Catching up

Been crazy busy and not been posting as much as I’d like.  Sorry.

First up, I want to say something about the NYT piece on the Dartmouth Atlas:

In selling the health care overhaul to Congress, the Obama administration cited a once obscure research group at Dartmouth College to claim that it could not only cut billions in wasteful health care spending but make people healthier by doing so.

Wasteful spending — perhaps $700 billion a year — “does nothing to improve patient health but subjects you and me to tests and procedures that aren’t necessary and are potentially harmful,” the president’s budget director, Peter Orszag, wrote in a blog post characteristic of the administration’s argument.

So what’s the problem?

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.

Even Dartmouth’s claims about which hospitals and regions are cheapest may be suspect. The principal argument behind Dartmouth’s research is that doctors in the Upper Midwest offer consistently better and cheaper care than their counterparts in the South and in big cities, and if Southern and urban doctors would be less greedy and act more like ones in Minnesota, the country would be both healthier and wealthier.

But the real difference in costs between, say, Houston and Bismarck, N.D., may result less from how doctors work than from how patients live. Houstonians may simply be sicker and poorer than their Bismarck counterparts. Also, nurses in Houston tend to be paid more than those in North Dakota because the cost of living is higher in Houston. Neither patients’ health nor differences in prices are fully considered by the Dartmouth Atlas.

The mistaken belief that the Dartmouth research proves that cheaper care is better care is widespread — and has been fed in part by Dartmouth researchers themselves.

I’m not sure where to begin.  On the one hand, I take no issue with the NYT pointing out an obvious limitation of the Dartmouth Atlas.  Yes, the data cannot control for all differences in the population, and, yes, that could account for differences.

What I do take exception with is the idea that because the research is imperfect that it is somehow not worthwhile.  That’s ridiculous.  I also think it’s bizarre that the NYT thinks this is such a journalistic coup.  They didn’t notice this before?  Like, when the research was published?  Did they talk to no one at the time?

No research is perfect.  Look up any study I have published, and you will see a section that begins, “Like any research, this study has limitations that warrant consideration.”  I often use those exact words.  All research has issues, and we should consider them as we judge its import.

If we throw out all research that has any limitations, there will be nothing left.  Deal with it.

So, yes, it is possible that there are differences between Houston and Bismark.  This is the same argument that is wheeled out whenever we compare the US to another country.  Why does our system cost more?  Cause we’re different!  Why does our system have middling outcomes?  Cause we’re different!  Why can’t we cover everyone?  Cause we’re different!

Except, when we look at differences that could account for this, we don’t find them.  We don’t smoke or drink more.  We aren’t sicker.  And, as Atul Gawande found, two communities in Texas (which ain’t that different) had wildly different spending with no good reason.  So the Dartmouth data isn’t crazy.

I don’t believe, as the administration does, that you can easily cut wasted care, save tons of money, and have no apparent changes in quality.  It won’t be easy.  I do believe, however, that we spend a ton of money that is wasted and doesn’t give us much bang for the buck.  That’s what the Dartmouth data tells us.  Those that extrapolate it into potentially misguided policy should be the target of our ire, and not the study itself.

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