bev M.D.
Guest
bev M.D.

Correction: “their” findings, not “there” findings. I am slipping. (:

bev M.D.
Guest
bev M.D.

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.

Rick
Guest
Rick

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… Read more »

Brad
Guest
Brad

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… Read more »

maggiemahar
Guest

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.

Jon Skinner
Guest
Jon Skinner

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.

maggiemahar
Guest

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… Read more »