Today, the New York Times published a piece about the Dartmouth research that is raising eyebrows– in part because there are so many factual mistakes in the story, in part because the tone is so personal.
“It sounds as if it were written by someone’s ex-spouse,” a source who is very familiar with Dartmouth’s work told me in a phone conversation earlier today.
“Harris and Abelson were determined to write a story that would ‘take down Dartmouth,’” confides a second source in Washington who spoke with the Times reporters.
This is the second critical piece that Times’ reporter Gardiner
Harris has written about Dartmouth’s highly-respected work in just four
months. I wrote about the first story here
noting that the article “garbled the facts” about the research, and
quoted Dr. Elliott Fisher, the senior researcher, out of context.
Others quoted in today’s story indicate that the Times’ piece distorted what they said:
“Every word is clearly accurate, but the implication is wrong,” says
David Cutler, a Harvard economist health care policy expert who has
advised President Obama on healthcare.
Dr. Harlan M. Krumholz, a professor of medicine and health policy
expert at Yale also was quoted as if he doubted the basic thrust of
Dartmouth’s work. The Times’ reporters used just one line
from his interview: “It may be that some places that are spending more
are actually getting better results.”
Today, Krumholz explained:
“What I spent most of the interview trying to convey is that a lot of
the back and forth [about bits and pieces of Dartmouth’s data ] is
inside baseball stuff – and we are all working hard to figure out how
to gauge costs and value better . But Dartmouth’s work on variation is
pivotal to moving us forward – and we all agree that there is lots of
waste and it is unevenly distributed across the country.
After reading the Times' piece, Mother Jones’ Kevin Drum was baffled:
“Bottom line: all the "data adjustments" the Times reporters talk about have, in fact, been done. Researchers at Dartmouth and elsewhere have controlled for price levels, for demographics, and for differing rates of sickness, and their results largely hold up. . . . In the end, then, the authors of the Times piece end up with almost nothing. By the time their piece is done, they've basically only got two things left. First, the Dartmouth researchers admit that, on occasion, they might discuss their findings more broadly than they should when they're talking to a lay audience. Second, there are individual bits and pieces of their dataset that other researchers have disputed. Just as there are with any large, complex dataset.
“In other words, there's no there there. The Dartmouth research is not the be-all-end-all of healthcare research, but its basic conclusions are extremely robust and have been confirmed over and over. Why the Times chose to pretend otherwise is a mystery.”
”
~~~~~~~~~~~~
First, some background on Dartmouth’s work: As regular HealthBeat readers know, what has become known simply as “the Dartmouth research” represents more than two decades of analysis of Medicare data focusing on “unwarranted regional variations” in how much care patients receive in different parts of the country. Dartmouth calls these variations “unwarranted” because they have little to do with patient’s medical needs, or even their wishes. After adjusting for differences in income, age, the underlying health of the population and local prices, the researchers have found that patients in some medical centers receive far more care than very similar patients at other hospitals: they see many more specialist, undergo more tests and procedures, and spend more days in the hospital . Yet when care is more aggressive and more expensive, both outcomes and patient satisfaction are no better—and sometimes they are worse. Their conclusion: “More care is not necessarily better care.”
As I noted in February: For some of Manhattan’s priciest hospitals this is a sensitive subject. As the Times itself points out in that first story: “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.” Today, the Times fretted that the research could lead Medicare to “penalize big city hospitals like those at the Ronald Reagan UCLA Medical Center and NYU Langone Medical Center — which look profligate by Dartmouth’s measures . . .”
Falsehoods vs. Facts
Before considering the peculiar tone of the story, let’s look at the factual errors.
Today, in a response to the article Dartmouth’s Elliott Fisher and Jon Skinner pointed to five of the biggest bloopers. ( Quotations from the Times article are in italics):
-
The Times disputes White House budget director Peter Orszag’s contention that the Dartmouth research shows that we spend perhaps $700 billion a year on in care that “’does nothing to improve patient health but subjects you and me to tests and procedures that aren’t necessary and are potentially harmful.’
“Mr. Orszag even displayed maps produced by Dartmouth researchers that appeared to show where the waste in the system could be found,” the Times reports. “Beige meant hospitals and regions that offered good, efficient care; chocolate meant bad and inefficient.” But Harris and Abelson claim, the maps tell us nothing about the quality of care where hospitals spend more:
“For all anyone knows, patients could be dying in far greater numbers in hospitals in the beige regions than hospitals in the brown ones, and Dartmouth’s maps would not pick up that difference.”
