Then Peter Bach in his NEJM article revealed that the entire enterprise, the foundation not only of the entire liberal effort to bend the curve on health care through government rationing but of a billion dollar business designed to "coach" people out of treatments for back pain, breast cancer, prostate cancer, etc... all to the financial benefit of hospitals and health plans, is medically bankrupt and statistically corrupt...
Here's Buzz Cooper putting the Atlas through the document shredder:
An important article appeared in today’s NYT, describing a new paper by Peter Bach, which is in today’s NEJM. Peter’s paper (“A Map to Bad Policy“) debunks the Dartmouth Atlas and cautions against its use. As I said in the Wash Post in September, the Dartmouth Atlas is the ”Wrong Map for Health Care Reform.”
More damning even than Peter’s analysis was Elliott Fisher’s reply: “Dr. Fisher agreed that the current Atlas measures should not be used to set hospital payment rates, and that looking at the care of patients at the end of life provides only limited insight into the quality of care provided to those patients. He said he and his colleagues should not be held responsible for the misinterpretation of their data.” Really? It was someone else’s interpretation? OK, Elliott, you’re not responsible. Just stand in the corner.
Peter is not the only leading epidemiologist to debunk Dartmouth in recent days. There’s also the report this week from the U of Wisconsin and RWJ by Pat Remington (another leader), showing that people who have the poorest health (and, therefore, the highest health care costs) live in the poorest counties (see my blog report and an earlier discussion of poverty and health care). And there’s the recent paper by Ong and Rosenthal (co-authored by Jose Escarce, editor of HSR, the leading health services research journal), showing that, when all care is measured (not simply end-of-life care, as measured by Dartmouth), hospitals that provide more have lower mortality, which was confirmed in the current issue of Medical Care by Barnato and associates at the U of Pittsburgh. When it rains, it pours.
What’s doubly important about the death of the Dartmouth Atlas is that it was the cornerstone of health care reform. Right from the start, Peter Orszag, director of OMB and the administration’s architect of health care reform, accepted Dartmouth’s ideological principles that health care spending was driven by doctors and hospitals who over-treated and over-charged, to no benefit. The funds for health care reform were readily available by simply getting rid of geographic differences. That alone would save 30% of health care spending ($700B). And that could be accomplished by making everything look like Mayo (white, middle class and efficient) and by having more primary care physicians (which Mayo doesn’t). And best of all, it could assure that no new taxes would be needed, just as President Obama had promised.
And here's Peter Bach explaining why cost driven health care policy is, well, bad for patients...
Say Hospital A and Hospital B each has a group of patients with a fatal disease. Hospital A gives each patient a $1 pill and cures half of them; Hospital B provides no treatment. An Atlas analysis would conclude that Hospital B was more efficient, since it spent less per decedent. But all the patients die at Hospital B, whereas only half of the patientsdo at Hospital A, where the cost per life saved is a bargain at $2. Although $1 cures are rare, changing the price or efficacy of the pill does not alter the fundamental problem with examining costs alone when cost differences are sometimes associate with outcome differences.
And finally Bach challenges what, until recently, the media, most foundation types, the underachieving liberal health bloggers drank as daily Kool-aid, that the Dartmouth Atlas controlled for severity of illness by looking at only dead people.
Another methodologic problem is that Atlas analyses assess hospital efficiency overall on thebasis of costs incurred for nonrepresentative patients — decedents who were enrolled in fee-forservice Medicare. This group varies among hospitals in terms of severity of illness and is notrepresentative of a given hospital’s overall spending pattern. Regarding illness severity, Atlas researchers note on their Web site (www.dartmouthatlas.org/faq/ hospital.shtm) that they focus on “patients who died so that [they can be sure] that patients were similarly ill across hospitals,” further explainingthat “by definition, the prognosis of all patients[who died was] identical — all were dead . . . therefore, variations [in resource use] cannot be explainedby differences in the severity of illness.” But 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.
"Dr. Peter Bach of Memorial Sloan-Kettering argues against using the Dartmouth measures to financially reward and penalize hospitals. There is a healthy and vital debate about how best to change hospital incentives. 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."
http://www.newyorker.com/online/blogs/newsdesk/2010/02/the-cost-conundrum-persists.html#ixzz0gOWwIFNc
Meanwhile Elliott Fisher sought the refuge of the Dartmouth student newspaper to set the record straight:
“There’s a pretty good correlation between treatment of patients over 65 and under 65,” Fisher said.
In a response published in the New England Journal of Medicine, Fisher wrote that Medicare data is closely associated with a single hospital, making it a good measure of hospital effectiveness.
Bach’s final criticism of the Atlas data focused on the variation of illness severity between hospitals. Because of this variation, hospitals that care for patients with very severe illnesses could appear less efficient than those that take care of patients with less severe cases, even if they actually operate with the same level of efficiency, he said.
Fisher responded in the interview that the Dartmouth Atlas data is “carefully adjusted” for variations such as illness severity, poverty and price differences.
Talking to a college student, admittedly, a very smart college student, Fisher can get away with a mixture of evasion and distortions.1. There is no correlation between health care spending between people age 65 and over vs people who are younger unless you truly control for severity of illness which the Atlas fails to do because it never looks at two people from baseline with the same disease over time and compare outcomes. The Medicare/ non Medicare variance is wide as the Bach article shows.
2. Dartmouth and Fisher claim to limit who they analyze to those with a list of common chronic diagnoses. All together, that is about 90% of all people who die in Medicare. Then they adjust for a few things like primary diagnosis and age and sex and stuff. They have never shown that they can capture the variability between hospitals in severity of illness and they cannot, even using far more sophisticated measures. But they do not think they need to risk-adjust for the regional variations stuff. When MedPac did that, most of the variations went away.
Despite all this, both Gawande and Fisher persist in claiming: "that Bach’s criticism does not undermine the main finding of the Atlas data: regional variations in health care spending show that higher costs associated with specialized procedures do not necessarily lead to better health outcomes. Costs can be lowered by creating more accountable hospitals and moving away from a “toxic payment system” that creates incentives for unnecessary tests, according to Fisher."
http://thedartmouth.com/2010/02/22/news/atlas
Why would they say that when the entire methodology is shot to hell?
Because both (and not just them) make big money off of speeches, consulting and businesses that push the less is more approach.
And the commercialization of the Dartmouth Atlas -- coaching people to ration their own care in my opinion -- culiminated in the formation of a company called Health Dialog by the Dartmouth folks. HD was purchased by a British concern for $750 million. And HD has lobbyists in Washington pushing the adoptiong of its products in the current health care reform bill.
