“It’s like whack-a-mole,” a Dartmouth researcher commented in a recent e-mail. He was referring to that fact that, as Congress moves closer to the day when it will reconcile House and Senate versions of health-care reform legislation, critics seem to be popping up everywhere to question more than two decades of Dartmouth University research which exposes the waste in our health care system.
Dartmouth’s researchers can barely keep up. No sooner have they responded to one Op-ed than another mole appears, attempting to undermine the credibility of the research.
Until very recently, “The Dartmouth Research” has been widely accepted. The work done by Drs. Jack Wennberg, Elliott Fisher and their colleagues has established the fact that in some regions of the country, patients receive far more aggressive and expensive care than in other communities. Yet—and here’s the shocker—when patients receive more intensive care, outcomes are no better. Sometimes they are worse.
Wennberg began this work in the 1970s, and for years, he stoically stood up to the skeptics. It was not easy for the medical establishment to accept the notion that when physicians “do more,” patients often derive no benefit.
His response? More research, more data, more facts—facts that would be very, very difficult to dispute.
"In the 1980s, people tried to poke holes in the data,” Glenn Hackbarth, chair of the Medicare Payment Advisory Commission (MedPAC) recalled when I interviewed him in 2007.
By the 1990s, it was getting harder and harder to shrug off Dartmouth's findings. “The fact that the work they have been doing is so rigorous, and the reputation of those doing it beyond reproach means that [it] brings issues to the table that we wouldn't be talking about otherwise—namely that more care leads to poorer quality,” Dr. George Isham, medical director of HealthPartners of Minnesota explained when I wrote a history of the Dartmouth research in 2007. “We are not just talking about wasting money," he added. When patients undergo an unnecessary procedure, they are exposed to risk without benefit.
With the 1996 publication of the first Dartmouth Atlas of Health Care, Wennberg’s work began making headlines nationwide, not just in medical journals, but in the mainstream media: the Wall Street Journal, USA Today, the St. Louis Post-Dispatch, the Philadelphia Inquirer, the Miami Herald and the New York Times all trumpeted Dartmouth’s findings: “Less care can be better care.”
“What is so profound—and so scary—is that the data is so powerful, and it doesn't change," says Dr. Christine Cassell, president of the American Board of Internal Medicine. "There is a stark correlation between reduced utilization and better outcomes.”
Most recently. New Yorker writer and surgeon Dr. Atul Gawande threw a spotlight on Dartmouth’s work in a widely-read June 1 article which used Dartmouth data to expose overtreatment in a small town in Texas.
Excess Capacity Drives Over-treatment
Two weeks ago the Washington Post published an op-ed by one of Dartmouth’s critics, Dr. Richard Cooper, a hematologist and professor of medicine with the Leonard Davis Institute of Health Economics at the University of Pennsylvania. Cooper who claims that health care spending is higher in certain regions of the country because patients in those regions are “poorer” and “sicker”—“and they stay sicker, despite the best efforts of physicians and hospitals. . . . poverty is expensive — the greatest ‘waste’ is the necessary use of added resources when coping with patients who are poor.”
What Dr. Cooper ignores is the fact that, when comparing academic medical centers across the nation, Dartmouth’s researchers adjust for differences in income, race, health, local prices, sex and age.
As I explained in an earlier post, the researchers understand that spending will be higher in areas where patients are sicker.
Cooper also ignores the reams of Dartmouth research which shows a consistent, extremely high correlation between the number of specialists and hospital beds in a community and the cost and intensity of treatment. The numbers are stunning. According to a 2008 Dartmouth report , high-cost regions where patients receive more aggressive care boast 32% more hospital beds, 31% more physicians, 65% more medical specialists, 75% more general internists, and 29% more surgeons than regions where patients receive less expensive, more conservative care.
This is true not just in gold coast cities like Los Angeles or New York. If you live in Lubbock, Tex., or Hattiesburg, Mississippi—places where there are twice as many hospital beds per 1,000 residents as in the average low-spending region—you are more likely to find yourself in one of those beds. And once you are there, “you are bound to see more specialists and subspecialists who prescribe “more tests and minor procedures,” Dartmouth’s Fisher observes, “because that's what we do to you when you're there."
Yet supply does not seem to be related to a community’s needs. “Differences in patient needs do not explain variation in the supply” of specialists in different regions,” Drs. Kevin Grubach and David Goodman reported in the Journal of the American Medical Association last year.
“In fact, studies show just the opposite: physician supply tends to be lower in communities with high proportions of minority and low-income residents with greater health needs, a pattern of resource distribution dubbed the ‘inverse care law.’ So while Macon, Georgia is in the top quartile when it comes to heart attacks per Medicare beneficiary, its per capita supply of cardiologists puts it in the lowest quartile nationwide.
As Jack Wennberg explains it, in areas where there are more specialists, very few of those doctors are consciously over-treating patients. The number of beds plays a subliminal role in a physician’s decision to hospitalize a borderline patient. If he knows that plenty of beds are available he’s more likely to use them. Similarly, if a cardiologist works in a town like Miami, which boasts an embarrassment of heart specialists, he has time to see his patients more often.
