Wednesday, the New York Times once again launched an attack on what has become known as “the Dartmouth research.” As regular HealthBeat readers know, more than two decades of studies done by medical researchers at Dartmouth suggest that hospitals that provide the most expensive care often are over-treating their patients, squandering billions of healthcare dollars, while exposing patients to unnecessary risks.
For some of Manhattan’s priciest hospitals this is a sensitive subject. As the Times notes: “Some proposals in Congress call for using the analyses . . . to begin spending less money on regions where medical care is especially costly, including places like New York City.”
Is the Mayo Clinic Really More Efficient?
The Times’ piece begins by grousing that medical centers like Minnesota’s Mayo Clinic may be overrated as models of efficiency: “For much of the past year, President Obama has lavished praise on a few select hospitals like the Mayo Clinic for delivering high-quality care at low costs.” Indeed, an article published by Dr. Atul Gawande in the New Yorker last year which relied heavily in the Dartmouth data became required reading at the White House. “But,” Times’ reporter Gardiner Harris declares, “a pointed analysis published Wednesday in an influential medical journal suggests that the president’s praise may be unwarranted.” He goes on to argue that an editorial published in the New England Journal of Medicine by Dr. Peter B. Bach, a physician at Manhattan’s Memorial Sloan-Kettering Cancer Center,” suggests that much of [Dartmouth’s work] is flawed and that it should not be used to compare the relative efficiency of hospitals.”
If fact. Bach begins by agreeing with the central conclusion of Dartmouth’s work: more intensive care—and more expensive care—is not necessarily better care. Often outcomes are worse. As he puts it: “the Dartmouth Atlas of Health Care has felled the notion that higher health care spending necessarily leads to improved health outcomes.”
But Bach does question Dartmouth’s methodology, claiming (wrongly as it turns out), that when Dartmouth assesses a hospital’s efficiency it doesn’t take into account the degree to which patients vary in terms in “of severity of illness.”
Since “some hospitals take care of sicker patients than others, the average severity of illness of patients who die also varies among hospitals. This fact is being ignored when all spending differences are attributed to differences in efficiency.”
Not true. I have read the Dartmouth Research—all of it. So yesterday, when Dartmouth’s Jonathan Skinner and Elliott Fisher sent me a response that they had just posted on their website, I knew that it was correct.
They wrote: “Dr. Bach . . . is mistaken when he claims that the 2008 Dartmouth Atlas end-of-life measures do not adjust for such differences. The Atlas sample comprises Medicare enrollees with at least one life-threatening chronic disease in their last 2 years of life. It further adjusts for the type of chronic disease and the presence of multiple diseases.”
Gawande Backs Dartmouth’s Research
Yesterday, Boston surgeon Dr. Atul Gawande posted his own response to the New York Times article on the New Yorker’s News Desk , stating that “none of the [Dartmouth] data” used in his landmark June 1 New Yorker piece “has been found erroneous or wanting. “ ( Here, Gawande is referring to the much-discussed article that investigated the money-driven medical culture of McAllen, Texas)
“If one wishes to try to reward hospitals that provide higher quality for lower cost,” Gawande adds, “one needs to be able to distinguish between high- and low-efficiency hospitals. Dartmouth researchers have come up with a way to rate hospital efficiency . . . In his opinion piece, Dr. Peter Bach of Memorial Sloan-Kettering argues against using the Dartmouth measures to financially reward and penalize hospitals. . . None of this, however, calls the Dartmouth researchers’ decades of highly respected work—or their fundamental findings—into question. If anything, the debate reinforces the importance of their research. . . it remains clear that there are substantial variations in the cost of care for people of similar health depending on which institutions they go to—and also that clinicians with the best results often have lower, not higher, costs than average. “
Rooting For the Home Team?
This is not the first time the Times has misreported the facts about the Dartmouth research. I’m afraid that misplaced hometown loyalties may be coloring the reporting.
