The Gardiner Harris of the NY Times describes a rebuttal to an influential Dartmouth study:
For much of the past year, President Obama lavished praise on a few select hospitals like the Mayo Clinic for delivering high-quality care at low costs, but a pointed analysis published Wednesday in an influential medical journal suggests that the president’s praise may be unwarranted.
Mr. Obama received his information about the hospitals from a widely cited analysis called the Dartmouth Atlas of Health Care, produced by the Dartmouth Institute for Health Policy and Clinical Practice. An article in The New Yorker magazine last year written by Dr. Atul Gawande that used the Dartmouth Atlas as its organizing principle became required reading in the White House last year.
But an analysis written in The New England Journal of Medicine by Dr. Peter B. Bach, a physician and epidemiologist at Memorial Sloan-Kettering Cancer Center in Manhattan, suggests that much of the Dartmouth Atlas is flawed and that it should not be used to compare the relative efficiency of hospitals.
Good job by Mr. Harris including a link to the article. I am ready to tell you their secret - they only studied dead people:
Atlas researchers might correctly argue that costs correlate poorly with outcomes. But poor correlation does not imply that outcomes are homogeneous, but rather that there are high-spending hospitals that use resources in a manner that improves outcomes and others that squander resources, failing to improve health. The same goes for low-spending hospitals. Figuring out which is which is the purpose of efficiency assessment, which therefore requires consideration of both costs and outcomes.
Say Hospital A and Hospital B each has a group of patients with a fatal disease. Hospital A gives each patient a $1 pill and cures half of them; Hospital B provides no treatment. An Atlas analysis would conclude that Hospital B was more efficient, since it spent less per decedent. But all the patients die at Hospital B, whereas only half of the patients do at Hospital A, where the cost per life saved is a bargain at $2. Although $1 cures are rare, changing the price or efficacy of the pill does not alter the fundamental problem with examining costs alone when cost differences are sometimes associated with outcome differences.
There is another problem:
The conceptual problem lies in the fact that in Atlas analyses all health care costs that are incurred by patients over the 2 years before their death are attributed to the hospital where they were admitted most frequently during that period. This method assumes that the hospital controls all, or at least most, patient care, even if it occurs outside the hospital or in another hospital. It thus seems to presuppose a system in which hospitals are accountable for all care — perhaps a noble long-term objective, but not a current reality.
Do read the Dartmouth reply, which includes this non-answer:
We agree with Dr. Bach that fragmentation of care — resulting in the admission of patients to multiple hospitals and nursing homes — can explain why some hospitals appear so expensive in the Dartmouth data. But patients need to know about such fragmentation. Do they really want to be cared for in a hospital–physician network where patients are bounced from one hospital to another? Furthermore, accountable care organizations are a promising approach to discouraging such poorly coordinated care.
Regardless of whether people want to be "bounced around" (I see empowered patients availing themselves of their free choice of multiple providers, but whatever), it still doesn't make sense to ding one hospital for all the costs incurred by that patient.
As to the reliance on dead people:
The Atlas sample comprises Medicare enrollees with at least one life-threatening chronic disease in their last 2 years of life. It further adjusts for the type of chronic disease and the presence of multiple diseases. As we show, appropriately risk-adjusted “look-forward” and “look-back” measures are very highly correlated.
I have to score that dispute as "beyond my pay grade". But it is not above the pay grade of the critic who just got his paper published in a prestigious journal.