Fisher and Skinner respond: False. For maps that do reflect quality of care – such as the quality of treatments for diabetics, patient satisfaction, and the quality of hospitals–see the Dartmouth Atlas website (www.dartmouthatlas.org) Here, you’ll find a map revealing where “Diabetic Medicare Enrollees are Receiving Appropriate Management” of their disease.
In the case of diabetics, “statistical adjustments are carried out to account for differences in age, race and sex.”
If you click on the interactive map, you will find that in New York City, only 75% of diabetics are getting care recommended as most effective. By contrast in many low-spending areas up to 91% of patients are receiving “appropriate management. “
-
The Times claims that “Neither patients’ health nor differences in prices are fully considered by the Dartmouth Atlas. “
Fisher and Skinner Respond: False. We have presented risk-adjusted measures of spending for chronically ill patients near the end of life, and in our published research (for example a recent New England Journal of Medicine study) estimated risk-adjusted spending for heart attack patients. There may not be a perfect approach to risk adjustment in all cases, but we have fully considered all feasible approaches.”
They continue: “More worrisome is the claim that differences in prices are not ‘fully considered.’ Since 1996, our Atlas reports have published actual measures of utilization – ranging from hospital days to physician visits to surgery rates. These rates clearly do not need price adjustment! As well, we have recently developed fully price-adjusted expenditure measures, they are freely available on the Atlas website. See this 2010 article published in Health Affairs
Harvard’s David Cutler backs them up: “I told Harris and Abelson that they Dartmouth does adjust for differences in local prices. And I explained ‘I don’t care about analysis that is not adjusted for prices’ by which I meant, the only data I look at is price-adjusted data. And Dartmouth’s price-adjusted data shows huge disparities” in how much care patients in different places receive.
“I don’t know why my comment was used to criticize Dartmouth,” Cutler added. “It would be critical if the research didn’t adjust for prices. But it does.”
In part 2 of this post, I’ll discuss other errors and misrepresentations in the Times’ article, and debunk some myths (for example that big city hospitals spend more, or that hospitals that treat the poor provide more aggressive, expensive care) I’ll also comment on the tone of the story– which puzzled many.
Disappointing piece. I sure wish they could have made this story more of a teachable moment. However, given tenor of the citizenry (see this from HA today: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2009.0296v1), we dont have too much to worry about.
At least if the Times wanted to focus on Dartmouth data, they could have drilled in on differences between commercial (<65 yo) market vs Medicare, or nuances of missing the differences within regions or cities and appropriate analysis in the context of ACA reform.
The Dartmouth folks did justice in their response, lets see if the NYT has the courage to give a difft angle in the future.
Nice job Maggie.
Brad
tone of story is totally unsurprising as it and content echo stories that appeared during the reform debate. reforms depend on the dartmouth hypothesis which is a real threat to the NYC medical establishment, especially the hospitals. gored oxen tend to express pain
Brad–
Very good to hear from you.
It is disappointing that the NYT story was so weak.
The Times does do some very good stories about healthcare, including stories done by R. Abelson in the past.
But here, they missed an opportunity. The Dartmouth research–and questions about refining the reserach–offer a chance to have meaningfu converseations about
health care reform and how we can safetly eliminate waste.
The folks at Darmouth are very open to these conversations–they don’t claim that their work represnts a “bible.”
They want more expensive and aggressive health care providers to engage in the conversation and explain why their care is more agressive and more expensive.
Then, those who are skeptical about “more care” can enter into
a meaningful dialogue with these hospitals– a collaborative conversation in which they talk about exactly how and why some hopstials are spending so much more.
I think you’re right: the Dartmouth response to the NYT article was
excellent. I hope the NYT
will respond in a meaningful way.
Let’s face it. Gardiner Harris is trying to protect the bloated high tech-high cost Manhatten Hospital Industry which probably accounts for a large portion of NYC’s “Metropolitan National Product” (MNP) and whose ads dollars flow to the Times
I’ve seen this unholy alliance between the Hospital Industry and mainstream media in Philly. And it would not surprise me to see it in other major cities whose main industry is hospitals?
Maggie- Keep digging – The breakthrough Dartmouth research deserves better treatment than this.
Dr.Rick Lippin
Southampton,Pa
Very good points Dr.Rick. But the unholy alliance between the Hospital Industry and mainstream media is not limited to major cities. Our County of Berk’s largest employer is Reading Hospital and Medical Center. It’s incestuous relationship with the Reading Eagle Newspaper has been folklore in the area for many years. With interlocking directorates and on any given day a multitude of hospital ads in the paper, have fed this unholy alliance. If Harris and Abelson were on the Eagle staff, they never would be allowed by the Edtior to write such a story about Reading Hospital.
