Thursday, June 2, 2011

A Dissenter Dissents from Traditional Health Reform Positions

Preface: For the last three years or so, “Buz” Cooper, MD, a professor of internal medicine and a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, has dissented from the world view of The Dartmouth Institute of Health Policy and Clinical Practice.

Susan Dentzer, editor of Health Affairs since 2008 , is a member of the Board at the Dartmouth Institute. She has declined to publish articles by Cooper, who disagrees with the Dartmouth Institute’s fundamental views on health reform - that regional variation of costs for Medicare patients is “unwarranted;“ that bringing these variations into line from the highest to the lowest payers would wring as much as 30% of “waste” out of the health system; and that provisions of more care by primary care physicians and less care by specialists - would save money and improve quality.

Cooper says these arguments are flawed and that poverty and delayed diagnosis, not too few primary care doctors, too many specialists, or provider greed, drive higher health costs and lower care quality. Here are Cooper’s latest thoughts. I will let readers decide if his arguments are persuasive.

Finally from Dartmouth: More is More

Posted on May 27, 2011

The Dartmouth machine has published a rather astounding new paper about the wonderfulness of primary care. The reason that it’s astounding is that it debunks decades of Dartmouth doubletalk and adds to the growing evidence that patients who receive more medical care have better health outcomes. More is more, just as you would expect. Here’s what the Dartmouth team did.

First, using the conventional approach to measuring physician supply (AMA Masterfile), they counted the number of primary care physicians and found no significant correlation with either Medicare spending or mortality. This directly contradicts earlier claims by Shi & Starfield that areas with more primary care physicians have lower mortality and by Baicker & Chandra that areas with more primary care physicians have lower Medicare spending, both of which are widely quoted. But we now know that neither is true. In fact, they never were.

Like the current study, Shi & Starfield had also failed to find a correlation between mortality and the total supply of primary care physicians, both family practice (FP) and general internal medicine (GIM). The correlation they found was only with FPs, although they called it “primary care.” However, as I’ve explained, this correlation exists because FP training programs (and therefore FPs) are more prevalent in the upper-Midwest, where minorities are sparse, poverty ghettos are rare and mortality rates are low. FP supply has nothing to do with it, and we now know that primary care supply doesn’t correlate with mortality. It never did. Ouch!

The same for Baicker & Chandra’s claim that areas with more primary care physicians have lower adjusted Medicare spending – about 30-40% lower. The current study shows that this isn’t true. In fact, it never really was. Baicker & Chandra’s claim was based on a statistical shell game that I exposed in Health Affairs. They responded that I was wrong, and Susan-the-Editor (and Dartmouth board member) responded with feminine furry, but it turns out that I was right.

As the current Dartmouth study shows, areas with more primary care physicians do not have lower adjusted Medicare spending. Ouch again!

Now for the big story. In addition to using the AMA Masterfile, the Dartmouth team counted primary care physicians a new way. They measured how many primary care services were billed and then converted services into the number of FTE physicians that would, if working full-time, be able to supply them.

But forget about the conversion. Stick with the measure. It’s a good measure. It measures services per beneficiary. The Dartmouth team found that areas with more primary care services also had more total clinical services (primary care plus specialty care), and these areas also had more Medicare spending. It is areas like these that the Dartmouth group previously called “high spending areas,” where patients were no sicker and didn’t get any better despite all of that added spending. This gave rise to the mantra about the unwarranted use of supply sensitive service needlessly consuming 30% of the health care budget.

But the current study found that patients in the high-spending areas were sicker. And despite being sicker, their mortality was lower. Mortality was lower in areas with more physician services and more Medicare spending. More was more. OUCH!

That’s the exact opposite of Elliott Fisher’s conclusion that more care is associated with higher mortality. According to Fisher and colleagues, this added care is not only wasteful. It’s dangerous. Only a few years ago, David Goodman (senior author of the current study) said, ”more physicians will make health care worse.”

And Susan-the-Editor said ”the greater the amount of health care you provide, the more likely it is to kill you,” somewhat awkward syntax but quite damning. And now the Dartmouth team has shown that more health care is associated with lower mortality. Ouch, ouch and ouch again. Three strikes and you’re out.

So how did the new paper spin these observations? It concluded that “a higher level of primary care physician workforce was generally associated with favorable patient outcomes.” Therefore, medical homes, train more, pay more, bla, bla, bla. But the workforce wasn’t measured. All that was measured was primary care services. And primary care services where greater where specialty services were greater, and these areas had more Medicare spending. The real conclusion is not about primary care. It’s about medical care. Medicare beneficiaries who received more medical care had better outcomes, even when they are sicker. MORE was MORE.

In publishing the same conclusion two years ago, I said ”let the simple truth that health care quality is better in states with more physicians, both primary care and specialists, sweep away the myths and permit greater clarity as planners work to solve the crisis in physician supply that now confronts the nation.” Possibly this latest study from Dartmouth will allow us to do just that.


1) Hua Chang, Therese Stukel, Ann Flood, David Goodman, “Primary Care Physician Workforce Outcomes and Medicare Beneficiaries’ Health Outcomes, “ JAMA, 305(20), 2096-2104, 2011.

2) B. Starfield and Li Shi, “Contributions of Primary Care to Health System and Health,” Milbank Quarterly, 83(3), 457-502, 2005.

3) K. Baicker and A. Chandra, “Medical Spending, and Beneficiaries’ Quality of Care, Health Affairs, January June,2004.

No comments: