The Times Confuses Readers on Dartmouth Research

Tuesday’s New York Times tries to tell a story at the very center of what is shaping up as a stormy debate over  just how much waste there is in our healthcare system.   But while striving to be even-handed,  the Times quotes both informed and uninformed sources—sometimes taking informed sources out of context—and in the process, makes hash of the facts.

The Times begins by reporting that the New Yorker article that I wrote about last week “has become required reading in the White House.” This story, by Dr. Atul Gawande, describes pricey and potentially harmful overtreatment of patients in McAllen, Texas, where Medicare spends more, per capita, than in any other town in the country.  The data behind the story comes from more than two decades of Dartmouth research showing “widespread and unwarranted variations” in how much care very similar patients receive in different parts of the country.  

The Times explains that the Dartmouth research focuses a “problem that intrigues the President very much . . . the huge geographic variations in Medicare spending per beneficiary.” What’s shocking is that “the higher spending does not produce better results for patients.” The paper goes on to quote Senator Ron Wyden (D. Oregon): The president “came into a [recent] meeting with that article having affected his thinking dramatically. He, in effect, took that article and put it in front of a big group of senators and said, ‘This is what we’ve got to fix.’”

“As part of the larger effort to overhaul health care, lawmakers are trying to address the problem,” the Times observes. 

So far so good. But then the Times engages in a bit of completely unsubstantiated speculation: “Members of Congress are seriously considering proposals to rein in the growth of health spending by taking tens of billions of dollars of Medicare money away from doctors and hospitals in high-cost areas and using it to help cover the uninsured or treat patients in lower-cost regions.

No doubt members of Congress from low-spending states such as Iowa and Minnesota have grumbled about subsidizing high-spending states such as New York and Massachusetts. As I have noted in the past, many members of the Senate Finance Committee come from low-spending states. But no one is seriously proposing simply slashing payments to doctors and hospitals in Manhattan, L.A. and Miami.

If we did “that would only make things worse, not better,” Dr, Elliott S. Fisher, one of the Dartmouth researchers, observed in a phone conversation with me. In order to keep their incomes steady, “doctors would increase the volume of what they do.”

Moreover, Fisher and others agree, while, on average, doctors in Manhattan order more tests and recommend many more procedures than doctors in a many other places, not every doctor in Manhattan over-treats her patients. An across-the-board cut would be irrational.

In fact, as the Times rightly points out, “Researchers at Dartmouth Medical School have also found wide variations within states and among cities.” For example, Dartmouth data shows that it costs Medicare far more when patients are treated at UCLA Medical Center than when very similar patients are care for at the University of California at San Francisco. (click on Dartmouth Atlas 2008) Similarly, while  Pennsylvania is not an extremely low-cost state, but the Geisinger Health System is superbly efficient, achieving better outcomes at lower costs than the vast majority of U.S. hospitals.           

How the Medicare Payment Advisory Commission Would Address the Problem

Neither President Obama or White House Budget Director Peter Orszag plan to rip “tens of billions of dollars” out of the hands of “doctors and hospitals in high-spending areas” in order to  cover the uninsured. Not in their wildest fantasies. (And I personally doubt that either man is prone to wild fantasy.)

Last week, President Obama expressed support for putting the Medicare Payment Advisory Commission (MedPac) in charge of MedPac, suggesting that MedPac would be able to find $200 to $300 billion of waste in Medicare reimbursements. Does that mean MedPac would slice reimbursements in some states?

In 2005 testimony before the Subcommittee on Health of the House Committee on Ways and Means,  MedPac chairman Glenn Hackbarth was very clear: MedPac opposes global across-the -board cuts in physicians’ fees. At the same time, it does recognize what “Dartmouth researchers and others have shown-- that often high quality care is not correlated with more services.  We know the private sector is taking steps to control volume in services such as imaging with very high growth rates.  Volume growth must be addressed by determining its root causes and specifying policy solutions.”   But a formula   . . . that attempts to control volume through global payment changes treating all services and physicians alike will produce inequitable results.

MedPac’s September 2008 report to Congress begins with the Dartmouth “map,” showing regional variations.   But the report does not advise regional cuts in reimbursements. Instead it recommends looking at how individuals hospitals and physicians affiliated with those hospitals use resources, and giving them feedback if they are doing more tests and procedures than hospitals that show better outcomes at a lower cost. The hospital and physicians would be told confidentially if they are outliers–providing an opportunity for them to use the information to improve care.  The information would be made public only after they had had two years to lift quality while lowering costs.  This is the type of reform Dartmouth would like to see, as  Elliott Fisher confirmed in this afternoon’s conversation.

The 2008 report also recognize that “information alone” would not be enough and recommended by bundling payments to doctors and hospitals, providing bonuses for improvement which would allow physicians and hospitals to share in savings. At the same time, MedPac suggested financial penalties for hospitals if they report an unusual number of readmissions. 

Peter Orszag’s Role in Bringing the Dartmouth Research to Washington

The Times article creates the impression that one man, White House Budget Director Peter Orszag, is responsible for bringing the Dartmouth research to Washington: “The research has become phenomenally influential on Capitol Hill since it was popularized by Peter R. Orszag,  as director of the  Congressional Budget Office and then as President Obama’s budget director. Aides said Mr. Obama had been intrigued by regional variations in health spending since before his inauguration. The topic came up at a meeting with Mr. Orszag in Chicago late last year.”

While Orszag has, indeed, written persuasively about the Dartmouth research—and understands it fully, he is hardly alone, nor is he a “popularizer”—someone who simplifies information in order to feed it to the masses.  Meanwhile,  Dr. Jack Wennberg has been doing this work since the 1970s,  and his name has been known in Washington at least since the early 1990s. Hillary Clinton was familiar with his work then, and when running in the presidential primary, she visited Wennberg in New Hampshire to talk at length about health care reform.

In a 2004 interview,  Wennberg recalls that the Dartmouth Research first became known in Washington back in the early 1980s: “It really began in 1984,” he recalled. “Health Affairs published a theme issue on practice variations, and we held a press conference at the Capitol to publicize it. Someone from the AMA spoke, I spoke, and some members of Congress spoke. I think that planted a seed. Some of the politicians were intrigued by variability. Over the years several hearings were held on the Hill. Bill Gradison [R-OH] in the House and David Durenberger [D-MN] in the Senate became interested and supportive. Dan Hanley of the Maine Medical Assessment Program really recruited George Mitchell [Democratic senator from Maine]. He and I met with Mitchell on more than one occasion and persuaded him that he needed to get involved.”

So this is not a case of one man (Peter Orszag) “falling for” a flimsy new theory that no one had ever heard of before he came to CBO-- and then getting the president’s  ear.. Yet, this is almost the way the Times makes it sound:

“Other researchers and politicians are not so sure [that what Dartmouth says is true.]

“They say it would be a mistake to cut or cap Medicare payments without knowing why spending in some places far exceeds the national average.” Here I would note that politicians are not researchers—lumping them together as expert sources muddies the waters. Nevertheless the Times proceeds to quote Senator John Kerry as an authority:

“There is too much uncertainty about the Dartmouth study to use it as a basis for public policy. Researchers can’t explain why some areas of the country spend more on health care than others. There are many reasons spending could vary: higher costs of living, sicker people or more teaching hospitals.”

No surprise, over more than thirty years, the Dartmouth researchers considered those possibilities. That is why the researchers adjust for differences in local prices, race, and the underlying health of population when making regional comparisons. Moreover, teaching hospitals do not invariably over-treat:  one of Dartmouth’s landmark studies showed major differences in spending at Yale-New Haven and Harvard.

Kerry defends his home state. “States like Massachusetts are concentrated centers of medical innovation where cutting-edge treatments are tested and some of the nation’s finest doctors are trained. This work might cost a little more, but it benefits the entire country.”

Cost a little more? See this Boston Globe story about Partners HealthCare gouging patients in Massachusetts, charging far more for commonplace procedures while also ratcheting up volume.  The Mayo Clinic is also a center of “medical innovation” and boasts “some of the nation’s finest doctors.”  Yet it costs Medicare 50 percent less when patients are treated at Mayo than when very similar patients are treated at some of the nation’s most prestigious academic medical centers. And Mayo is not alone. The Cleveland Clinic, and the Geisinger Health System also serve as benchmarks for better care at a lower price.

Clearly, Kerry hasn’t read the research. Someone briefed him on it—and did it poorly.

Finally, the Times solicits comments on Dartmouth’s work from a source who is clearly biased. As the reporter himself notes, Dartmouth has cited Cedars-Sinai [in Los Angeles] as having very high Medicare spending per beneficiary. Yet the reporter then turns to Dr. Michael L. Langberg, senior vice president of Cedars-Sinai for an expert opinion:  “’The statement that Medicare costs can be cut by 30 percent has been repated so many times that it has come to be viewed as a proven fact by some,’”  Dr. Langberg declared a recent letter to the Senate Finance Committee. “’It is not a fact. It is a gross oversimplification of an untested theory.’”

Why Is the Times Printing These Allegations?

For a number of years, the New York Times has regularly quoted the Dartmouth research in numerous excellent articles on overtreatment. Why, now, publish a piece suggesting it may be an “unproven theory?

“It’s a standard journalist caper,” says one source who is very familiar with Dartmouth’s work. “You spend a year or two building it up—then you take a whack at it. I’ve been waiting for this.”     In other words, he is suggesting that the Times needed a new slant on the Dartmouth story. (As a long-time journalist, I am afraid that I have to say I have seen this happen. “Hey, we keep doing stories about how interest rates are going up! Why don’t we find someone who will say they’re going down?”)

But I would also note that the piece appears, not in the paper’s “Health” section but under the banner “Politics.” And this certainly is a story about politics in D.C. Those who profit from overtreatment are becoming very, very nervous as they hear President Obama and Peter Orszag talk about Dartmouth’s data--  and the need to excise waste from the system. On top of that, the president’s support for MedPac must be sending shivers down the spines of many a lobbyist.  MedPac has been writing about the Dartmouth research for a number of years.

To be fair, the Times also  seems to be trying to write a “balanced story” by quoting people on both sides of the issue. The problem is that Dartmouth’s critics appear either ignorant of how the work is done, or indignant because its findings casts a particular institution in a poor light. (This is always a problem when you try to report “both sides” of a story when in fact, one side is largely true and the other isn’t.)

MedPac’s Robert Berenson and Dartmouth Agree on Solutions

And finally, when the Times does turn to a very well-informed source—someone who has has no axe to grind—it misinterprets what he is saying.

Dr. Robert Berenson, senior fellow in Health Policy at the Urban Institute, has had frontline experience with Medicare. He oversaw policy and operational matters at the Centers for Medicare and Medicaid (then called the Health Care Financing Administration) during the Clinton years. Recently, he was appointed to MedPac. And he is not just a policy wonk. As an internist, he practiced in a Washington D.C. group practice for a dozen years. (Finally, Bob Berenson has the distinction of being a member of The Century Foundation’s Working Group on Medicare. I have learned a great deal from him.)

In the past, when testifying before Congress, Berenson has pointed to the Dartmouth research as evidence that “a lot of spending in Medicare is wasted.”

Yet, today, the Times quotes Berenson saying “There remains too much uncertainty about the Dartmouth findings to ground public policy on them.”

The Times also cites “Research by Dr. Robert A. Berenson and Jack Hadley of the Urban Institute suggests that much of the geographic variation in health spending can be explained by differences in “individual characteristics, especially patients’ underlying health status and a range of socio-economic factors, including income.”

Today, Berenson sent me an e-mail from Europe. In response to my request for a comment on the Times’ story, he wrote: “there is substantial intra-area variation as well as cross area variation.”  In other words it would make no sense to cut fees across the board in a given region since there are both high-spending and low-spending hospitals within a single region. Here, he and Dartmouth’s Fisher are in agreement. This is what Berenson meant when he said that there “remains too much uncertainty” about Dartmouth’s findings “to ground public policy on them.” You can’t generalize and say reimbursements should be reduced throughout California.

But, Berenson agrees that Medicare is paying for many ineffective and unnecessary treatments, and he notes “we can use efficient hospitals, regardless of location, as benchmarks”—for other hospitals. Like the Dartmouth researchers, and like MedPac, he is recommending measuring less efficient hospitals against benchmarks like Mayo and the Cleveland Clinic..

In other words, Berenson agrees with the Dartmouth –and with Dr. Atul Gawande—on the solution.

“There shouldn’t be a food fight with Bob Berenson,” Elliott Fisher told me this afternoon. Many of us are in agreement-- including Bob & I. We know enough about what is going on in Medicare to begin reforming Medicare. We need to move to accountable care,” Fisher added, referring to the “accountable care organizations” that I discussed when write about Gawande’s recent New Yorker story. “We need to move away from volume-based reimbursements to quality- base-reimbursements.”

This is the heart of the Dartmouth Research, and here there is a consensus: More Care is Not Better Care. Often, it is worse. Spending more is not helping patients. We must squeeze the waste out of the system. 

Comments

[Scott McIntyre]

It's great having someone with your expertise and connections to expand on what the mainstream media reports. But while I think the flaws you see in the NYT's reporting are legitimate, it has more to do with the iherent limitations of trying to report on these complex issues than with any media bias or hidden agenda. I'm personally grateful for the Times and other media finally putting this issue and the Dartmouth Atlas research in the spotlight. And I think most readers would reach the same conclusion you did in this post.