Wonky fight shows complex health care data a poor tool for sound-bite politics.
For more than two decades, the Dartmouth Atlas project has aggregated and analyzed Medicare data. The inescapable conclusion: the delivery of medical care differs substantially by location. This suggests that practice of medicine is driven more by the particular medical training of individual physicians and regional custom than by evidence-based principles derived from empirical data.
Yes, one-sixth of the nation’s economy operates like an 18th-century cottage industry with third party payment:
-- Prithy, good cooper, whilst thou make me a barrel?
-- Aye, but oak is dear in these parts and we make them a special way; a pretty penny shall I charge. But you’ve only a 20-shilling deductible.
-- Zounds! I’ll take ten.
The other consistent finding in the Atlas studies is a fundamental disconnect between cost and quality in health care. Regions spending much more on health care simply don’t seem to get much value for the additional investment.
However, recent New York Times coverage of the issue suggests that Dartmouth researchers Dr. Elliott Fisher and Jonathan Skinner may have overstated their case in statements that have proven influential in Congress and with the Obama administration. The Times argues that it is one thing to say that cost and quality aren’t correlated – it is quite another to say that spending more on health care inevitably leads to worse care.
The Times makes a convincing argument that the Atlas data supports only the narrower conclusion. As is often the case with health care utilization data, the dispute centers on how to adjust for severity of patient illness and local cost-of-living variations. While Atlas attempts to make adjustments in specialized studies, the Times argues that the group’s dramatic regional maps do not.
Why does this matter? Because Congress is contemplating changes in reimbursements that would radically slash payments to providers in localities at the top end of the Medicare cost curve. If high-dollar hospitals are simply inefficient and paying them less will rein in bad care, then making draconian cuts is an easy call for Congress. The Times suggests that Congress could make the wrong call by relying too heavily on simplistic maps that don’t reflect important nuances of the data.
The dispute has vaulted a long-simmering academic debate into national prominence. The Times raised questions on June 3; Atlas authors fired back on their website on the same day and again on June 7, accusing the Times of “shaky reporting.” Today, the Times responded to researchers. For health care wonks, this is like the World Cup and the Super Bowl all rolled up with a Star Trek convention.
But the dispute should matter to all Americans. Is a hospital in New York at the top end of the cost scale woefully inefficient? Or do its higher charges simply reflect that everything in big-city locales costs more? Does the Atlas methodology do enough to consider and adjust for the relative “sickness” of patients? Without Medicare collecting more rigorous data on how patients present versus final health care outcomes, this question may be impossible to answer.
It is anyone’s guess what Congress – desperate for simple, popular responses to cutting health care costs – will do with all this. But if the Times is right that spending more on care simply doesn’t correlate in any way with quality, isn’t that quite bad enough? Isn’t that still a pretty compelling case for changing how we pay for health care? I think it is, especially given that most Americans are still convinced that more health care is always better.
So far, Congress has fled from comprehensive reform in favor of the politically expedient and sound-bite-friendly approach of insurance reform. It will take more than that to rein in our nation’s runaway cost trends.
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