The Times addressed the issue back in June when it reported that Congressmen from states where Medicare spends less per capita—such as Iowa, Minnesota, Montana, North Dakota, Oregon and Washington—were suggesting that Medicare should cap reimbursements in states where Medicare lays more per capita: “Nationally, according to the Dartmouth Atlas of Health Care, Medicare spent an average of $8,304 per beneficiary in 2006. Among states, New York was tops, at $9,564, and Hawaii was lowest, at $5,311.”
Then in September, The New York Times heard that the Medicare Payment Advisory Commission (MedPAC) was doing a study on regional variations in the intensity and cost of care. At the time, the paper reported that MedPac staffers, “recently told Congress that much of the [regional] variation [in Medicare spending]could be explained by local differences in the cost of providing care and in the health status of beneficiaries, as well as by extra payments, authorized by Congress, for hospitals that train doctors or treat large numbers of low-income patients.”
In this early report the Times seemed to be suggesting that MedPAC had found a fatal error in the Dartmouth research—and that, in fact, New York City’s most expense hospitals are not overspending on unnecessary services.
In September, when the MedPac report finally came out, I posted on it, explaining, that it focuses, not on the dollars spent on patient care, , but on the volume and intensity of tests and treatments that patients receive.
The Dartmouth researchers acknowledge that when you look at cost per patient, the numbers can be skewed by various factors including differences in local pricing, and differences in how much Medicare pays a hospital, depending on whether it is a teaching hospital that has extra expenses, or a hospital located in a rural area where the cost of labor is lower. Moreover, when a hospital serves many low-income patients, they are likely to be sicker, and spending may be higher —assuming that they receive the care that need.
But Dartmouth looks, not just at the dollars Medicare spent per patien, but at what percent of of patients see 10 or more specialists during their last six months of life, how many days they spend in the hospital, how many tests they undergo. In other words, it looks at the volume of services they receive—quite apart from prices. .
“When you look at utilization, you don’t have to price-adjust,” for differences in local prices, the higher cost of labor in Manhattan, or how much Medicare pays hospitals to trains doctors, Dartmouth Dr. Elliott Fisher explained to me in a phone interview. “If you look at hospitals in affluent parts of Manhattan, you’ll find that utilization is twice as high as in Rochester, New York.”
The table below compares spending and utilization in Rochester and in Manhattan for Medicare patients suffering from very similar chronic diseases. The table zeroes in on two hospitals—NYU Medical Center in Manhattan and Strong Memorial Hospital in Rochester.
Source:The Dartmouth Atlas of Health Care
Still, when The New York Times looked at the MedPac report, it once again defended the home team: “the commission found that the use of health services per Medicare beneficiary was 98 percent of the national average in the New York metropolitan area . . . As hospital executives in New York City often point out, their patients tend to be sicker than average.”
But if you look at the MedPAC report’s Appendix, you’ll find that the statistics for “the New York metropolitan, area” include a, heterogeneous area described as “New York-Northern New Jersey-Long Island, NY-NJ-PA.” This really doesn’t tell us much about use of services at Manhattan’s brand-name hospitals.
If you want to zero in on Manhattan’s brand-name medical centers, see this January 10 Health Affairs article which reveals that when researchers compare how hospital days similar chronically ill patients spent in the hospital during the last two years of life they found that Manhattan Hospital Referral Region is 78 percent above the national average—far exceeding the rates in Los Angeles (43 percent above average) and Miami (48 percent).
As for the notion that Manhattan hospitals use more resources because their patients are poorer and thus sicker than average, Dartmouth’s Jon Skinner observes: “Certainly people with lower incomes experience a greater disease burden. But it is also important to understand that there are considerable access problems facing people in poverty – they typically don’t have their own doctors, often have to travel long distances for their care, and often do not have any of the “Medigap” policies that pays the often sizeable copayments and deductibles in the Medicare program. For this reason, peer-reviewed research has typically found quite modest associations between zip code income and Medicare expenditures.” (In part two of this post I’ll take a closer look at the importance of poverty in explained variations in cost and intensity of the care that patients receive. .)
