Thursday, June 3, 2010


The New York Times' Reed Abelson and Gardiner Harris return again to the increasingly dubious and refutable claims of the Dartmouth Atlas of Health Care, which is more and more looking like the medical equivalent of "Climategate" or any other scandal that ends with the "gate" suffix.  This has been a theme here at SMS, too, going back to February, when we noted the Times noting the work of Dr. Peter B. Bach, of Memorial Sloan-Kettering Cancer Center in New York City, who had just published an iconoclastic article in The New England Journal of Medicine, debunking Dartmouth.  By now Bach's work is passing into the conventional wisdom--of course the Dartmouth Study was a fraud, like Obamacare itself--but Dr. Bach was daring when he published his piece, and NEJM deserves credit, too, for publishing it.

But it’s important to dwell on this Dartmouth publication, because it formed the Ivy League-validated intellectual heart of the Obamacare argument: That there was much waste in the system, that the Dartmouth Atlas had identified it, and so it was just a question of finding it--which, of course, the Obama administration was well-equipped to do.  You know, after they get through capping leaking oil wells.

As the Timesmen note:

In selling the health care overhaul to Congress, the Obama administration cited a once obscure research group at Dartmouth College to claim that it could not only cut billions in wasteful health care spending but make people healthier by doing so.

Wasteful spending — perhaps $700 billion a year — “does nothing to improve patient health but subjects you and me to tests and procedures that aren’t necessary and are potentially harmful,” the president’s budget director, Peter Orszag, wrote in a blog post characteristic of the administration’s argument.

Mr. Orszag even displayed maps produced by Dartmouth researchers that appeared to show where the waste in the system could be found. Beige meant hospitals and regions that offered good, efficient care; chocolate meant bad and inefficient.

The maps made reform seem relatively easy to many in Congress, some of whom demanded the administration simply trim the money Medicare pays to hospitals and doctors in the brown zones. The administration promised to seriously consider doing just that.

Ah, yes, the power of a map--the power to deceive, as well as the power to enlighten.  Like any tool, it couldbe used for propagandization, just as easily as for information.   A map is akin to a “dashboard”--be it a dashboard for a car, or for a computer.  But again the key variable is the ethics of the dashboard maker.

Being  polite is the Times way, Abelson and Gardiner start totting up the flaws in the Dartmouth study:

But the atlas’s hospital rankings do not take into account care that prolongs or improves lives. If one hospital spends a lot on five patients and manages to keep four of them alive, while another spends less on each but all five die, the hospital that saved patients could rank lower because Dartmouth compares only costs before death.

“It may be that some places that are spending more are actually getting better results,” said Dr. Harlan M. Krumholz, a professor of medicine and health policy expert at Yale.

Failing to receive credit for better care enrages some hospital administrators. But for the Dartmouth researchers, making these administrators uncomfortable is the point of the rankings.

“When you name names, people start paying more attention,” Dr. Fisher said. “We never asserted and never claimed that we judged the quality of care at a hospital — only the cost.”

But of course, the whole thrust of the study was that quality was independent of cost--and now we know that not to be true.   If healthcare costs more in the Sunbelt than in the Upper Midwest, maybe that's because Sunbelters are unhealthier, and because the cost of living is greater.

And there's this:

Last June, as Mr. Obama campaigned for his health care overhaul, he visited Green Bay, Wis., praising the city for getting “more quality out of fewer health care dollars than many other communities.”

Two of Green Bay’s hospitals, Bellin and St. Mary’s Hospital Medical Center, rank fourth and 11th within Wisconsin on the Dartmouth list.

But again, Dartmouth ranks hospitals only by costs and number of treatments and procedures. A different picture emerges from work done by the Wisconsin Collaborative for Healthcare Quality, a voluntary group of health care organizations that uses both price and quality of care measures. In an analysis of heart attack care, for example, it ranks Bellin second, and St. Mary’s 15th, among the 22 hospitals in the state.

And a Medicare ranking based on its own data that shows how many people die after treatment for certain conditions — statistics that exclude costs entirely — puts Bellin fifth, but drops St. Mary’s to second-to-last: 67th of the 68 hospitals statewide that were measured by both Dartmouth and Medicare.

Do the Green Bay hospitals favored by Dartmouth really offer better care? Maybe not.

In other words, even within the Snowbelt, the Dartmouth data are not trustworthy.

We can close with this caustic commentary of Chris Jacobs, health policy analyst for the Senate Republican Policy Commitee:

The New York Times is out this morning with a feature analysis that dispels some of the myths surrounding the Dartmouth Atlas survey.  Some of the criticisms have been previously reported – for instance, a December Times piece examined a study highlighting a California studyfrom last year indicating that spending in the last year of life presents a potentially misleading picture of hospitals’ efficiency, because (by definition) it does NOT examine care interventions that successfully saved lives.

 Two startling quotes from Dartmouth’s Eliot Fisher stand out in this morning’s article.  First, Fisher admitted that he and his Dartmouth colleagues have made unsupported claims that more spending equals worse care, even though there is “little evidence” to support this claim.  Fisher admitted “that he was sometimes less careful in discussing his team’s research than he should be” by drawing conclusions without data to back them up.

Second, Fisher made this stunning statement about his research for the Dartmouth Atlas: “We never asserted and never claimed that we judged the quality of care at a hospital — only the cost.”  So if you were wondering where Sir Donald Berwick – the Administration’s nominee to run the Medicare and Medicaid programs – obtained the notion that we should cap health care spending and “ration with our eyes open,” you may have just found your answer.

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