Healthcare Reform And The Death of Dartmouth Atlas
An important article appeared in the NYT recently, describing a new paper by Peter Bach, which is in today’s NEJM. Peter’s paper (“A Map to Bad Policy“) debunks the Dartmouth Atlas and cautions against its use. As I said in the Wash Post in September, the Dartmouth Atlas is the ”Wrong Map for Health Care Reform.”
More damning even than Peter’s analysis was Elliott Fisher’s reply: “Dr. Fisher agreed that the current Atlas measures should not be used to set hospital payment rates, and that looking at the care of patients at the end of life provides only limited insight into the quality of care provided to those patients. He said he and his colleagues should not be held responsible for the misinterpretation of their data.” Really? It was someone else’s interpretation? OK, Elliott, you’re not responsible. Just stand in the corner.
Peter is not the only leading epidemiologist to debunk Dartmouth in recent days. There’s also the report this week from the U of Wisconsin and RWJ by Pat Remington (another leader), showing that people who have the poorest health (and, therefore, the highest health care costs) live in the poorest counties (see my blog report and an earlier discussion of poverty and health care). And there’s the recent paper by Ong and Rosenthal (co-authored by Jose Escarce, editor of HSR, the leading health services research journal), showing that, when all care is measured (not simply end-of-life care, as measured by Dartmouth), hospitals that provide more have lower mortality, which was confirmed in the current issue of Medical Care by Barnato and associates at the U of Pittsburgh. When it rains, it pours.
What’s doubly important about the death of the Dartmouth Atlas is that it was the cornerstone of health care reform. Right from the start, Peter Orszag, director of OMB and the administration’s architect of health care reform, accepted Dartmouth’s ideological principles that health care spending was driven by doctors and hospitals who over-treated and over-charged, to no benefit. The funds for health care reform were readily available by simply getting rid of geographic differences. That alone would save 30% of health care spending ($700B). And that could be accomplished by making everything look like Mayo (white, middle class and efficient) and by having more primary care physicians (which Mayo doesn’t). And best of all, it could assure that no new taxes would be needed, just as President Obama had promised.
The problem is that it didn’t make sense. Voters knew it, even if they didn’t know the methodological details. And the CBO figured out. And congressmen had to scramble to find ways to pay for health care reform without actually paying for it, because it was supposed to be for free – the 30% solution said so, and folks all over Capitol Hill cited it. And now the spiral of hypocrisy has finally unraveled. Like Madoff’s investments, the Dartmouth Atlas was shadows and mirrors. But this time, the price tag is more than the $50B that Madoff cost. It’s the likely loss of health care reform. But don’t worry, Elliott. We won’t blame you.
*This blog post was originally published at PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies*
I must take issue with the phrase “Dartmouth’s ideological principles.” Ideology is for politicians and policy-makers. The Dartmouth Atlas is a brilliant method of looking at how health care is delivered in various places, but the conclusions are frequently drawn from the perverse perspective of the current political and ideological discourse, none of which has any bearing on “truth.”
I appreciate the discussion on the pros and cons of The Dartmouth approach, but the misrepresentations have been Machiavellian. The Dartmouth group has always made the effort to control for various confounders in understanding a very complex system. It appears to me that they have done a reasonable job controlling for poverty for example, but it is doubtful than any statistical approach would be better.
It makes sense for anyone with a scientific frame of mind to support Fisher’s data, but distance themselves from the politics and the ideology.