Forgive my lack of expertise, but something with these numbers is bothering my need for logic.
Assuming that a hospital’s goal is to save lives, we seem to be measuring how much is spent on failure to do so. It would be helpful if these numbers were accompanied by a measurement of the rates of failure.
If we spend a lot and fail frequently, that is obviously bad medicine, but if we spend a lot and rarely fail, that’s a completely different story.
Of course, one could argue with the basic assumption of viewing death as a failure in these cases, but that’s a different argument altogether, and if it’s not, then we need to clarify this point as well. The contention that success is not measurable because folks may survive only one more month or so, is not acceptable (to me), since we should be able to measure and display as much granularity in outcomes as we are willing to collect.
Maggie, I recall you were a cheerleader for the Dartmouth study early on. Let the critics have their say–It will eventually get sorted out. But one would hate to think that the Administration’s eagerness to find savings in Medicare (without cutting benefits) was based on faulty premises.
The thing that makes Dartmouth look bad is the financial link to the for-profit insurers. And you know how I feel about the latter!
Greg & Dr. Rick–
Yes, I’m afraid you’re both right. Hospital ad revenue is important to newspapers. Both this NYT story and the February story express concern that if we follow the DArtmouth reserach and try to cut back on overtreatment , NYC hospitals might suffer. (They don’t put it that way, of course, but the stories do explicitly mention NYC hospitals)
Jim–
You write; “gored oxen tend to express pain.” Well put.
Margalit–
Let me suggest that you read Shannon Brownlee’s book “Overtreated” or chapter 6 of my book “Money-Driven Medicine”. The chapter is titled “When More Care Is Not Better Care.”
This has nothing to do with death being a failure or not being a failure.
This has to do with people receiving unncessary tests and procedurs that do them no good. Yet all tests and treatments carry some risk. So they are exposed to risk without benefit.
More than two decades of Dartmouth reserach shows that some hospitals bill far less per patient and have better outcomes. The Mayo Clinic stands out.
Patients who go to Mayo
undergo fewer tests (because the doctors take a careful history, listen to the patient, talk to him, actually look at him and arrive at a diagnosis sooner). They undergo fewer procedures. They spend fewer days in the hospital. (In each case, they are being compared to very similiar patients at other hospitals). There are fewer medical errors; fewer infections; fewer preventable readmissions.
Patient satisfaction is higher,, doctor satisfaction is higher; outcomes are better and the final bill is lower.
More than 20 years of Dartmouth reserach shows that lower spending and higher quality often go hand and hand.
Some of the very expensive marquee hospitals that we think of as “the best” have very high infection rates (See New York State’s recent study of hospital infection rates—they name hospitals). Some have high rates of errors.
Some have high rates of unnecessary surgery; much back surgery, many angioplasties and some by-passes do patients no good.
We have medical evidence on this. We know which patients don’t benefit. But we keep on doing the surgeries. Why?
Custom. Habit. Doctors who have been doing these surgeries for years refuse to believe the medical evidence. Hospitals make money on the surgeries.
Throughout the 1990s, doctors did bone marrow transplants on breast cancer victims with absolutely no proof that this would help the patients. By the mid 1990s it became clear that there was no benefit, and the transplants were causing terrible suffering.
Still, doctors did them. Finally toward the end of the 1990s, a breast cancer patient advocacy group (I think it was the Breast Cancer Coalition) had to send a letter to all oncologists, pointing out that they were making a huge amount of money on the procedure, and thus had a conflict of interest.
The Coalition made it clear that the procedure had not saved or prolonged a single life. But it did make patients very, very sick–so sick that some weren’t able to say good-bye to their loved ones as they were dying.
I blame President Bush for this NYT story.
Maggie,
I did read your book and watched the TV version. I do understand that people are over treated and that treatments are overpriced, and I do understand that the reasons are not aligned with patient interests.
However, I think Dartmouth data will immensely benefit from a side by side display of outcomes and quality to go with the spending figures, similar to the Wisconsin data presented by the NYT. If it can be shown that all big spenders have equal or worse outcomes compared to their thrifty counterparts, the argument will be finally put to rest.
So what is preventing Dartmouth from offering such presentation? Obviously the data is available.
Margalit–
First, thanks for reading the book and seeing the film.
