Friday, February 19, 2010

Electronic Medical Records: The Limits of Data Intervention

Inside Account of How the Obama Policy
of Escalating Data Use was Reversed

The regional variations in health care spending that are documented by the Dartmouth Atlas of Health Care have been cited by many as the justification, and possible basis, for changes in provider payment rates. The articles below – and the responses that follow them – address concerns about the Dartmouth data.

“Perspective,” February 18, 2010, New England Journal of Medicine

History has these lessons to teach. Sometimes human behavior on the ground is more important than policies in the air. Sometimes how people react to crisis runs counter to what data dictates. Sometimes in hospital and physician settings, the patient in front of you delineates what needs to be done, rather than what data indicates.

In 1989, Peter Hoopes, a Pentagon official and an historian, wrote The Limits of Intervention: An Inside Account of How the Johnson Policy of Vietnam Escalation was Reversed. Hoopes, a Pentagon insider, had helped develop Pentagon policy. Secretary of Defense, Robert McNamara based his policies on data – body counts, skirmishes won, enemy troop estimates – as criteria for the war effort’s efficiency. Yet the U.S. was losing ground to North Vietnam troops and South Vietnamese guerillas and ultimately lost the war.

Today the Obama administration is losing its battle to control Medicare spending. One of its weapons has been data generated by Medicare data from the Dartmouth Atlas of Health Care, led by Elliot Fisher, MD. The budget director, Peter Orszag, has embraced this data as a tool for reigning in Medicare spending. Orszag has said regional variations in spending are “unwarranted, “ and if we could only we could homogenize spending by bringing down spending in high cost places (like Miami, McAllen, Texas, and major cities) to low cost areas (like the American Midwest), we could slash Medicare spending by 30%.

The Dartmouth data indicates more spending does not lead to improved health outcomes, with body counts (death rates in the last two years of life) being one criteria for efficiency. As Peter Bach, MD, a Sloan Kettering physician and former Medicare official, notes in the February 18 NEJM , “Some policymakers, included President Barack Obama, have proposed the that the features of high-performing, “efficient” health care systems should be identified and their lower-cost practices emulated.”

But two huge flaws mar this policy: one, data is only as good as its assumptions, e.g., that high spending represents “waste” and low spending represents “efficiency.”; and two, Medicare spending is not about “efficiency,” it’s about poverty.

Richard “Buz” Cooper, MD, Professor of Medicine and Senior Fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, has consistently insisted and clearly demonstrated high costs are mostly correlated to poverty in inner cities, especially in large metropolitan areas, and rural regions, particularly the American South, rather than avaricious providers.

The poor are sicker, and present with more advanced disease, than their healthier and more affluent brethren. Consequently, the poor cost more to treat, and hospitals and doctors simply do what they have to treat them and to save them.

Here is Doctor Cooper’s response, in part, to two articles in the New England Journal (1,2), which question the Obama administration’s theories of efficiency and cost savings.

“ I'm sure most of you have seen the article in today's NYT about Peter Bach's paper in the NEJM, which debunks the Dartmouth Atlas ("A Map to Bad Policy") and cautions against its use. As I said in the Washington Post in September, its the ‘Wrong Map for Health Care Reform.’ “

“More damning even than Peter's analysis was Elliott Fisher's reply: "Dr. Fisher (Fisher is a leader at the Dartmouth Institute) agreed that the current Atlas measures should not be used to set hospital payment rates, and that looking at the care of patients at the end of life provides only limited insight into the quality of care provided to those patients. He said he and his colleagues should not be held responsible for the misinterpretation of their data.”

“The Dartmouth work, through Peter Orszag, was the cornerstone of health care reform. It forged the principles that there were pervasive incentives that led doctors and hospitals to over-treat and over-charge, to no benefit, and that the money for health care reform was easily available - no new taxes (as Obama promised) - just make health care "more efficient" and the nation could save 30% ($700B). And to do that, just make everything look like Mayo (white, middle class) and have more primary care physicians (which Mayo doesn't). Now, that has all disappeared. Like Madoff's investments, it was all shadows and mirrors. But this time, the price tag is more than the $50B that Madoff cost. It cost us health care reform. But don't worry, Elliott. We won't blame you.”

1. Peter Bach, MD, “A Map to Bad Policy – Hospital Efficiency Measures in the Dartmouth Atlas : NEJM, February 18, 2010.

2. Jonathan Skinners, PhD, Douglas Steiger, PhD, and Elliot Fisher, “Looking Back, Moving Forward, NEJM, February 15, 2010.

3. Richard Cooper MD, Blog: “Physicians and Health Care Reform: Commentaries and Controversies, “ February 18, 2010.


HaynesBE said...

Thank you for alerting me to this set of articles. Regardless of who is right, neither point of view should be the basis for legislation. I elaborate on that point here.

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