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 forThe 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.)
That the NY Times printed it is remarkable given the turnaround in thinking by David Leonhart in the Economix blog on the NY Times over the years to being a thoughtful Dartmouth proponent. It’s end even more remarkable that they didn’t even quote Buzz Cooper, probably the leading thoughtful Dartmouth critic. Longtime THCB readers will expecting me to start writing about dogs licking their sores….
Dartmouth has pretty much immediately refuted their article (and I suspect it didn’t take too much research). But what they really missed was the big announcement yesterday that HHS is now releasing a whole lot of datasets that researchers can use to put these and other data together and are encouraging the private payers to add to the mix (FD The Health 2.0 Developer Challenge is helping convene tech developers to work on this). Is it really true that Sacramento is cheap according to Dartmouth but expensive to private payers. And why?
There’s lots more work to be done here, but this article doesn’t help.
If you want a deep deep dive into this problem, here’s the article Daniel Gilden wrote on my blog last year. With lots of intelligent back and forth in the comments (including one from a Nobel Prize winner!).
It was about a palliative care doctor who faced her own end-of-life issues in a very different manner from the way she would have advised many of her patients.
[A]s the doctors began to understand the extent of her underlying cancer, “they asked me if I wanted palliative care to come and see me.”
She angrily refused. She had been telling other people to let go. But faced with that thought herself, at the age of 40, she wanted to fight on.
While she and her colleagues had been trained to talk about accepting death, and making it as comfortable as possible, she wanted to try treatments even if they were painful and offered only a 2 percent chance of survival.
It is never right to be judgmental about these matters. Each person faces this kind of situation in his or her unique way, and we have no right to dispute the choices people make.
But I was struck by how this doctor personified the public policy debate that surrounds terminally ill patients. Here’s a an example of that kind of discussion from Canada (single payer, government run system!):
The high cost of dying has more to do with soaring health care costs than the aging population does, according to the Canadian Institute of Actuaries. In its submission to the Romanow commission on the future of health care, the institute said that 30 to 50 per cent of total lifetime health care expenditures occur in the last six months of life. Noting the sensitivity of the subject, the group suggested greater use of less expensive palliative care and living wills.
Dr. Pardi’s experience shows how hard it is to go from a policy-level discussion of such matters to the decisions made by individual patients and their families. Without giving credence to the nasty and politically inspired debate about “death panels,” the ambiguity in such situations suggests the difficulty in adopting formulistic approaches to the decisions around end-of-life care.
Besides abortion, it is hard to think of a part of medical practice that is more likely to be politically divisive and personally uncomfortable. Given that, is it worth the debate? Alternatively, how can we best have a productive discussion about it?
By MARK HALL, Wake Forest University School of Law
Immediately after passage of health care reform, over a dozen state A.G.s sued to declare it unconstitutional, as violating states’ rights. The Florida complaint is here, and Virginia’s here. Reminiscent of southern governors in the 1960s blocking their state universities’ gates, these legal officers in effect are saying “not on our sovereign soil.” Since the constitutional issues have already been hashed through so thoroughly, what’s new to talk about?
First, the Florida complaint, which a dozen other states joined (AL, CO, ID, LA, MI, NE, PA,SC, SD, TX, UT, WA), focuses mainly on the financial burdens of expanding Medicaid. This is challenged under the “commandeering” principle, as requiring states to devote sovereign resources to achieve federal aims. But, as we know, states are free to withdraw from Medicaid, so the argument seems to fall entirely flat. The complaint makes a bait-and-switch type of estoppel argument , that states got into Medicaid without any expectation of this expansion, and now it’s too damaging for them to withdraw. So, in effect, states argue that the Constitution allows them to keep the federal carrot but refuse the federal stick. Good luck selling that to an appellate court.Continue reading…
By GARY S. KAPLAN, MD, Chairman and CEO Virginia Mason Medical Center
The selection of Austin Ross for the Modern Healthcare Hall of Fame is fitting. His ideas on leading and managing in health care – which he’s written about extensively in books and articles dating back to 1959 – laid the foundation for successful health care administration nationwide. His leadership has guided me and countless other health care leaders and administrators across the country.
