Data, use and misuse, regional variation - Dartmouth, Doctors, and Data

It has always amazed me how two groups of expert s, each with honorable intentions, can look at the same facts and reach entirely different conclusions. Some of these differences may be due to political ideologies, others to where one sits in the health care arena, others to belief in the raw power of data to modify behavior, still others to top down idealisms vs. bottom up realities.

In health care, these differences are important because they may determine the future of health care quality and access to care in the United States.

Two Sets of Experts

First, take the experts at the Dartmouth Institute for Health Policy and Clinical Practice. Their mission is to change the status quo by improving and redesigning health care systems. The Institute contains six Centers, led by experts in their fields working to initiate societal change.

• Center for Health Policy Research - This is the home of the Dartmouth Atlas Project. It aggregates Medicare data by region and has shown care varies enormously by region.
• Center for Informed Choice - Dedicated to making patients partners in care through shared decision making and informed choice.
• Center for Leadership and Improvement - Fostering the development of people who will advance the measurement, organization, and improvement of patient care quality, safety, and value as part of the process of the ongoing reform of health care.
• Center for Medicine and the Media – Informing the media so they will question the relentless expansion of medical care, disease definition, overmedicalization, and exaggerated messages that drive these trends.
• Center for Aging Research – Health services aimed at improving care for older Americans to promote integrated and coordinated care, and mental and physical health promotion and self-management.
• Center for Leadership - Educating health care professionals and future health leaders through a unique curriculum that goes beyond traditional MPH, MS, and PhD studies.

Out of this confluence, coalition, and cauldron of “experts” have come a set of views that may profoundly change health care policy in Washington. D.C. The Institute is working hand in glove with officials of the Obama administrative to bring about reform.

These views include,

1) The importance of using Medicare data to demonstrate overuse, underuse, and misuse of health care services.
2) The belief that this data indicates the U.S. has too many specialists doing too many procedures, and numbers of specialists and unnecessary procedures they perform should be curtailed.
3) The conviction that local, regional, and national variations in costs and quality are “unwarranted” and should somehow be homogenized, with the high cost regions performing similar numbers of procedures at similar costs as the low cost regions.
4) The belief there is a 30% waste in the system, and that too many specialists decrease quality of care due to lack of coordination and communication, both due to inadequate linking information systems.

These points are view have been widely published in such prestigious publications as Health Affairs, numerous other health policy journals, The New England Journal of Medicine, The Atlantic, The Wall Street Journal, and in recent books, such as Overdose, by Shannon Brownlee, and Critical by Thomas Daschle. Furthermore, Peter Orszag, Director of the Office of Management and Budget, often uses Dartmouth Data on variations and doctor excesses as examples of what needs to be done to rein in health costs.

• Second, consider the experts’ “take” in organizations representing and studying physicians , including The American Association of Medical Colleges, the AMA, numerous specialty organizations, state medical societies, Merritt Hawkins and Associates, The Physicians’ Foundation, the Council for Doctor and Nursing Shortages at the University of Pennsylvania, and community hospitals and community clinics across the land. These organizations believe we have a growing, already desperate shortage of primary care physicians and specialists. They also believe the variation of care, specialist-induced demand, and doctors’ desire to meet or surpass “target incomes” has been overstated and is mainly due to socioeconomic differences in various regions and to cultural demands for care in those regions. They maintain primary care physicians are underpaid Finally, they assert the laws of supply and demand dictate that the nation must take every step possible to increase the supply of physicians to overcome current shortages and to anticipate future population increases.

Status Quo, Ipso Facto, Ergo Reasoning

I am convinced even experts indulge in what I deem status quo, ipso facto, ergo reasoning. The experts set out to change the status quo, act from a set of particular facts, and therefore pursue certain actions.

Here is my stream of conscious thoughts of how this works. As befits stream of conscious expressions, there are no punctuation marks to interrupt the flow.

Dartmouth– The status quo is intolerable and we must change and redesign the system Medicare data reflects what is happening in the system as a whole health costs are too high and there are too many specialists charging too much specialists induce their own demand to meet target incomes in their practices and the hospitals where they work show 30% variation from high cost to low cost areas therefore these variations are unwarranted therefore it must be the fault of hospitals and doctors that costs are so high and therefore if we have the same costs in high cost areas as low cost areas we could eliminate 30% of unneeded waste and we can assure this will happen if we install electronic medical records everywhere to monitor and assure compliance with efficiency quality and better outcome standards and comparative effective standards to assure better health for the American people as dictated by our reading of the Medicare data.

Organizations representing doctors, hospitals, and consumers – The status quo is intolerable we have too few doctors to give access to patients if we want to expand coverage we are 50,000 doctors short now and this may grow to 200,000- 250,000 by 2020 to 2025 the shortage includes specialists and primary care doctors alike community hospitals, community clinics, doctor groups and doctor recruiters everywhere are telling us they are having a hard time finding a doctor this is particularly true in Massachusetts which is nearing universal coverage and in rural areas where there is an appalling lack of primary care doctors, general surgeons and other specialists without whom hospitals cannot offer needed services therefore if we are to serve the public and offer access to all we must pay primary care doctors more, relieve medical students’ debt burdens, remove caps on graduate medical education, and produce more doctors in existing and new medical schools and as far as the cost variation problem we must Medicare data does not reflect health care as a whole we must recognize costs vary according to the socioeconomic status and health literacy of people in urban, inner city, suburban, and rural regions therefore is well nigh impossible to homogenize health care and to stamp out variations.