Tag: Medicare

The Dartmouth Team Responds (Again)

Jun 23, 2010• 16

By JONATHAN SKINNER, PhD

Reed Abelson and Gardiner Harris, the authors of the June 4th New York Times article critical of the Dartmouth Atlas and research, have acknowledged Elliott Fisher and my concerns and clarified the record in their posting on the New York Times webpage. They originally claimed that we failed to price adjust any of the Atlas measures. They now acknowledge that we do, but they’re hard to find on the Atlas website, a point we concede. They originally claimed that quality measures were not available on the Atlas website. They now acknowledge that quality measures are on the website, but they don’t like them. We agree quality measures can be better – the type of research we do is always open to improvement — and Dr. Fisher has recently co-chaired an NQF committee with precisely this goal. (See our more detailed response.)

But the primary purpose of this posting is to respond to the attack by Mr. Harris on the professional ethics of the Dartmouth researchers. The key issue seems to be whether the research in two landmark 2003 Annals of Internal Medicine articles (here and here) were misrepresented by the Dartmouth researchers. In his posting Mr. Harris asserts:

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.

We are disappointed by this accusation. We can understand Mr. Harris’s frustrations in understanding the research, as it is often nuanced and tricky to follow. This lack of understanding is illustrated by their recent New York Times posting, where they state:

In statistical terms, [the Dartmouth researchers’] claim is referred to as a negative correlation between spending and health outcomes, which means that when spending goes up, the health of patients goes down.

They have confused the idea of a correlation (high spending hospitals on average do slightly worse on quality and outcomes) with causation (if a hospital spends more money, outcomes for those patients will get worse).

The more fundamental point, however, is their claim that we misrepresenting the two 2003 Annals of Internal Medicine studies written by Dr. Fisher and others. Ms. Abelson and Mr. Harris state that

The Dartmouth work has long been cited as proving that regions and hospitals that spend less on health care provide better care than regions and hospitals that spend more…. As the article noted, [Dr. Fisher] asked in Congressional testimony last year, “Why are access and quality worse in high-spending regions?”

Commentology: Times Reporters Respond

Jun 22, 2010• 19

New York Times health policy reporter Gardiner Harris responded to THCB founder and publisher Matthew Holt’s comments on the recent series of reports he has authored with business writer Reed Abelson questioning the science behind the Dartmouth Atlas. Gardiner had this to say in defense of his newspaper’s investigation:

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

Nope. Won’t Happen.

Jun 20, 2010• 50

By MAGGIE MAHAR

Friday, June 18, the Senate aproved a plan that blocks a 21 percent cut in Medicare payments to physicians; the axe was scheduled to fall that day. Leadership on both sides of the aisle pushed for the reprieve; it will remain in place for six months. The measure will now need to be considered by the House, which in May approved a fix that would last longer. If the House agrees–and it is all but certain that it will–the 21 percent cut wil be replaced with a 2.2 percent pay hike. The bill will not add to the deficit. The proposal is fully offset by changes in Medicare billing regulations, antifraud provisions and the tightening of some pension rules, eliminating Republican objections that it would push the federal government deeper into debt.

In six months, Congress will have to consider the matter once again, just as it has ever year since 2003. This is the third time this year that Congress has averted Draconian cuts to physician’s payments. What, you might wonder, is going on? Here is the backstory: in 1997, Congress enacted a so-called “sustainable growth rate” (SGR) mechanism to keep Medicare physician reimbursement rates in check. Congress has never allowed the full cuts called for under the SGR formula to take effect and it never will.

Why don’t legislators simply repeal the cuts to doctors’ fees that they have been postponing for years? Why just put off the measure for another six months?

Because too few of our elected representative possess the chutzpah to stand up and say that blind across-the-board cuts were an extraordinarily dumb idea in the first place.