In a medical culture which traditionally has assumed that “more is always better” there is an automatic tendency to use whatever resources are available—whether time, beds or technology. The process proceeds quite naturally. Yet none of the factors shaping these decisions has much to do with medical science or the needs of the patient. U.S. doctors are trained to be aggressive. “Let’s go in there and see what’s going on,” a surgeon might say. “It can’t do any harm.”
But of course it can.
No matter how skilled the physician, every treatment carries the possibility of side effects. And every patient who doesn’t absolutely need to be in the hospital runs the risk of falling victim to a hospital error—or a particularly resilient hospital-acquired infection.
Obama is Elected: Dartmouth’s Critics Suddenly Find Flaws in the Research
It’s worth noting that those who have begun trying to undermine the Dartmouth research are, by and large, Johnny-come-latelies. When I was writing Money-Driven Medicine five years ago, I did exhaustive research, and heard barely a word of skepticism regarding Wennberg’s work. Now, however, the doubters are coming out in force.
Why? Because some who profit from an estimated $800 billion in unnecessary treatments –one third of the dollars that we spend on health care– are threatened by White House budget director Peter Orszag’s conviction that we can cut back on Medicare spending without lowering the quality of care. Orszag has digested hundreds of pages of Dartmouth research, and he understands that we can enhance the quality of care by eliminating much of the waste in the system. Care will be better, not worse, if we protect patients from unnecessary and unproven treatments. And on this subject, he has the president’s ear.
No wonder those who feed on health care inflation are now on red alert. When Cooper’s Washington Post op-ed was reprinted in the Monterey Herald, the headline was a little more direct: “Obama health pledge based on wrong data.” The attack on the Dartmouth research is, in truth, an attack on President Obama’s plan for health care reform.
In his op-ed Cooper makes his target clear: “President Obama pledged on Wednesday that reducing the waste and inefficiency in Medicare and Medicaid would pay for most of his health-care plan. This echoes remarks from Peter Orszag, his director of the Office of Management and Budget, who has claimed that one-third of health-care spending more than $700 billion, is wasted annually.” Cooper then dismisses the Dartmouth data as a “theory that doesn’t hold up.”
According to Cooper, we could never have too much health care: “To really achieve health-care reform, and find a way to pay for it, the president will have to give up on the Dartmouth suggestion and grapple with some painful truths. . . . more is more and less yields less — the best care is the most comprehensive care, and it costs more.”
Really? Boston surgeon Dr. Atul Gawande doesn’t agree: “nothing in medicine is without risks,” he warns in the June 1 New Yorker. “Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do . . . In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.”
Yesterday, Cooper struck again–and the Washington Post again served as the vehicle for his views, quoting Cooper in a news story headlined “Is the Mayo Clinic a Model Or a Mirage? Jury Is Still Out,”
The Post's reporters noted that President Obama often points to the Mayo Clinic in Rochester, Minnesota as a model for health care reform. This is true: the Dartmouth research shows that when a patient is treated at Mayo, it costs Medicare far less than when a patient suffering from the same condition is treated at other, less efficient hospitals.
In a study comparing some of the nation’s most prestigious academic medical centers, including the Mayo Clinic in Rochester, Minnesota, researchers looked at outcomes and quality of care for heart attack, colon cancer and hip fracture patients, and found major variations in how much care very similar patients received.
One might think that marquee medical centers would all follow the same guidelines for “best practice.” One would be wrong. After adjusting for underlying differences in health, race and income, and local prices Dartmouth found that centers located in high-spending cities like L.A. and Manhattan reflected the local medical culture, providing more expensive, and aggressive care than academic medical centers in places like Rochester, New York, or Columbia, North Carolina. As a result per-patient costs were about 60% higher in the areas where care is more aggressive– with no better outcomes or quality of care.
Why is Mayo so much less expensive? Patients see fewer specialists, undergo fewer tests and treatments, and spend fewer days in the hospital. Mayo’s doctors all work for the clinic, on salary and they collaborate. They are all looking at the same chart, and so there are fewer mis-communications, errors and medication mix-ups. Thus, the final bill is lower. Meanwhile outcomes, patient satisfaction and doctor satisfaction are higher.
The Washington Post quotes President Obama: “So what we want to do is we want to help the whole country learn from what Mayo is doing. That will save everybody money.”
But the headline on the Post story insists “The Jury is Still Out,” leaving readers uncertain as to whether they should trust Obama and the Dartmouth research.
Rather than weighing the facts and evidence on each side of the argument, the Post’s reporters quote Cooper, scoffing at Mayo’s reputation: “If 98 percent of our patients were middle-class Scandinavians and no one was poor, we'd have low costs, too," Cooper declared, referring to the University of Pennsylvania where he works.
Are 98% if the patients at Mayo really Swedish? Are they all blonde, middle-class, and above-average? .
In part 2 of this post, I wiill consider the truth of Cooper’s many claims, both in the Washington Post and in articles he has published in Health Affairs and other journals.
I’ll also look into why Richard Cooper is campaigning against the Dartmouth Research. What special interest does he represent?
Finally, I’ll explain why Dr. Cooper has been banned from publishing in Health Affairs for five years.