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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?”

Deobfuscating HITECH

Jun 23, 2010• 10

By MARGALIT GUR-ARIE

Software developers sometimes use a technique called obfuscation to protect their intellectual property.

They use tools to add, remove and displace the original flow of the code until no human can understand what it does or how it does anything. Judging by the ample confusion expressed by large numbers of physicians, it almost looks like a giant obfuscator has been applied to the HITECH act leaving the medical community to wonder what to do, why do it and how to proceed.

The prevailing wisdom is that, for some misguided reason, the Government is paying for EHRs, but there are so many strings attached that it is very unlikely anybody will ever see a dime of the much advertised $44,000.

First we should figure out what these EHRs can do, or more accurately, will one day be able to do.

Store all your paper records electronically in a computer and make them accessible to many other providers of care, including patients. EHRs, if allowed, can also make all your records available to insurers, Government and any other agencies or corporations who manage to obtain access. There will of course be laws and regulations, consents and all sorts of policies in place to prevent or punish unauthorized access. Electronic data is much more liquid than paper based data, leading to better collaboration, better visibility and like all liquids, has better chances of leakage.Continue reading…

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

Click4Care Talks Tools

Jun 22, 2010• 2

By Matthew Holt

At the AHIP Conference, Click4Care gave a presentation titled “Confronting the Quality of Care Crisis: Next Generation Care Management Technology.” I was able to have a conversation with CEO Rob Gillette and Executive VP of Sales and Marketing Keith Dayton. On the exhibit hall floor, the two Click4Care leaders spoke about the fast growing company and what differentiates their products from the competition.

Deobfuscating HITECH

Jun 21, 2010

By MARGALIT GUR-ARIE

Software developers sometimes use a technique called obfuscation to
protect their intellectual property. They use tools to add, remove and
displace the original flow of the code until no human can understand
what it does or how it does anything. Judging by the ample confusion
expressed by large numbers of physicians, it almost looks like a giant
obfuscator has been applied to the HITECH act leaving the medical
community to wonder what to do, why do it and how to proceed. The
prevailing wisdom is that, for some misguided reason, the Government is
paying for EHRs, but there are so many strings attached that it is very
unlikely anybody will ever see a dime of the much advertised $44,000.

First we should figure out what these EHRs can do, or more accurately,
will one day be able to do.

Store all your paper records electronically in a computer and
make them accessible to many other providers of care, including
patients. EHRs, if allowed, can also make all your records available to
insurers, Government and any other agencies or corporations who manage
to obtain access. There will of course be laws and regulations, consents
and all sorts of policies in place to prevent or punish unauthorized
access. Electronic data is much more liquid than paper based data,
leading to better collaboration, better visibility and like all liquids,
has better chances of leakage.

EHRs can slice and dice your data and present you with flowsheets
for an individual patient and many reports across your entire panel of
patients. You could see how your patients are doing, which ones need to
be reminded to come in, or schedule screening tests. It’s hard to do
that on paper.

Just like your data is available to others, theirs is available to
you. You can see medication lists, specialist notes or PCP histories,
hospital records, test results and even home monitoring devices input in
real time. Coordination of care should become less time consuming.

EHRs can help you directly communicate with patients (and other
doctors) via secure email or even secure teleconference. It can automate
making appointments, paying bills, obtaining pre-authorizations and
even the entire check-in/check-out process.

EHRs can provide you the latest guidelines and evidence, in a
patient specific context. Perhaps even CMEs. Computers are supposedly
better at calculations and cross checking large amounts of data, hence
they could alert you when an error is about to occur or present you with
the latest checklists.

No, all these things are not there now. Some of the simplest ones
are, and the rest should become reality after enough physicians start
using EHRs and enough EHRs get interconnected to form a critical mass
necessary for progress.

OK, so where is the catch? Truth being said, there is more than one
catch.

You have to feed the beast. Computers cannot deliver any of the
wonderful, or less wonderful, things above, unless somebody enters data
into the EHR to start with. While most data can be entered by staff,
lare portions will have to be collected by the physician.

