Earlier this week the NYTimes’ Robert Pear did a piece that delved into the Dartmouth Atlas of Healthcare, one of my all-time favorite publications. The Atlas, and the research that spawned it, provides a clear and detailed picture of the cottage industry that is American health care; practice patterns vary wildly and widely.
As just one example, the rate of back surgeries for Medicare members is five times higher in Fort Myers than in Miami, while the hip fracture repair rate is essentially identical. And no, it’s not because the population is different or sicker, it is because that’s just the way medicine is practiced in those two areas.
Well, despite the terrific, well-respected, and well-regarded research behind the Atlas, the NYT got this one wrong, citing some folks who claimed that it is inaccurate, biased, or just plain wrong.
Author Robert Pear is usually one of the best in sorting thru the chaff to find the wheat, but he quoted several individuals without comment, even when the quotes were flat-out wrong. Pear failed to refute critics, even when it would have taken precious little research to do so.
Here are a couple examples:
“There is too much uncertainty about the Dartmouth study to use it as a basis for public policy,” said Senator John Kerry, Democrat of Massachusetts. “Researchers can’t explain why some areas of the country spend more on health care than others. There are many reasons spending could vary: higher costs of living, sicker people or more teaching hospitals.”
Wrong, Senator. Absolutely, flat-out, incontrovertibly wrong.
There is almost no uncertainty about the study and little confusion about why spending is different. It isn’t sicker people, and the issue of cost of living and excess hospital costs are discussed in detail – and corrected for – in the Atlas. The Mayo Clinic among other excellent providers delivers great care for a lot less money than hospitals in your state, and there are wide variations in hospital admission patterns between New Haven and Boston – patients are admitted far more often for COPD in Boston than in New Haven. That’s just practice pattern variation, for no reason other than ‘that’s the way we do it’ in Boston.
And this.
“Dr. Michael L. Langberg, senior vice president of Cedars-Sinai Medical Center in Los Angeles, is among the critics.
“The statement that Medicare costs can be cut by 30 percent has been repeated so many times that it has come to be viewed as a proven fact by some,” Dr. Langberg said in a recent letter to the Senate Finance Committee. “It is not a fact. It is a gross oversimplification of an untested theory.”
Dr. Langberg endorsed the goal of covering the uninsured, but said, “We do not believe that rushing to make large cuts in Medicare payments to hospitals is the right way to fund that coverage.”
Good to see that automatic kneejerk response is still functioning. There is no question, none, that much of US health care spending is wasted on unproven procedures, hospitalization of patients that could be treated on an outpatient basis, and for devices and drugs with minimal positive impact on health.
Maggie Mahar does a much more in-depth dismantling the disappointing reporting/writing/editing by the Times here.
Jun
10
Robert Pear’s piece referenced an article by Atul Gawande in the June 1 edition of the New Yorker in which he (Dr. Gawande) describes the “cost conundrum” in McAllen, TX. This is a very serious observation for it underscores at least two considerable cost drivers in our health care system.
At a minimum, Dr. Gawande’s findings highlight the importance of the disclosure of physicians’ financial interest in allied health care providers and the apparent encouragement of finder’s or referral fees paid by allied healthcare providers. The practice is insidious as well as costly. The other glaring observation is the failure of the peer review system to rein in the unjustified use of various and sundry tests that contribute little to nothing to the patient’s outcome.
In managed care networks that require all providers to disclose their financial involvement or arrangements with other healthcare providers, an opportunity arises to either not include that provider(s), or ask them to end that practice as a condition for inclusion in the network. The other cost containment technique that should be codifed in contracts with participating providers, particularly when it comes to inpatient admissions, is the power to perform retrospective reviews of inpatient stays that pierce the outliers of the treatment guidelines employed by the managed care company or third party payer. This contractual tool – an inherent part of the early PPO contracts – has fallen in disuse for reasons that make no sense if cost containment is truly the goal of the managed care company and its payer clients.
Enforcing those two techniques will surely restrain the cost drivers so clearly described in Dr. Gawande’s article. I can personally testify to their contribution as they were applied in a workers’ compensation PPO some 15 years ago!