If you go to http://www.dartmouthatlas.org, you’ll find they have put out a huge amount of information in studies looking at individual academic medical centers, comparing outcomes, patient satisfaction and cost.
This information has been reprinted in medical and health policy journals like Health Affairs and NEJM.
It rarely appears in the mainstream press, though people like David Leonhardt, at the Times, have tried to get the word out.
Why isn’t it more widely reported?
First, because it’s complicated. As the Wisconsin Collaborative explains in my most recent post, their relatively simple quality/outcomes data is meant for internal use– so that hospitals can try to improve. It’s hasn’t been rigorously vetted and so isn’t really ready for prime-time.
Many adjustments have to be made to quality data: some hospitals are treating sicker patients, or more difficult cases. In some cities, the overall health of the population is poorer,
There are many, many variables that have to be taken into account.
You then have to explain these adjustments to people. Many readers would find the statistical adjustments hard to understand.
More importantly, people don’t want to know that the hospital they trust is in fact, over-treating people, exposing them to
all sorts of risks and medical errors. It’s just too scary to contemplate the fact that your hospital–the hospital you count on– is exposing thousands of patients to unnecessary risks.
In the past, New York State has published numbers on the percent of patients who died as a result of heart surgery at hospitals in the state– naming the hospitals.
There are huge disparities. Some hospitals are simply much safer than others.
But when the numbers were publshed, patients ignored them and continued going to the hospital closest to home or the hospital their doctor recommends.
Finally,as other readers have noted, newspapers depend on hospital advertising. They don’t want to publish bad news about hospitals (except very poor public hospitals that cannot afford to advertise.)
For instance, New York State recently looked at infection rates at various hospitals in the state and published the results.
NYC hospitals did poorly– including brand-name hospitals like Mt. Sinai.
We didn’t read about this in the newspaper. I didn’t hear about it on TV.
Btw Maimonides, in Brooklyn, was one of very few NYC hospitals that showed low infection rates.
Maimonides also does well in the DArtmouth data.
My daughter, who lives in Brooklyn, very close to Manhattan, is thinking about having a baby. If she does, she plans to have it at Maimonides, not at a Manhattan hospital– based on what I know about NYC hospitals.
So it’s not that Dartmouth doesn’t put the information out there.
Admittedly, they don’t simplify it– reading thes studies on http://www.dartmouthatlas.org takes time and some of it is heavy sledding.
But there have been many articles in Health Affairs, NEJM that are more readable, by Elliott Fisher and others. (Though I recently spent 4 days translating one of these articles into a post about over-diagnosis. It was very dense, and I had to work very hard to unpack it.)
The good news is that White House budget director Peter Orszag, his health care advisor, Dr. Zeke Emmanuel, Dr. Don Berwick, who will soon be heading Medicare, and a handful of very intelligent hard-working Congresspeople have read this research and are aware of what needs to be done.
They understand that hospitals in NYC need to compared to the best benchmark hospitals– and Medicare will use financial carrots and sticks to persuade the most costly hospitals to begin to approach those hospitals that serve as benchmarks for efficiency (defined as better care at a lower cost)
But the vast majority of the American public still believes that “More care is better care.”
“More expensive care is better care>”
“MOre aggressive, intensive care is better care.”
People have been told this for many, many years. It will take many years to unlearn that lesson. In the meantime, reformers will go forward and do what needs to be done.
Margalit–
First, thanks for reading the book and seeing the film.
If you go to http://www.dartmouthatlas.org, you’ll find they have put out a huge amount of information in studies looking at individual academic medical centers, comparing outcomes, patient satisfaction and cost.
This information has been reprinted in medical and health policy journals like Health Affairs and NEJM.
It rarely appears in the mainstream press, though people like David Leonhardt, at the Times, have tried to get the word out.
Why isn’t it more widely reported?
First, because it’s complicated. As the Wisconsin Collaborative explains in my most recent post, their relatively simple quality/outcomes data is meant for internal use– so that hospitals can try to improve. It’s hasn’t been rigorously vetted and so isn’t really ready for prime-time.
Many adjustments have to be made to quality data: some hospitals are treating sicker patients, or more difficult cases. In some cities, the overall health of the population is poorer,
There are many, many variables that have to be taken into account.
You then have to explain these adjustments to people. Many readers would find the statistical adjustments hard to understand.
More importantly, people don’t want to know that the hospital they trust is in fact, over-treating people, exposing them to
all sorts of risks and medical errors. It’s just too scary to contemplate the fact that your hospital–the hospital you count on– is exposing thousands of patients to unnecessary risks.
