In today’s New York Times, Reed Abelson and Gardiner Harris challenge the findings of the now infamous Dartmouth Atlas of Health Care health economists, whose maps of U.S. health care spending variation have convinced generations of policy makers that more is not always better. While the debate around the Dartmouth research has been ongoing, Abelson and Harris focus on the claim that lower spending regions have better health outcomes than higher-spending regions:
But while the research compiled in the Dartmouth Atlas of Health Care has been widely interpreted as showing the country’s best and worst care, the Dartmouth researchers themselves acknowledged in interviews that in fact it mainly shows the varying costs of care in the government’s Medicare program. Measures of the quality of care are not part of the formula.
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. As any shopper knows, cheaper does not always mean better.
It’s certainly true that non health economist types may have used to Dartmouth’s “sexy maps” to make blanket statements like: ‘regions that spend less always have better health outcomes or ‘we’re spending more and getting less.’ But an overreading does not undermine the researcher’s fundamental conclusion: more expensive services do not necessarily improve health outcomes. As the Times’ article itself points out, other non Dartmouth studies support this conclusion. “A 2003 study found that patients who lived in places most expensive for the Medicare program received no better care than those who lived in cheaper areas,” the authors note.
Whatever methodological problems exist — and I would be surprised if the Dartmouth research didn’t account for the fact that patients are dying in greater numbers in higher-spending regions — it’s 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.” As our in house payment reform expert Ellen-Marie Whelan points out, “the Dartmouth Atlas research remains very important because it was the first to show regional variation in Medicare spending – it helped to identify the problem.” “In part because of the success the Dartmouth researchers had in helping to identify this variation — and the fact that these spending differences are probably not often associated with better outcomes — there is now increased focus on how we can offer better care at lower costs. This also reinforces the importance of the “Center for Innovation” at CMS which is allowing groups of providers to present how they propose to deliver care that is better at lower costs.”
The NYT criticism is important, but it should not swing the pendulum in the other direction and encourage policy makers to spend more money to lower-spending regions. As Merrill Goozner observes in his response to the NYT, “Higher quality care lowers costs, it doesn’t raise costs.” “Take a few additional steps to keep operating rooms germ free and rates of hospital-acquired infections and their attendant higher costs plummet. Do a knee implant right the first time and you don’t have a patient back within a year for a revision.”
“A careful mapping of quality, which has never been done by Medicare or anyone else since good data isn’t available, and cross-checking it with spending patterns may provide researchers with crucial clues for determining what accounts for variations in spending across the U.S.,” he concludes.
The Dartmouth Researchers have issued their own rebuttal.