Finally, in the past, the New York Times has quoted Manhattan hospital administrators explaining that their patients are simply more sophisticated, and more demanding than patients elsewhere. But Dartmouth researchers explain that in general, patients who want more aggressive management of their illnesses are likely to choose academic medical centers. Yet not all academic medical centers recommend equally aggressive and intensive care.
For instance, a Dartmouth study that compares similar patients at Stanford University Medical Center to Medicare enrollees who were cared for at New York University (NYU) Medical Center finds that the NYU patients spent more than twice as many days in the hospital (twenty-seven versus ten) and were visited by seventy-six physicians versus twenty-three during their last six months of life. It’s hard to imagine that this is because patients at NYU are significantly more knowledgeable, discerning or demanding than patients at Stanford
In Part 2 of this post, I’ll take a closer look at which Manhattan hospitals see a larger number of poor patients—and whether they use more medical resources. I’ll also discuss the high correlation between Dartmouth’s end of life data and analysis which looks at heart attack patients which looks forward, for one year, from the first day of admission. In addition I’ll explain that different Dartmouth reports adjust for different variables—local prices, severity of the illness (risk), race and income, and this can be confusing for those who read only one or two of the reports . But the research discussed in Wednesdays’ Times adjusts for all of these variables.
Finally I’ll discuss how the recent Times article misquotes Dr. Elliot Fisher, taking his words out of context to suggest he agrees that “the current Dartmouth Atlas measures of efficiency and quality should not be used to set payment rates” for individual hospitals 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.”
How likely does it seem that, after devoting nearly two decades to the ground-breaking Dartmouth reserach, Dr. Fisher would offhandedly tell the Times that it offers "limited insight" and that is "really isn't very useful"?
In fact, after speaking very briefly to Fisher (and not at all to Skinner) the reporter misinterpreted what Fisher was saying. As Fisher and Skinner write in their response: “In sum, the New York Times article provides a distorted picture of the Dartmouth research. It is understandable that some may be concerned about how we measure the costs and quality of hospitals – particularly those who stand to lose the most under meaningful health care reform. But we should not be confused by misleading claims about the reliability of measuring hospital performance. The potential exists – now — to improve the efficiency of U.S. health care by implementing reforms that would hold hospitals and their associated physicians accountable for both cost and quality.”
I trained at NYU, and can tell you that the patient population plays a huge role in utilization patterns there. A significant proportion of NYU inpatients are from the ultraorthodox enclaves of Borough Park and Williamsburg; a few of my elderly patients from that community bore tattooed numbers from concentration camps. For religious reasons they believe in doing everything humanly possible to preserve life, even if the expected benefit is very small. Having cared for many such patients, I’ve found (I don’t mean to generalize; I’m just speaking overall about my experience) that family members will generally want to make sure they have heard about all of the treatment options available; only on rare occasions and after formal consultation with religious authorities have I seen anyone forgo any aspect of medical care. Of course, the attendings who work there are more than happy to facilitate those beliefs by providing them with expensive services, but it wouldn’t happen without clearly-expressed demand from the community.
NYU is only one hospital and I’m sure other high-spending hospitals don’t face this particular issue, but I felt it was important to clarify the facts of NYU’s case since it is the only example you seem to offer in this post. The hospital administration is well aware of what is going on and I suspect that if you had bothered to ask them they would have told you; instead, all you offer is a glib assertion that “It’s hard to imagine that this is because patients at NYU are significantly more knowledgeable, discerning or demanding than patients at Stanford”. You point out that, while the New York Times did not contact Skinner, you took the trouble to get the full story from him. I wish you had offered NYU and its patients the same courtesy.
I don’t live or practice in New York any more, and I wouldn’t personally make the choices many of my patients at NYU made regarding end-of-life care. But I know they made them out of deeply and sincerely held religious beliefs which our health care system (last time I checked) was supposed to respect. Saying that everyone should follow the same treatment patterns for reasons of safety and efficacy is fair enough, but saying that beliefs such as these should not be allowed to influence service utilization seems at best unrealistic and a little inhumane.