In the past, New York State has published numbers on the percent of patients who died as a result of heart surgery at hospitals in the state– naming the hospitals.
There are huge disparities. Some hospitals are simply much safer than others.
But when the numbers were publshed, patients ignored them and continued going to the hospital closest to home or the hospital their doctor recommends.
Finally,as other readers have noted, newspapers depend on hospital advertising. They don’t want to publish bad news about hospitals (except very poor public hospitals that cannot afford to advertise.)
For instance, New York State recently looked at infection rates at various hospitals in the state and published the results.
NYC hospitals did poorly– including brand-name hospitals like Mt. Sinai.
We didn’t read about this in the newspaper. I didn’t hear about it on TV.
Btw Maimonides, in Brooklyn, was one of very few NYC hospitals that showed low infection rates.
Maimonides also does well in the DArtmouth data.
My daughter, who lives in Brooklyn, very close to Manhattan, is thinking about having a baby. If she does, she plans to have it at Maimonides, not at a Manhattan hospital– based on what I know about NYC hospitals.
So it’s not that Dartmouth doesn’t put the information out there.
Admittedly, they don’t simplify it– reading thes studies on http://www.dartmouthatlas.org takes time and some of it is heavy sledding.
But there have been many articles in Health Affairs, NEJM that are more readable, by Elliott Fisher and others. (Though I recently spent 4 days translating one of these articles into a post about over-diagnosis. It was very dense, and I had to work very hard to unpack it.)
The good news is that White House budget director Peter Orszag, his health care advisor, Dr. Zeke Emmanuel, Dr. Don Berwick, who will soon be heading Medicare, and a handful of very intelligent hard-working Congresspeople have read this research and are aware of what needs to be done.
They understand that hospitals in NYC need to compared to the best benchmark hospitals– and Medicare will use financial carrots and sticks to persuade the most costly hospitals to begin to approach those hospitals that serve as benchmarks for efficiency (defined as better care at a lower cost)
But the vast majority of the American public still believes that “More care is better care.”
“More expensive care is better care>”
“MOre aggressive, intensive care is better care.”
People have been told this for many, many years. It will take many years to unlearn that lesson. In the meantime, reformers will go forward and do what needs to be done.
“But we keep on doing the surgeries. Why?
Custom. Habit. Doctors who have been doing these surgeries for years refuse to believe the medical evidence.”
Can you, and other progressive reformers, at least acknowledge that patients also have a role in the perpetuation of expensive medical tests?
I’m interested in your take on the recent Health Affairs piece that shows as much:
http://content.healthaffairs.org/cgi/content/full/hlthaff.2009.0296v1
Best,
Kevin Pho, MD
KevinMD.com
Kevin M.D.–
Thank you for your comment. I am, frankly flattered, not just that you read HealthBeat, but that to took the time to weigh in. (I read what you write, and can’t quite imagine how you manage to write what you do and practice medicine.)
I read the Health Affairs article you cited. And I completely agree with it.
Most Americans don’t want to hear about guidelines. They would prefer to think that their doctor knows what will help them. They certainly don’t want to hear about the dangers of over-treament. Please see my response to Margalit above.
Most Americans believe that more care–and more expensive, more aggressive, care- is better care.
So yes, patients are complict in expecting over-treatment. But they have been taught that more care is better care by a medical establishment that includes Pharma, hospitals and, yes, doctors
So to some degree, this is a chicken/egg question: do doctors over-treat because patients want over-treatment, or do patients want over-treatment because this is what docs have told them that this is what they need?
As one of Dartmouth’s reseracher’s said to me: “Patients, like everyone else, want what they are accustomed to.” Even if what we are used to isn’t good for us, we want it.
Let me add, the vast majority of docs are sincere on this point. In med school, they were taught: “Don’t just sit there, do something.” As residents, they were taught that the residents who are most “thorough”–doing more tests– are the best.
But I do think that since docs know far more about medicine than most patients, they have a responsibility to try to explain to patients that “more” often is not better–even if patients don’t want to hear it.
If a patient leaves the doc because the patient doesn’t like the message, so be it. Most good doctors (and certainly primary care docs) have far more business than they need. They can afford to be honest with patients–in a kind way. If they lose some patients, that’s fine. At least they aren’t hurting people by overtreating them.
But many docs aren’t trying to educate patients. The Health Affairs article reports that:
“Only 34 percent of respondents recalled a phsycian ever discussing what medical reserach showed about the best way to manange their care.”
