Myth 33. Reducing geographic disparities will reduce spending without sacrificing quality.
Tuesday, January 12, 2010 at 10:26PM The cure for excessive U.S. medical spending, according to prominent academics as well as Peter Orszag, director of the Office of Management and Budget (OMB), is called the “30% solution.”
Its basis is the Dartmouth Atlas, produced by the Dartmouth Health Policy Group, whose leaders concluded that “if we sent 30% of the doctors in this country to Africa, we might raise the level of health on both continents.”
The recently passed House reform bill, H.R. 3962, would implement the Dartmouth Atlas by force of law, writes Louis Keeler, M.D., past president of the Medical Society of New Jersey, referring to sections 1157–1160, pp 497-520.
What the Dartmouth group did was to divide the U.S. into quintiles based on levels of Medicare spending. It found that outcomes were the same or better in the lower-spending areas.
The Group claimed to have adjusted the data for age, sex, mortality, disease incidence, and prices. The cause of spending differences “must therefore lie in how physicians and others respond to the availability of technology, capital, and other resources in the context of the fee-for-service payment system,” conclude Elliott S. Fisher, M.D., of Dartmouth, and coauthors (N Engl J Med 2009;360:849-852).
Other academic agree: It is “well-established” that higher spending in some regions does not translate into higher quality (Chernew ME, et al., N Engl J Med doi:10.1056/NEJMp0910294).
“What we now know about regional variation in costs within the United States suggests that nearly one third of health care costs could be saved without depriving any patients of beneficial care, if physicians in higher-cost regions ordered tests and treatments in a pattern similar to that followed by physicians in lower-cost regions” (Brody H, N Engl J Med doi:10.1056NEJMp0911423).
Physicians, Brody writes, are not “innocent bystanders” watching costs zooom out of control.
“Unproven or unnecessary medical interventions should not be available in any system,” writes Allan S. Brett (N Engl J Med 2009;361:440-441).
The Dartmouth analysis has, however, been subjected to a devastating critique by The Physicians’ Foundation, led by Richard A. Cooper, M.D., former dean of the Medical College of Wisconsin.
Dartmouth’s “adjustments” are “all shadows and mirrors, or simply malarkey,” writes Dr. Cooper. The Dartmouth adjusted data looks very much like unadjusted data from MedPAC (Medicare Payment Advisory Commission).
The main source of disparity is poverty, the report concluded, noting that the poorest 15% of Americans consume twice as much medical care as the richest. The “30% solution” would reduce the volume of care in communities where the need was greatest.
The “poster child” for the Dartmouth solution is a study comparing Birmingham, Alabama, with Grand Junction, Colorado. Cooper points out that if Alabama had the resources to provide all needed care to its citizens, utilization should not have been 34-48% higher in Birmingham compared to affluent Grand Junction, but rather 100% higher.
One of the “unexplained” regional variations is in the use of home oxygen supplementation for patients with chronic lung disease. It is indeed higher in some states—those where patients live at higher altitude and thus need more oxygen.
The short summary of the report: “Dartmouth strikes again—at poor people.”
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Reader Comments (4)
Did this study take into account the fact that a person who must pay a co-charge would not go to a doctor or an emergency room ( much more expensive) more readly, than a person who is on a state or goverment program? I have worked in the E.R.
How about this; do doctors over test to cover themselves from lawsuits? Maybe even more so in poorer regions?
There are solutions to health care and unfortunately congress is made of a lot of lawyers and "tort reform" is not in the thought process.
I think that the critque by Dr. Cooper and Ms. Stone's comment are right on the money. Tort reform is the first step toward improving the delivery of health care services. It would be useful to do an analysis of the legal climates in the referenced quintiles to see if there is a correlation between provision of medical services and malpractice suits/awards.
For further illumination read Matthew S. Rice, M.D., piece in the Winrer 2009 issue of the Journal of American Physicians and Surgeons entitled "Legal Care: It is Time to Lower Legal Costs and Ensure Affordable, Accessible Legal Coverage for All." Send it to your "favorite" lawyer and listen to the tort
bar howl!
President Obama and his Congress know perfectly well that implementing Tort Reform would go a long way toward solving Americas' healthcare related problems....but, that is the one thing he (they) will not do, regardless! President Obama owes a great deal to the Bar Association for the role they played in getting him elected; he is unfortunately much more dedicated to supporting the various lobbying groups, the Bar Association, SEIU, the NEA, the Fed, the ever-morphing Acorn, his old cronies in the Weather Underground and the like than he is to seriously and honestly taking any kind of action that might actually turn Americas' problems around....healthcare in particular! It is not that our President cannot address our so-called healthcare crisis in positive ways....what has become all too apparent is that he won't!
Nothing a Democratic administration can do will improve health care, because it is based upon a socialist philosophy. If you want to see how it works, travel to Russia! The average elderly person there is 55 years old. The people there avoid the warehouse type hospitals like they do the police .If the Left here was worried about the 33,000,000 uninsured, they would find ways to create equitable health insurance without tqking it away from those who have paid for it out of their pockets. ALL Americans get health care. In the inner cities the emergency rooms are crowded with those who cannot or will not buy health insurance; Nothing is free ,but who pays? I am retired, but I still pay about $300 a month for health insurance.Mr. Obama now wants me tp pay for the insurance of others, also. Now there are signs that Medicare wants to micromanage all the health care they cover. Further, these beaurocrats want to inject social agenda into the system. It is about control - not care.
Thank you.