I read this NY Times article. I wonder if it is just lazy reporting rather than a home team booster. I read a side bar in the Times a few days ago. It dealt with the 39% increase in premiums being charged by CA’s Anthem Blue Cross Blue Shield. I had to get fairly far down before I saw any mention of the fact that the subscribers have decreased in number and the ones left in the pool are the sick ones. I think the Times is just not very good at this subject, and sadly, like many others, journalists and politicians, they are not interested in learning about it.
no longer in NYC–
Thanks for your comment and welcome to the blog.
Interesting points. The story rings true to me because this is what I heard from an administrator at Maimonides in Brooklyn (they also have fair number of Orthodox Jewish patients who do their best to live to 105)
I have actually contacted NYU in the past and I’ve read there resopnses to others asking about their outlier status on the Dartmouth charts. .
(I’ve been a reporter for over 25 years, and so I do know how to check with sources.)
NYU stone-walled me. Same story that UCLA Medical Center gives out : we give better quality care– top of the line, cutting edge. service. Our patients are sicker. Our patinens are more sophisticated.
I suspect that NYU is not as forthcoming about having a large number of Othodox Jews who want “everything possible” because they consider religion a sensitive issue,
Can’t imagine that they would tell the NYT– “Conservative Jews demand extensive end-of-life care, and so we give it to them, though of course it costs Medicare a fortune.”
(And if they did, the NYT would never print it.)
I, by the way, think it is perfectly appropriate to respect a patients’ religoius beliefs in terms of end-of-life care.
I’m less comfortable with teh family pushing for everything possible. They are not the ones suffering.
Ideally, the patient is in good enough conditon to make his/her own decisions after talking to a good palliative care team that lays out options and gives the patients a chance to express his or her feelings without steering him. .
Regarding NYU–I also contacted them about the study that NYC Legal Aid did 4 or 5 years ago showing that NYU does not welcome poor patients. (The study looked at quite a few NYC hospitals to see which ones actually welcome and treat the poor.)
IT was a pretty shocking investigation. . When I and called NYU, first they said they would respond, then they said that they wouldn’t.
Residents who worked at both NYU and Bellvue confirmed that “the poor know where they are and aren’t welcome. They aren’t welcome at NYU.”
A well-known doctor who has treated mainly Medicaid and indigent patients for years confirmed this.
Another NYC health care official said: “Check out NYU’s ER. You’ve never seen a smaller ER. IT’s sending a message: we don’t want people walking in off the street.:
Columbia-New York hospital sees more more poor patients (Dominicans who live in Washington Heights)–and uses fewer resurces. Bellveue– right down the street–weclomes the poor–and uses fewer resources.
I’m wondering if the larger number of Orthodox Jewish patients at NYU balances out the fact that they see fewer poor patients? IF so , there over use of resources still suggests overly-aggressive care.
Finally, I quote the Dartmouth reserachers at length because they are very open with reporters. They will take phone calls, explain at length–especially if you have taken the time to read their voluminous reserach and so are asking intelligent questions.
The NYT tends to describe the Dartmouth research as “arcane” (much as they describe MedPac’s excellent 250-page reports as arcane).
This is reporter-speak for “this is just too damn much for me to read.”
The DArtmouth reserachers have nothing to hide–they are willing to express their reservations about their own reserach, explain what they are still working on. And Dartmouth Hopsital just isn’t a political place the way most NYC hospitals are political. Here, even well respected doctors are afraid to talk to you for attribution saying things like “the politics are so rough here, I could lose my job.)
Hi Maggie
Just to clarify one oversight above in citing the Jan 10 HA paper. The purpose was to look at per capita costs, adjusted, per Mcare beneficiary. NY area hospitals had significant downward adjustments, more so than other regions, due to DSH, GME payments, and other local factors.
However, the paper goes on to say that EOL costs in NYC, the last 2 years, indicate a different pattern, with a 78% increase in costs.
They are different measurements.
Brad
The New York Times health and health care reform reporting is sclerotic and increasingly irrelevant. (with the exception of Paul Krugman’s rants)
This paper is MUCH too tied to the status quo which is obviously failing.