Part of the problem is that docs aren’t paid to talk to patients. They are paid to “do things.” Under the reform legisation, I’m quite certain that this will change. Medicare will begin paying docs to talk to patients, and private insurers tend to follow Medicare.
Also,when it comes to patients wanting more treatment . . . Most patients really don’t want to undergo surgery. (Okay, maybe some patients in Manhattan L.A, and Miami do. It gives them something to talk about. But these people are outliers).
In most cases, if a doctor tells a patient: “I really don’t think the benefits of surgery would be worth it, given the risks” (as a doctor told me about heart surgery more than 20 years ago) they would be greatly relieved (as I was.) (I have a genetic defect, but no incidents since then.)
The Dartmouth researchers also point to “natural experiments”: for instance, when a military base closes in a high-treament town, and a large number of people in the town move, when others move in from various parts of the country (including low-cost areas) they wind up filling all of the hospital beds and undergoing far more treatments than they ever had before.
Bottom-line: In general, patients follow their doctors’ cues. If a doctor tells you that you need a test, a procedure or to be hospitalized, you believe that is what you need.
At the same time, this is, as I said above, to some degree a chicken/egg question. But I believe that it’s up to docs to break the chicken /egg cycle by gently educating patients.
Some studies have suggested American medical oncologists overuse cancer drugs, particularly in the last months of patients’ lives after the patients have failed to respond to treatment.
Conventionally, chemotherapy is recommended according to guidelines generated by statistical data. However, there are no guidelines for the appropriate use of chemotherapy at the end of life based on scientifically controlled trials or consensus statements. Advocates for cancer patients say that Medicare’s reimbursement system encouraged overtreatment.
The MMA legislation of 2003, tried to change some of the encouragement by paying medical oncologists to think. It reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiatlion therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival.
However, the new system still had major flaws, in that it continued to provide incentives to administer chemotherapy, in the same way that surgeons have a financial incentive to recommend surgery. Additionally, it is almost certain that there will be large differences between the profit margins of administering different drugs, providing continuing incentives to base drug selection on profit margin.
But the new system was an improvement from the standpoint of cancer patients, taxpayers and advocates of basing drug selection on individual tumor biology, rather than on a least common denominator approach which invites conflict-of-interest medical decision-making.
What this shows is that simply reducing reimbursement for drugs isn’t the answer to the biggest problems, which are financial incentives for infusion therapy over oral therapy or non-chemotherapy, and financial incentives for choosing some drugs over others.
Is it that simple?
Health care does not exist in vacuum. Our culture teaches us that expensive things are usually better. From cars, to houses, to food stuff and clothing, the more you pay, the better product you receive. Our language is rich with phrases like “you get what you pay for”, or “there’s no free lunch”, or “you’re not rich enough to afford cheap things”. Shoppers hunt for bargains, where a bargain is defined as something that used to be expensive but “just today” it’s half off.
So how do you convince people that for health care, cheap is better? And is it really true? Is it always true?
If we are really honest, we would have to admit that this is only true sometimes, but not always. So how are people with no medical training supposed to make these value judgments? If your child has cancer, wouldn’t you mortgage your own soul to get her to Sloan instead of the local community hospital? You would, no matter how liberal your arguments have been in the past.
This goes to the very core of human behavior and while it is easy to agree that a patient with advanced Alzheimer should not receive heart surgery, even this becomes heart wrenching when the patient is your beautiful wife of 50 years, without whom you are nothing.
It will take a long time to reverse history and teach people to accept death, with the same equanimity as they did a hundred years ago, when all our values are geared towards technology solving everything, including maybe keeping those we love alive just a bit longer, and who knows, “maybe they’ll find a cure”.
Harriette–
I was not a “cheerleader” for Dartmouth early on.
I didn’t become fammiliar with Dartmouth’s work until about 2004, when I was writing my book.
By then Dartmouth’s research–which had begun in the 1970’s–was established as the gold standard for research on health care delivery.
In the 1980s, people were questioning it, trying to poke holes in it, but no one was ever able to discredit it. By the 1990s, virtually everyone among the healh care cognoscenti trusted and respected the Dartmouth reserach.
IT is only in the last year or two, as we began to talk seriously about health care reform, that
hospital and some providers became nervous that reformers will use the Dartmouth reserach to cut waste–and so they’ve been trying to discredit it– with no success.
The business about Dartmouth being tied up with private insurers is another piece of misinformation in the article.
