Friday, September 11, 2009

What's really wrong with healthcare

Having spent enough time consulting (where you have data, but don't spend much time in the field), and spending time in the field, particularly in ERs, this interview with Richard Cooper, MD rings 100% true:
Regional variation is a product of regional differences in wealth, overlaid with differences in poverty. It’s not generally appreciated that health care expenditures for people in the lowest 15% of income are 50% to 100% greater than for people of average income. There’s also a difference at the high end. The wealthiest 15% also consume more, but only about 20% more. So there’s greater utilization at both ends of the income spectrum, but for different reasons and with different outcomes...

A good example is the Dartmouth study of academic medical centers. You find that one group of academic hospitals provide more care than another group. The Dartmouth folks say that Mayo is more “efficient” in resources used per patient or in number of doctors devoted per unit of patient care than in LA, Philadelphia, Miami, Chicago, and New York City.

But the so-called “inefficient” hospitals are all in dense urban centers, while “efficient” hospitals are all in smaller cities, often college towns liked Madison, Wisconsin or Columbia, Missouri, or in places like Rochester, Minnesota, where Mayo is located. Rochester is 90% Caucasian with low poverty. But in fact, Mayo is the most resource intensive center in the upper Midwest. Among peer institutions in similar socio-demographic environments, Mayo actually uses more resources.
What drives such appallingly bad "analysis"?
[Dartmouth claims that] Mississippi, the poorest state in the nation [has the most spending, and highest number of specialists, and poor quality healthcare]. It does, indeed, have poor quality, but how could it have the highest spending and the most specialists? The answer is it doesn’t. Mississippi, as you know, has the fewest specialists, and although it does have high Medicare spending, it has very low health care spending overall. It’s not surprising that low total spending and few specialists are associated with poor quality. In fact, when all of the states are examined, more total spending and more specialists are associated with better quality – just the opposite of the Dartmouth-Harvard message but just what you would expect.

You might wonder how they arrived at the opposite conclusion. Well, they never really measured how many specialists were in Mississippi or anywhere else. They did some statistical maneuver where everything was converted into residuals, and I guess that Mississippi has a lot of residuals. It just doesn’t have a lot of doctors.

I published my observations about these studies in two papers in the December 2008 issue of Health Affairs online. But much to my surprise, they were accompanied by two rebuttals from the Dartmouth crowd, each with summary statements by the editor that said I had simply reconfirmed the Dartmouth work.

But it all made sense when I learned that the new editor of Health Affairs, Susan Dentzer, is a Member of the Board of Overseers of Dartmouth Medical School, the former Chair of the Board of Dartmouth College, a former Trustee of Dartmouth-Hitchcock Medical Center and winner of the alumnus of the year award from Dartmouth. She has a profound conflict of interest which she failed to reveal in her editorial – an egregious ethical breach. So, it all made sense. And it all is rather remarkable. Fortunately, truth has a way of surviving, and the truth is that states with more health care spending and more specialists have better quality health care.
You can read more about Susan Dentzer here and check the boxes: PBS, Robert Wood Johnson, Association of Health Care Journalists, the American Psychiatric Association, US News, ABC, CNN, Harvard, Council on Foreign Relations (no, I am not kidding), International Rescue Committee, Dartmouth, Dartmouth Medical. You need a lot to overcome what anyone can see with their own eyes.


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