Dr. Rick Lippin
Southampton,Pa
These medical institutions are big advertisers. Just like they are big campaign contributors.
The truth is hard to prove, but we all know it.
If a person’s religious beliefs cause them to want to torture their aged loved one with less than effective interventions then I think we should leave them to their own consequences. That’s an issue that is too distracting and emotional for me.
I read the article in the NYT briefly and I think your analysis is correct.
It only briefly mentioned volume of treatments as a measure and left the reader thinking that Dartmouth ignored the fact that increased interventions produced a better result in some cases.
When you remind the reader that their analysis was on patients in the last two years of their lives the notion of improved results fades. In the end everyone had the same result. The difference was that some hospitals got that result with more cash than others.
I was interviewed once by a NY Times reporter and my facts did not match what her preconceived notions were so she ignored part of the interview and twisted other information to make her story match her preconceived notion.
So I don/t put much faith in any NYT stories.
Hi everyone–
Thanks for you comments.
I’ve been travelling all week– back home Sat.,
will catch up with replies on Sunday–
Best, Maggie
P.S.– these are hard times for newspapers; many layoffs, which means reporters have less time to report stories or fact-check.
So this may explain part of the problem with the story.
But since a series of NYT
stories have been skeptical about the Dartmouth reserach ever since Congress began talking about rewarding hosptials that are more efficient (better outcomes at a lower price) and penalizing those that don’t approach efficiency
benchmarks, it seems likely that editors as well as reporters at the NYT are inclined to think the Dartmouth reserach must be wrong.
Most New Yorkers think that our brand-name hospitals are the best hospitals in the country–and in the world.
When it comes to efficiency, that just isn’t true. And outcomes really are better at hospitals where very similar patients are treated in fewer days. (The more days you spend in the hosptial the greater the danger of errors, infections, medication mix-ups. And the more procedures you undergo, the greater the risks.)
But as I said, most New Yorkers don’t want to believe this. And they are afriad that if NY hospitals are forced to be more efficient that New York patients won’t get all of the treatment that they need. (In fact, if NY hosptials are forced to be more efficient, outcomes at these hospitals should improve and patients would be safer. NY Docs who understand the Dartmouth reserach agree on this.)
But New Yorker like to think that the way we do things is the best way!
John H., Ginger C., Ed, Rick, Martha, Brad
John H—
You make a good point.
Reporters at many publications (not just the Times) sometimes have already decided how the story will turn out before they begin reporting it. To be fair, in the best-case scenairo cases, this means that the reporter actually has done a great deal of research and knows the field well. Even so, he or see should be open to hearing opposing arguments—though that doesn’t mean tha tshe she should quote all points of view as equally true if she has the facts and knows better.
Example: If I were writing a news story about research into obesity, I wold start out the the thesis that it is an incredibly complex disease. (I have done enough research to know this.)
I might quote someone saying: “actually it’s just a matter of will power.” But I would then make it clear that medical reseraechers and physicains who have speent time working with obese patients and studying the components of the diease know that this is not true.
I would then go on to quote reserachers talking about various causes—genetic, nerological, enironvmental (why growing up in poverty is correllated with obestity) cultural, psychological etc. At that point, I would present these ideas as equally true (unless someone gave me evidence ot the contrary) because from what medical reserachers know at this point, all of these factors are involved.
Finally, all too often, it’s not the reporter who has a preconceived idea but the editor. This means that part of what the reporter finds out in the course of reporting the story may well be cut —or pushed ot the bottom of the story—while both the lead and the headline trumpet the editor’s poitn of view. When the facts in the last few paragraphs don’t quite fit—or even seem ot contradict –the lead and headline, that’s probably what happened.
Ginger C—
Thank you for you comment.
I disagree on only one point. I’m not convinced that the fate of the elderly should be determined by middle-aged aged children or other relatives –even when religious beliefs are involved. The elderly person , like everyone else, has individual rights and too often his or her desires are ignored while their middle-aged children take charge.