What they are talking about is the fact that Dartmouth helped create the “shared decision-making” protocol which gives patients the opportunity to learn about the risks as well as the benefits of elective surgery. Both insurers and hospitals puchase the shared decision-making materials (a video and a pamphlet that focuses on a particular treatment) and give them to patients. This is an outstanding program and in this case, insurers that purhcase the materials actually add value.
I’m afraid that your obsession with the idea of single-payer blinds you to other things going on in medicine.
Jenga-
I do too.
I do agree with your chicken/ egg analogy, Kevin does make a good poitnt about patients driving decisions, you left that out when discussing your bone marrow transplant example. Insurers did not approve such treatments until they were forced to by lawsuits from patients. The blame for that issue can’t be laid entirely at the oncologists feet. I know of no one that has ever operated on a patient against their will, that is why informed consent exists. A topic we’ve covered before and I do like shared decision making. I try to incorporate it into every case. A surgeon is also taking on risk, when doing a case and they should be compensated for that as well as the skill and effort required to carry that out. I would love to get paid more to sit around and talk, but that really doesn’t renumerate based on my skill or the risk I am assuming, as well as my patient. It doesn’t make much sense to pay my plumber come over to talk about my clogged toilet, rather than fix it. In my field, no matter how much I write or talk to a fractured femur. It ain’t going to fix itself. It is physically demanding and there is risk to me and my family not only litigious but a real risk of disease transmission. Patient driven care is much more frequent than those that don’t practice clinical medicine would have you believe. I see daily haphazard MRI usage, for a multitude of reasons, very often it is patient-driven. Some of it is patient conditioning over the years. I also think it is our culture of instant gratification and expanding technology that is largely at play. That or it could also be President Bush’s fault.
Jenga–
I think it’s President Bush’s fault.
Seriously . . . You’re rigth that patients sued insurers to cover bone marrow transplants, but the media played a major role in making consumers believe l that they should sue.
The producers fo the evening news loved the stories: “Mother of 3 denied needed care.”
If oncologists had been honest with their patients, they would have told them: “we don’t have any medical evidence that this will help you. We hope it will, but it is an experimental treatment.”
This is not what most oncologists who did the transplants told patients.
Also, many patients resisted pressure from doctors to try this treatment. Phil Longman, who wrote the book about the VA, lost his first wife to breast cancer in the 1990s. He writes about how, instinctively, he and his wife rejected the offer of a bone marrow transplant.
No doubt they were both better-educated than many patients, and more skeptical.
By and large, partients follow what a doctor or a hospital tell them that they need. See “An Very Open Letter From An Oncologist” on this blog.
When oncologist knows that he can’t help a patient, he tells them that they are dying, and that he can’t make them well. Then he says: “You need to think about what you want to do in the foreshortened time you have left . You can spend that time in my office with me and mys assitants.
If you want chemo we can and will do that. But there might be something else you would like to do. with that time”
The vast majority of his patients choose to spend the time with family, to travel, to see friends . . .
If a doctor is totally honest, most patients will listen. (This is also what palliative care specialists report.) A certain number of patients who are terrified of dying will insist on doing more, even if told that medicine cannot make them well. And, certainly, it takes most patients time to come to terms with the fact that they are dying.
I realize that basically healthy patients may ask for unnecessary MRIs–especially in some regions of the country. But doctors are learning how to say No. And when it comes to the big-ticket items — unnecessary surgery, futile chemo, death in an ICU–very few patients ask for these things. They simply do what their doctors tell them they need to do.
People look up to their doctors. They trust them (They may not trust the majority of doctors, but they believe that their own doctor is all-wise. It is too scary to think otherwise, especially if you are very sick.)
Margalit–
I’ve known people who died of cancer in Sloan-Kettering, and they died very, very painful deaths.
Too little pain management. Too many doctors not communicating with each other. Doctors telling families totally different things within the same hour.. ..
Secondly, I would never expose my child to the aggressive treatment for cancer that too many hospitals provide.
I think you said you saw the film of my book, Money-Driven Medicine. If so, you must remember Dr. Jim Weinstein , who greatly regretted how much his very young daughter went through as doctors insisted on treating her cancer with one aggressive treatment after another–for years.. The doctors never really gave Jim and his wife the time to share in decision-making. At one point, the doctors threatened to sue Jim and his wife if they wouldn’t go along with the next recommended treatment! And Weinstein was a highly-respected physician. .
