Controversy erupted across several blogs yesterday following a critical New York Times article of the Dartmouth Atlas Project, an influential body of research that shows huge geographic variations in the amount of care that hospitals and doctors provide. The Times article raised the question of whether the Dartmouth research provides a guide to quality of care, as some people have asserted. Conservative and libertarian health policy bloggers were largely silent, ignoring the debate.
Health Beat’s Maggie Mahar says the article “is raising eyebrows– in part because there are so many factual mistakes in the story, in part because the tone is so personal. ‘It sounds as if it were written by someone’s ex-spouse,’ a source who is very familiar with Dartmouth’s work told me in a phone conversation earlier today.”
Jonathan Skinner and Elliot Fisher, leaders of the Dartmouth project, responded (pdf) strongly, calling the article “shaky reporting” and listing five items they call “factual errors.” Skinner and Fisher conclude, “In sum, readers who wish to understand the problems confronting the U.S. health care system will have to look further than this superficial piece in the Times. An accurate understanding of our work can best be gained by reading the written response that the Times kindly posted with the article. More importantly, the Times article leaves the impression that we have somehow backed off on our conclusions. We have not.”
The Health Care Blog’s Matthew Holt calls the article a “a confused, woffly attack on Dartmouth from Reed Abelson & Gardiner Harris. This is a dreadful article. Period.”
Economist Brad DeLong posts a response from Harvard economist David Cutler, who was quoted in the Times piece: “[T]he reporter asked ‘what do you make of the fact that the price adjustment changes the ranking of communities?’ I said something to the effect of ‘why do I care about the non-price adjusted data.’… [T]he Dartmouth people have done the price adjustment, so we don’t have to fight about what such an adjustment would do. Hard to tell why my comments are beating up on anything (except a mythical version of the Dartmouth data in which they had never done price adjustment)…”
Merrill Goozner isn’t as critical as many others, saying that quality data is important to completely understand what’s happening with overutilization: “This is an important debate. But as is often the case in journalism, the attempt to reduce complex realities into a single-factor analysis that can be summarized in a headline or a single ‘why this story is important’ paragraph can leave a mistaken impression. Regional variation in Medicare spending is one indicator of gross overutilization. … But that by itself tells us nothing about why that overutilization occurs. … A careful mapping of quality has never been done by Medicare or anyone else since good data isn’t available. … The reform law will generate much better data, but that is years away. But when it is done, comparing those maps to spending patterns may provide researchers with crucial clues for determining what accounts for variations in spending across the U.S. One thing is for certain. Quality data will provide patients-as-consumers with information about what hospitals and physicians to avoid — something that spending patterns by themselves can never do.”
On the New York Times’ the Economix blog David Leonhardt responds: “Last year, I spent time reporting at Intermountain Healthcare, a network of hospitals in Utah and Idaho, and what I saw there helped persuade me that variation is a problem. … As Intermountain has analyzed its variation, it has found that overtreatment is a significant problem. In other words, a decent amount of care Intermountain had been providing wasn’t making its patients any healthier. That’s a microcosm of what happens around the country. Not surprisingly, the hospitals that practice very intensive medicine, like U.C.L.A., tend to disagree. And they are right that more care does sometimes lead to better results. But it can also lead to worse results.”
The New Republic’s Jonathan Cohn writes, “I’ve long admired Abelson and Harris’ work. They are right to highlight some of the ambiguities in the Dartmouth research–and the extent to which its more evangelical promoters gloss over them. But the fundamental argument of reform is not, as Abelson and Harris suggest, that cheaper care is better care. The argument is that cheaper care can be better care–or, at least, equally good care. And the evidence for that proposition is pretty overwhelming.”
But The Washington Post’s Ezra Klein says coverage of the Dartmouth data debate focuses too much on what it might mean for the health overhaul law: “So if the Dartmouth guys are totally wrong, that’s a bummer in that it means there’s less low-hanging fruit to pick, but it won’t change the numbers on the bill. The Times might be strafing the Dartmouth Atlas guys, and they might be strafing the rhetoric of politicians who want to believe we can balance the books by getting rid of things no one needs in the first place, but they’re not saying much about the health-care bill.”
And NPR’s Scott Hensley writes on the Shots blog “When it comes to health care, nobody we’ve met has all the answers. But it’s hard to imagine tackling the problems of cost and value without looking at the differences in what gets spent where — and to what end.”