AMA and Congress: Playing “Chicken” Again

Jun 20, 2010• 1

By JANE M. ORIENT, MD

Nine times in the past eight years, Congress has, at the last second, delayed the automatic cuts in doctors’ Medicare fees that it decreed some 13 years ago to prevent Medicare spending from outpacing other consumer expenditures.

The AMA threatens that doctors, especially primary care doctors, will stop accepting Medicare patients if the cuts go through. Congress hurtles toward the head-on collision, citing runaway budget problems. Doctors are kept in suspense, their claims held in abeyance while carriers wait for Congress to fix the problem retroactively if it has missed its deadline. The AMA claims credit when the wreck is averted, and urges doctors to continue paying their dues while it feverishly works for a permanent “fix.” Only the AMA, it implies, stands between Congress and certain disaster.

Every time cuts are postponed, the next scheduled cut gets deeper. It’s like a balloon mortgage payment in reverse.

And the controversy gives columnists another occasion to rail against those greedy overpaid doctors, unwilling to assume a bit of shared sacrifice despite the economic downturn.

Doing Their Homework: Times Reporters Respond in Dartmouth Atlas Spat

Jun 20, 2010

By MERRILL GOOZNER

Over the weekend, the two New York Times reporters who challenged the core findings of the Dartmouth Atlas of Health stuck to their guns in a detailed response to the rejoinder to their critique. The Dartmouth Atlas, which documents regional variation in Medicare spending, provides the intellectual underpinning for assertions by health care reformers (including those in the White House) that 30 percent of all health care spending is wasted and does not improve either the quality or outcome of care.

The Times‘ original critique (see this GoozNews post) contained three main ideas:

The Dartmouth researchers fail to adjust their maps for regional variations in prices;
The Dartmouth researchers fail to adjust their maps for illness burden; and
The assertion that more spending leads to worse outcomes is not borne out by the data. In some cases more spending leads to better outcomes.

Some of this back-and-forth may sound like a quibble over language. Is it “30 percent” of health care is wasted or “up to 30 percent,” as the Dartmouth researcher now state in public? Reed Abelson and Gardiner Harris provide a link to the original 21-page response to their queries. “We think the 30 percent estimate could be too low,” the Dartmouth researchers wrote in a highlighted section.

On the other hand, the Times reporters appear to be taking a step back on the price issue. They went back to David Cutler, the Harvard health care economist whom they originally quoted. Cutler told them that the original 2003 articles by John Wennburg and Elliott Fisher of Dartmouth that appeared in the medical literature did, in fact, adjust for price. “But he said he agreed with the Times assertion that most of the atlas’s maps and rankings, as distinct from the group’s academic work, are not fully adjusted for prices,” Abelson and Harris wrote.

Notably, Cutler is now hedging his bets on the “30 percent is waste” argument. “Some believe that number is higher, and others think that it’s lower,” he wrote in the latest Health Affairs. “But there is little disagreement that health care is characterized by enormous waste.”

In my view, it is the dispute over quality that really needs to be explored by other researchers and policymakers. Eliminating waste ought to improve quality. It has always been true in manufacturing that reducing steps and reducing waste not only reduces costs, but it improves the quality of the finished product.

There’s no reason to think it won’t be true in delivering a complicated service like health care, which some have compared to building and flying jet airplanes. Doing more than necessary to get the job done will only increase the possibility that errors will occur in the process, which in health care translates into more complications, further costs and, in some cases, lost lives.

Yet the Times reporters continue to assert through their dissection of the Dartmouth data that more spending on more services may actually result in higher quality. They go back to the original research — the two studies published in 2003 — to make their point:

The researchers are incorrect in saying that the results of those 2003 studies were “all in the same direction.” In fact, two of the various measures of quality and mortality cited in the articles actually seemed to show that more spending could correlate to better care. [footnotes 2 and 3] Heart attack patients in the most expensive regions, for example, were more likely to receive necessary beta blockers – a positive correlation between spending and quality. Similarly, hip fracture patients experienced “a small decrease in mortality rates” in more expensive places – another positive correlation.