You ask about the evidence showing that, in general, more care is not better care, and that less care can be at least as good–and often better. Dartmouth has done research looking at hospitals that provide less aggressive care (for example, the Mayo Clinic, where patients see fewer specialists and undergo fewer tests and procedures) as well as countries in Western Europe that provide much less aggressive care In both cases, less aggressive care leads to outcomes that are as good or better– as well as higher patient satisfaction. (
You might want to read the Dartmouth Research at http://www.dartmouthatlas.org.
But it’s time-consuming–thousands of pages, and it’s dense. You have a demanding full-time job and may well not have the time to plow through it.
As an alternative I would recommend that you read Shannon Brownlee’s book: “Overtreated.” She does an excellent job of describing the Dartmouth research, the evidence behind it, and what it shows.
Finally, yes, most Americans believe that “more is better,” “more expensive is better,” and “you get what you pay for.”
On the other hand, these days, many Americans are beginning to realize that “less is more” (smaller portions, smaller homes, smaller cars, etc.) and that many products and services are wildly over-priced. Consumers are becoming more skeptical–more aware of bubbles. This will help them understand that we’ve been in a health care bubble for the past 20-30 years–overpaying for many drugs, and devices, some specialists’ services and hospital services, while undergoing so many unnecessary surgeries, tests and procedures. This isn’t just a waste of moeny. Patients are exposed to unnecessary risks.
As Harvard surgeon Dr. Atul Gawande points out, the number of surgeries done in the U.S. has shot up in the last ten years, yet there is no evidence that the population is any healthier, or that outcomes for various diseases are any better as a result.
Maggie
It really would be nice if medical oncologists would spend more time in their office going over the pros and cons of treatment and the foreshortened time that may be left. I cringed at your statement, “If you want chemo we can and will do that. But there might be something else you would like to do with that time.” This is not what they get paid for, they get paid to administer chemo. I agree there is a need for more palliative care specialists. I believe though, treating a human being is not on the same plane as fixing a toilet.
Presentation highly influences decision-making. When no alternatives are presented, people will tend to seize what is available. When relative risk numbers that really do not relate to actual risk are given, it makes informed decision making even more difficult. The methods used to present information about chemotherapy influences treatment decisions.
On the more-is-less and less-is-more vein, emerging evidence shows that many of the highly expensive targeted cancer drugs like Avastin may be just as effective and produce fewer side effects if taken over shorter periods and in lower doses. Dr. Ian Haines reported in the Journal of Clinical Oncology that the dose being used is 15 milligrams per kilogram of body weight, despite research showing it may work with 3 milligrams per kilogram.
Pharmaceutical companies are attracted to studies looking at the maximum tolerated dose of any treatments. As the increasing number of drug studies are developed through collaborations between academic medical centers and drug companies, it is important to understand the influence that industry involvement may have on the nature and direction of cancer research.
Greg–
I’m a little confused by your comment.
I’m not sure whether you are saying that doctors shouldn’t tell patient that they might think about other ways they might spend the foreshortened time they have left . .
And it seems that you may be endorsing hugely expensive medications that give patients some extra month sof poor quality life .. .
But I may well be mis-reading your post.
Maggie
I agree that there is a need for more palliative care specialists working with medical oncologists to go over the pros and cons of treatment (or no treatment) and if it be, the foreshortened time that they may have left. They are still being reimbursed for administering chemo and the methods used to present information about chemo greatly influences treatment decisions. The MMA tried to change some of the encouragement to treat by paying medical oncologists to think. However, it continued to provide incentive to administer chemo the same way surgeons have a financial incentive to recommend surgery.
Greg–
Okay, we are on the same page (or as someone said to be recently, at least we’re in the same pamphlet.)
Cancer patients need to talk to palliative care specialists because oncologists are in a position where they may be a conflict of interest–even if its subconscious.
They are, after all, trained to administer chemo. This is what they do. If you’re a hammer, everything looks like a nail.
Although cost/quality tradeoffs in the American health care system is a high-stakes issue and various opinions should be considered, I agree with the commentary here that the NY Times authors make some gaffes in making this point. Ultimately though, dissenters’ views shrink under scrutiny and the Dartmouth Atlas comes out on top. (Full disclosure, I’m a TDI grad).
Sam–
Yes, quality analysis is complicated. But this story doesn’t help us understand what the Dartmouth research shows:
quality can be better(but isn’t necessarily better) when cost is lower. And more aggressive, more expensive care, is not necessarily better. Sometimes (not always) it is worse.
This is what the Dartmouth researchers have said repeatedly.