This is one of the many reasons I like palliative care: a palliative care specialist will make sure that the patient herself has a chance to express her feelings (assuming she is still able to do that) —and, if necessary, the palliative care specialist will explain to the relatives that ultimately this is the patient’s decision.
But I agree that , the fact that all of these patients died at the end of the two years does suggest that those who got more aggressive, more intensive treatment probably couldn’t be saved. This mean that much money was probably wasted.
Though to be pefectly fair, some of that money may have been spent on treatment that might have saved the patient. Sometimes doctors just don’t know which patients can be saved. .
In other cases, however, they realize that there is little or no hope of “savnig” the patient. .
Then, the question becomes, will the extra treatment give the patient more time? And, what will be the quality of life during that time?
This is where the patient needs to be involved in the decisoin-making. For some patients (say a mother with a one-year and a three-year-old) the benefit of a treatment that gives a patient another 6 months (with an outside chance of 18 months) would be huge. (Three or six months is a long time in a two-year-old’s life, and could give a mother time to prepare and nuture the child so that the loss of a mother won’t be as devastating.) On the other hand, a 70-year-old who kows that she’ll have to go through more treament for the extra 6 months (and, at best, feel very tired during those extra 6 months because she’s also suffering from 1 or 2 other chronic diseasesemight decide that she would rather spend her final motnhs at home, no longer undergoing reatment, and, receiving home hospice care to make sure that she is as comfortable as possible.
Ed—Good to hear from you.
It is true that New York’s largest brand-name hosptials place ads in the New York Times.
It’s impossible to know when or whether this actually effects a story.
But I do know that when I was at the Times (as an editor) I edited a very good and witty story about a new cigarette for woman, developed by Philip Morris, that was a longer version of Virigina Slims. I still remember the writer’s lead : “Does it make you nose look shorster, your fingers look longer . . . . ?” ) She went on to riff on what possible advantage a longer Virigina Slims could offer women, while playing on the whole notion of “production extension.”
I edited the story, but I was not the top editor on the story , and when the top editor saw it, he was not happy. “Philip Morris is an Advertiser!” he exclaimded—and labled the story “New Jouranlism” (which means., to some people, that the reporter’s opinion and personality are too prominent in the story.. I think that some New Jouranlism is excellent (Joan Dideon, for example),but I also believe that much of it is self-indulgent)
Rick— Thanks for your comment. Always good to hear from you. The New York Times actually has a couple of ( probably maybe more than 2) excellent medical reporters. But somehow, their stories don’t appear in the Times that often. Some of the most important stories seem to be assigned to other reporters.
Brad—Good to hear from you. You’re right: the bulk of the study is about Medicare payments per capita over time, while the end of the paper (which I quote) is looking at end of life costs during the patients’ final two years. Here I would just point out that other Dartmouth studies have shown that hospitals that offer expensive, intensive care during the last two years of life also offer expensive intenisve care to Medicare patients who are not dying, but have fractured a hip.
I also sent your query to Dartmouth , and they point out that after subtracting the extra money that Medicare pays New York Citiy’s teaching hospitals simply because they are teaching hospitals, the amount of money that Medicare spends on patients at these hospitals appears to be about average.
But—and this is important– Medicare pays NYC hospitals significantly more for teaching than it pays teaching hospitals in other cities. No one is quite sure why, though probably it has to do with the amount of money and political influence that New York’s brand-name hospitals have..
So Medicare is over-paying NYC hospitals (assuming that there is no reason to pay them so much more than other hospitals that train medical students and residents.)
Secondly, when you look at utilization, you find that patients at many NYC hospitals spend many more days in the hospital than patients at more efficient hospitals—with no better outcomes. And they are seen by many more specialists while in the hospital. Finally, Dartmouth pointes out, the vistis from specilaits number doesn’t include the resdients that they see. (Dartmouoth can’t count the residents because resident cannot bill for treatment so they don’t show up in Medicare records.)
Thus, hopsitals in NYC hospitals see many more specialists than patients in hopsitals where care is less aggressive—PLUS they are seen my by many more resdients.