We have very poor metrics for measuring quality of care, and one of the examples they cite shows why. Giving beta blockers is a “process” measure. We know from clinical trials that giving beta blockers after a heart attack improves outcomes. But does it improve outcomes the same in regions where the ratio of obesity-related heart attacks to stress related heart attacks differ? Does it have the same effect in regions with higher proportions of mild heart attacks (because they are more likely to use a sophisticated blood test to categorize chest pains as a heart attack) than it does in a region with a higher proportion of serious heart attacks?

These are the confounding variables that no data set can capture adequately until it fully reflects both the diagnoses of the incoming patients as well as the care delivered. The Dartmouth Atlas data, which relies on Medicare claims, falls far short of that goal. And the Times reporters, by trying to re sift the data to make a counterpoint, only add another blind man’s hands on the elephant in the room — the absence of electronic data about the actual medical conditions of the patients behind those Medicare claims.

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.

Apples to Grapefruits

Jun 7, 2010• 9

By MAGGIE MAHAR

Last week, I commented on a New York Times story that appeared Wednesday, June 2, attacking the Dartmouth Research. The work that Dartmouth has done over the past two decades suggests that hospitals in some parts of the country are over-treating patients. Over-treatment means that patients who didn’t need to be in the hospital in the first place are exposed to the side effects of treatment as well as gruesome hospital- acquired infections, medication mix-ups and a host of other medical errors. Thus unnecessary care puts patients at risk while helping to drive health care bills heavenward— and suggests that we could rein in Medicare spending by squeezing some of that hazardous waste out of the system. But according to the Times: “Data [from Dartmouth] Used to Justify Health Savings Effort is Sometimes Shaky.”

In Part 1 of this post I discussed what two of the Times’ sources told me about how the Times’ reporters misrepresented what they said. Both Harvard economist David Cutler and Yale’s Dr. Harlan M. Krumholz complained that the story made it seem that they are critics of the research, when in fact they agree with Dartmouth on the basic message of the data, and see the work as, in Krumholz’ words “pivotal to moving us forward . . . we all agree that there is lots of waste and it is unevenly distributed across the country.” A third source in Washington D.C. who talked to the Times reporters confided that they seemed to have a clear agenda: “to take down Dartmouth.”

Today, I received evidence from yet another unhappy source—the Wisconsin Collaborative for HealthCare Quality, a voluntary consortium of organizations working to improve the quality and cost-effectiveness of healthcare in Wisconsin. Chris Queram, the Collaborative’s president, and Jack Bowhan, who guides the development of value metrics for the group, report that they tried to caution New York Times reporter Gardiner Harris that he was misusing their data, “comparing apples to grapefruits,” and “jumping to a conclusions that you just can’t make.” Harris ignored their warnings.

As proof, they produced a series of e-mails that they sent to Harris, and with their permission, I’m quoting from those messages. But first, an excerpt from the Times’ story talking about the Collaborative’s data.

Support for Berwick to Head Medicare Grows

May 28, 2010• 9

By MAGGIE MAHAR

Even Fox News acknowledges that: “In the two months” since President Obama named Dr. Donald Berwick, president of the Institute for Healthcare Improvement (IHI), as his candidate to head the Centers for Medicare and Medicaid, (CMS) “not one industry group has voiced opposition to his nomination.”

This, despite the fact that Berwick will be charged with beginning to squeeze $400 billion worth of waste and fraud out of the Medicare system over a period of ten years. One man’s sludge is, of course, another man’s bread and butter. One might expect that drug-makers, device-makers, hospitals and others who profit from the current system would join the fear-mongers who have begun the assault on Berwick, claiming that he plans to “ration” care.

But that isn’t happening. In fact the American Hospital Association (AHA) gave Berwick a flat-out endorsement in a May 20 letter addressed to Senators Max Baucus, chairman of the Senate Finance Committee, and Tom Harkin, chair of the Health, Education, Labor and Pensions Committee:

“His work at the Institute for Healthcare Improvement (IHI) has engaged hospitals, doctors, nurses and other health care providers in the continuous quest to provide better, safer care.” wrote AHA President and CEO Rich Umbdenstock. “This includes dramatic advances in quality improvement, patient safety and end-of-life care through IHI’s collaborative, breakthrough series and other activities,” he added, referring to IHI’s success in success in cutting hospital infection rates and implementing better asthma care and coronary surgery improvements with little additional costs.Continue reading…

One Big Little Change

May 27, 2010• 4

By ROB LAMBERTS, MD

It’s just plain stupid.

Why does the government not allow patients with Medicare part D to use pharmaceutical discount cards? What is the ethical rule broken by making the government pay less? What is the legal reason that the elderly should be prevented from saving money?

I know there are probably reasons having to do with discounts not being allowed that are not extended to all Medicare participants, but isn’t that a little silly? As long as the discount is available to all Medicare participants, why can’t they receive help from the pharmaceutical industry.

I do my best to prescribe the cheapest medications possible. I love the $4 list at Wal-Mart et. al., and I try to never use a brand when a generic would do the trick. But there are times where I have no choice. These newer drugs are sometimes the only choice we have to help control their blood pressure, diabetes, or pain. Without these drugs, we end up with worse blood pressure, worse diabetes, and more pain. What do you think is the consequence of that? More people:

Develop complications of chronic disease poorly controlled.
Are hospitalized for these complications.
Visit the doctor for management and/or treatment.
Have pain.Continue reading…

Are New Yorkers Sicker Than Patients in Atlanta–or Are They Just More Likely To Be Diagnosed?

May 21, 2010• 48

By MAGGIE MAHAR

At a dinner party in Manhattan, someone mentions the problems he has been having with his sinuses, and his doctor’s diagnosis. Since everyone at the table is over 40, his comment quickly leads to a lively discussion of back pain, rotator cuffs, high blood pressure, skin cancer, and diverticulitis. It seems that everyone in the room has been diagnosed with something. Finally, someone asks “Are we really that old? Can’t we talk about something else?” Everyone laughs and the conversation turns to politics.

I couldn’t help but recall that evening while reading an article in the May 12 New England Journal of Medicine (NEJM) titled “Regional Variations in Diagnostic Practices” written by a team of investigators at Dartmouth.

Earlier work done by researchers at Dartmouth has shown that patients in some regions receive moretreatment than others. This newest study, written by Yunje Song, senior author Elliott Fisher, and colleagues, goes further, to suggest that patients in places such as Miami, New York or McAllen, Texas are more likely to be diagnosed in the first place. “Their doctors order more tests and refer more patients to sub-specialists than doctors in Atlanta, Phoenix or Jackson, Mississippi,” explains Jonathan Skinner, one of the co-authors, “and so they discover more disease.”Continue reading…

When Medicare “Cuts” are Medicare “Savings”

May 11, 2010• 19

By MAGGIE MAHAR

In a post titled “Slowing Down that Revolving Readmissions Door” the New America Foundation’s Joanne Kenen writes about avoidable readmissions. “I once interviewed a patient who literally could not remember how often he had been hospitalized within just a few months,” Kenen recalls, referring to a story published in the Washington Post last year.

There, she reported that “one of five Medicare hospital patients returns to the hospital within 30 days–at a cost to Medicare of $12 billion to $15 billion a year—and by 90 days the rate rises to one of three, according to an analysis of 2007 data by Stephen Jencks.” Within a year, two out of three are back in the hospital—or dead—says Jencks who consults on this issue for the Institute for Healthcare Improvement (IHI).

This is money that health care reformers could use as we expand care to the uninsured. It’s worth noting that what many call “Medicare cuts” are really “Medicare savings”—billions that could be reclaimed if we rescued patients from that revolving door.
Under reform legislation, hospitals with particularly high rates of avoidable readmissions will have Medicare payments reduced, beginning in 2011. I would guess that some private insurers will follow Medicare’s lead.