Computers are intrusive. The EHR will make its presence felt in the
exam room. It will alter your interaction with your patients. There are
tips and tricks to minimize the change, but it cannot be eliminated
altogether.

EHRs are not a finished product. When you “adopt” one, you become
part of a learning effort on how to computerize medical records. EHRs
have “glitches”. The Internet and broadband have “glitches”. Computers
in general have “glitches”. People have many “glitches” too. Nobody
invented the perfect method for documenting encounters, for viewing
longitudinal records, for ordering tests and most important, EHRs are
not yet able to communicate with one another on a large scale.

The Government will have easy access to your records. Your
performance may be judged (perhaps inappropriately) and reimbursement
may be affected. Patients (and their attorneys) will have unfettered
access to your records. Mistakes will be found. Little notes you made
just for yourself in the paper chart, are not just for yourself anymore.

EHRs can be expensive. They don’t have to be, but they can be.
Picking the wrong piece of software, not getting proper training, not
managing the implementation process correctly and failing to
continuously manage change may cost you a small fortune, mainly in lost
productivity. There are no “lemon laws” for EHRs.

My first cell phone weighed over a pound and had huge buttons and a
very ugly antenna. My second cell phone was a flip phone and my third
one was Java enabled. I now have an iPhone. My first computer was a main
frame IBM 370. I was madly in love with the power of that machine. My
second computer was an IBM PC. I named him and took him with me on a
long vacation overseas and back. I now have a thin and much more
powerful Sony Vaio. I could have sat this whole thing out waiting for
the iPhone and the Vaio to be perfect, which they still are not, but I
would have been left behind I think. I would have certainly avoided the
embarrassment of dragging a 30 lb computer through several airports and
the excruciating wait for the modem to connect, or the inconvenience of
dropped calls every time I drove by an electricity pole. But I would
have also missed the ability to help a Hospital keep receiving lab
reports on a Friday night and the opportunity to walk a technician
through an entire database restoration from a mountain lodge in the
middle of nowhere.

If I were a physician in a small private practice today, I would do my
research and locate the cheapest EHR that can do what needs to be done
relatively well. I would “adopt” the contraption, regardless of the
promised $44,000, probably name it Lucifer and keep an eye on it to make
sure it behaves itself. And I would try my hardest to become part of
the future and part of the solution, because folks, whether we like it
or not, paper is over.

Margalit
Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at
GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing
services for physicians. Prior to GenesysMD, Margalit was Director of Product
Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large
non-profit hospital organization.

A NY Times guest (inadvertently) spanks its professionals

Jun 21, 2010• 26

By Matthew Holt

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!

Op-Ed: Health Care For Profit

Jun 20, 2010• 36

By JOHN GOODMAN, PhD

I’ve noticed at The Health Care Blog quite a few people are obsessed with the role of profit in the health care system. Many apparently believe that for-profit entities have no legitimate role in an ideal world and that all organizations should be nonprofit.

My own view, interestingly enough, is the exact opposite. Were I a Health Care Czar, I would remove the nonprofit status from almost all health care organizations and force them to be for-profit under tax law. I would be willing to consider some exceptions here and there, and in special cases allow for-profits to set up nonprofit subsidiaries. But the vast majority of all patients in my ideal world would be dealing with for-profits — in getting health insurance and in getting medical care. And in return they would get lower-cost, higher-quality care.

Why do we have such radically divergent views on this subject? As so often happens in public policy, much confusion is caused when people are not familiar with basic economic principles. In this case, the antiprofit folks are confused about (1) the economics of capital, (2) the economics of competition and (3) the economics of motivation in complex social systems.

Suppose the government builds a hospital and plans to have the entity be self-sustaining (all operating costs are to be paid from expected revenues). Following conventional public sector accounting, the cost of the capital needed to build the hospital will be treated as zero. (Afterall, all we need is for the Treasury to write a check.) And even though the plan to cover costs with patient revenues is far from certain to pan out, the accountants will also ignore the cost of that risky decision.

This example is Exhibit A in my case for abolishing the nonprofit status of hospitals.

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.