So it does seem that patients in NYC hospitals are exposed to what could be an ecessive amount of poking and prodding. One reseracher at Dartmouth speculates: “It may be that these hospitals keep patients longer because they need to give their many residents a chance to practice their clinical skills.” He emphasizes that this is speculation—we don’t know.
But we do know that the the bottom line (factually) is this:A) NYC hosptials have somehow arranged to get Medicare to pay them significantly more for educating medical students that it pays most academic medical centers ( I assume this has to do with power politics) and B) patients in NYC hospitals stay longer and see more specialists, which means that they are exposed to more risks.
So it appears that the NYC hospitals are overpaid and patients are probably over-treated—as in other high-spending cities like Miarma or LA.
But in N.Y. A & B don’t seem to be closely linked The hospitals are not overpaid because patients stay longer and see more doctors. They are over-piad for training medical students.
At the same time, patients also stay longer and see more docs—without better outcomes- which isn’t good for patients.
Bottom line (IMHO): someone should look into why NYC hospitals are paid so much for training.
Martha—
You write: “I read this NY Times article. I wonder if it is just lazy reporting rather than a home team booster. I read a side bar in the Times a few days ago. It dealt with the 39% increase in premiums being charged by CA’s Anthem Blue Cross Blue Shield. I had to get fairly far down before I saw any mention of the fact that the subscribers have decreased in number and the ones left in the pool are the sick ones.”
You are absolutely right. And let me add that the Anthem/Blue Cross story has been poorly reported, not just in the Times, but in most of the mainstream media.
The truth is that the 39% increase doesn’t apply to all—or even most—Anthem policies. And, secondly, as you say, the pool of subscribers has lost many healthy subscribers—making insurance more expensive.
It’s interesting that you found the facts at the very end of the story. (See the 4th paragraph of my reply to John H above. This means that a reporter got the story right, and an editor decide to bury the facts at the bottom, while leading with the crowd-pleasing conventional wisdom)
The fact that Anthem’s pool of customers is now sicker should have been the lead—and the headline. Most newspapers got the story wrong. The Times could have corrected the misinformation, and then gone on to explain why healthy customers left Anthem and why they were left with a pool of much sicker patients.
Then, someone at the Times should have asked, “Who at Anthem made the knuckle-headed decision to jack up premiums by 39% for some customers all at once?” This just ’t isn’t fair to those sick customers, and inevitably, would draw headlines and terrible PR.
Finally, as I said in another reply, the Times actually has at least two or three extremely knowledgeable, very, very intelligent and experienced medical/healthcare reporters. They just don’t seem to use them on some of these very important stories—particularly stories with a political dimension.
The Times tends to tie the Dartmouth research to the Obama administration, always citing the fact that the Obama administration has read the Dartmouth research and believes that it can be very useful in understanding what we need to change. I take the administration’s familiarity with the Dartmouth research as a sign that at last, we have an administration in which intelligent people like Peter Orszag and Zeke Emmanuel are willing to wade through pages and pages of research in order to understand the subject. But the Times tends to present it as if the Obama administration has been duped by Dartmouth researchers.
I have no idea why.
No Long in NYC—I replied to your post a few days ago—scroll down, you’ll find it below.
Thanks for the response Maggie.
My guess is residents have less to do with variation, and more to do with local culture. If trainees were an independent variable, my guess is all educational sites would be outliers–which is not the case (Mayo, UCSF, Cleveland Clinic, etc).
On the NYC front, I have been speaking with a Dartmouth researcher as well. Curious that despite high utilaztion, post adjustment for non-clinical payments, per capita costs in NYC are average. Speculation on this is other Part A inputs outside of the hospital, but still needs teasing out. As always, this stuff is nuanced, but agree, at the heart of it, NYC needs a magnifying glass and a 2×4.
Brad
I’m not very familiar with how things work in NYC, but one wonders if the higher number of hospital days reflects an inability to accomplish things as an outpatient that could be done as an outpatient. That is, patients are kept in the hospital to see specialists because it is just too hard to arrange all that outside the hospital.