Virginia Mason was privileged to benefit from Austin’s expertise for most of his 36 year career. He came to what was then Virginia Mason Hospital and Clinic in Seattle as an administrative resident in 1955 after completing his MPH degree from the University of California, Berkeley. By 1968 he was the hospital administrator and in 1977 he became executive administrator, a position he held until his retirement in 1991. Austin’s leadership is credited with putting Virginia Mason in the national spotlight as a foremost example of how to integrate a multi-specialty group practice with a hospital.Continue reading…
Sometimes with something so egregious gets written that, even if it’s in the Wall Street Journal, you have to notice it. Angela Braly, the CEO of Wellpoint—compensation a hair under $10m in 2009—ought to be happy, even though Joseph Rago in the WSJ is surprised about that. It looks like the health reform bill which put much of Wellpoint’s highly profitable individual and small group business at risk is dead, and this week Wellpoint started putting up rates between 35% and 80% in the California market (where it’s Anthem Blue Cross).
But the WSJ quotes her as calling health reform a “wasted opportunity”. Funnily enough Wellpoint and the trade association it funds, AHIP, were on both sides of the debate. Pushing Congress to give it 30 million more customers as part of the bill, and then surreptitiously funding the Chamber of Commerce to oppose health reform (and putting pressure on the Blue Dogs, and the DINOs in the Senate) when some of the terms of the House Bill started to look less favorable (85% Med loss ratios limits among them).
I’d had some semi-decent hopes for Braly and her team.
Todd Park is definitely one of health care IT’s good guys. Todd was the brains (though not the mouth!) behind athenahealth. After he left athenahealth, he spent a year back in California doing angel investing (Ventana among others) and being a dad. But despite his desire to stay on the west coast, he was dragged into the vortex known as Washington DC, and for the last 5 months he’s been the (first) CTO of HHS. (By the way, he cashed out his investments, and politely turned down my proposal to “care for” his cash while he was being a public servant!)
Todd gave the keynote yesterday at the Health IT Summit for Government Leaders. He describes his job as unlocking HHS’ “inner mojo” in terms of data use and technology innovation. So what are the big deals he sees? These are my notes on his fast talking!
1) HITECH/ARRA is not about for paying for software. Its purpose is to incentivize “meaningful use”. He wants to make sure that people understand that the NHIN (National Health Information Network) is not a thing. It’s a set of policies and services that people can use to make health data work over the Internet. It is NOT a parallel network. And at the end of the day, what’s going to make this work is the private sector — including vendors modifying their products to match these policies.
2) Leveraging the power of HHS data for public good. The amount of data HHS has is “ridiculous”. It has a set of sets of data. Todd is a paid up member of Tim Berners-Lee “free the data” club. They’re adding all kinds of data sets to data.gov including every grant, patent et al licensed/paid for by HHS. Todd calls this “data liberation”. They’re also creating community health maps where data on community health performance can be mashed up with other types of maps (real estate, job listings, et al). In addition, they’re doing “smart targeting” — an attempt to combine findings from different/disparate data sets without waiting to do the big database integration. He’s hoping to use techniques that the intelligence community uses to link, say, emails and bank wires, to similarly track, say, disease outbreaks, drug interactions, etc.
When you’re at a party and someone explains to you that they just read a great article in the NY Times explaining why Peggy Noonan doesn’t understand basic math, and you know that they’re referring to Uwe Reinhardt, then you’re over-wonked. That’s surely my condition
Here’s what Uwe said—you can’t just ban medical underwriting as Noonan suggested, because the individual insurance market will collapse. Both the history of New Jersey (and Washington state) in the 1990s, and in current Massachusetts where people can buy insurance or pay a lesser fine, show that healthy people won’t buy insurance until they need it.
The answer is to force everyone into a universal insurance pool
But of course, that means younger and healthier people will likely pay more. For the good folks from Heritage writing on the WSJ Opinion page this is an outrage. Using their complex model they came up with the amazing analysis that if you give uninsured younger people with no health condition the choice of paying a smaller fine or a higher premium—surprise surprise—most will pay the fine. And of course that’s exactly what’s happened in Massachusetts.
The problem is of course that most younger people who have no insurance are in low wage jobs, They therefore place a much higher value on receiving money now than forgoing it to later stave of a potential risk of catastrophe from having no insurance
So we deal with this in a very sensible way in the rest of society’s transactions.
I spent summer 1984 in Boston and generally found it an oppressively hot place. I’ve spent a few winter days there and found it an oppressively cold place. I’ve always thought that, given the absence of passport controls, if you lived there and could move to California and didn’t, you were probably crazy. And yesterday the residents of that fair state proved me right.
As I said earlier this week, it now appears that health care reform is dead. I just can’t see a scenario in which there are 60 votes to pass anything. I also don’t see the Dems having the cojones to go to reconciliation or to cram the current Senate bill through the House quickly. Instead (as Bob Laszewski says below) the moderate Dems will run for their lives away from health insurance reform—although I just don’t understand what Bob thinks “reform” would have meant if it had really required 6–10 Republican Senators.