The Mayo Clinic excels at outpatient efficiency. It demonstrates what an integrated inpatient/outpatient practice can accomplish with the least amount of fuss.
Maggie,
Re your comment about UCLA “stonewalling” (in comment to no longer in NYC). They have published a study on nearly 4000 patients at http://circoutcomes.ahajournals.org/cgi/content/full/2/6/548 that concludes: “California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences. ”
What do you think?
Harry–
I am famliar with the study and interviewed one of the doctors invovled in it.
He acknowledged that it is hard to interpret the results. It is a very small study of a few hospitals. Some (not all) of the reserachers set out to try to prove that spending more equals better care in order to justify the high cost of care at places like UCLA>
I’m very sketpical. Darmtouth has been doing very large studies for more than two decades, and they all show that more expensive care is not better care–sometimes it is worse.
Over those decades, other reserachers tried very hard to prove that DArtmouth was wrong. (Many hospitals and doctors resisted the idea that more care isn’t always better care, or that they were overtreating patients.)
But no one has been able to refute the Dartmouth resreach. The doctor I spoke to who was invlved in the California study agrees with the basic thrust of the DArtmouth reserach.
By the mid-to late 1990s, the DArtmouth resreach was just about universally accepted.
Then,in the last year or so, we’ve started talking seroiusly about health care. And people have begun to say: Why should Medicare spend so much more in Southern California than it spends in Iowa? People in Iowa put the same percentage of their paycheck into Medicare. Why should they fund over-treatment in L.A.?
This has been some people very, veyr nervous. And so we’ve seen a sudden new wave of criticisim of the Dartmouth reserach.
Certainly the Dartmouth reserach needs to be refined. The folks at Dartmouth say that– this is why they keep doing new studies, adjusting for various factors.
But the basic lesson to be drawn from the Dartmouth resesrach is this: more care is not necessarily better care. Often, outcomes are worse because when people are over-treated they are exposed to risk without benefit.
And supply drives overtreatment. As Dr. Don Berwick, president of IHI puts it: “We have overbuilt our health care system; And having created excess capacity, now we have to use it.”
Perhaps one answer is to have sick/elderly people and their families be told about the possible results of treatments in such a way that they will make reasonably thoughtful decisions about what they want done.
My 98 year old father, for instance, has already made two very significant decisions. When hospitalized for kidney failure four years ago, he decided that he would NOT undergo dialysis if it became necessary. He had had a friend subjected to frequent dialysis for the last six month of his life, and did not want the deterioration he had seen in his friend. (Dad did recover after a few days in the hospital).
He has also decided that if his heart stops again he does NOT want CPR or any other “recovery” measure. That’s an interesting situation. He wears a MedicAlert NO CPR bracelet, and has signed all of the appropriate paperwork required in MD. We discovered recently that we MUST take a copy of this paperwork with him if he enters our local hospital, even though the original documents were signed in the hospital. The ER electronic records automatically mark him as a “full code” every time he comes in for something, the staff doesn’t seem to be able to see his bracelet until we tell them about it, and they have to be convinced every time that this is still what he wishes.
And one of the great horrors of my life is the thought that I’ll probably have to defend him from a person who’s been trained in CPR trying to force that on him if his heart stops in a crowded public place…
Brad, Chris, Harry in MD
Brad, I agree– there are many teaching hopsitals that don’t over-use resources, so residents are probably not the “key.”
Chris– Yes, getting something done in NYC hospitals can be very hard.
Because most doctors are in private practice, if you want to call in several specailists to look at a patient, it’s easier to hospitalize him, and then call them into to consult. (At Mayo the specialists would be there.)
So many people are involved in one patient’s care, and they don’t all work for one organization, so co-ordinating care becomes time-consuming, and costly.
Harry in MD
We need palliative care specialists in all hospitals to a) lay out the options for the patient and his family and b) protect the patient from doctors who think it’s their duty to “save” the patient.
As for a good samaritan coming forward to do CPR–that is, indeed, a horrifying thought.