Atlasians vs. Cooperites: Poverty and the Dartmouth Atlas

Dr. Richard Cooper continues to generate controversy on the Kaiser Health News site and in the latest issue of Managed Care Magazine. Of course, regular readers of the Disease Management Care Blog are unsurprised, because they were given a heads up about this tempest in a theoretical teacup, this duel of dons, this locking of learned horns, this wrestling of wonks months ago.

The DMCB efficiently explains.

The Dartmouth Atlas folks are holding firm to their assertion that regional variations in Medicare spending cannot be explained by demographic factors or the regional burden of illness. Since healthcare in many areas of the country cost more and have nothing to show for it compared to cheaper areas, the Atlasians assert this otherwise unexplained discrepancy must be due to subjective patient and physician preferences. These unecessary preferences are bankrupting the country.

Not so says the professor from the University of Pennsylvania. When regional variations in the degree of poverty are superimposed on the local health care systems, it turns out that hospitals in poor areas can't attract the human or financial capital to adequately care for persons with and without Medicare, resulting in greater inefficiencies caring for a much sicker population that needs a lot more health care. The Cooperites believe we are getting our money's worth and punishing these hospitals with reduced payments is foolhardy. Not recognizing this will cause hospitals to go bankrupt and risks having providers refuse to see patients with Medicare.

One reason why Dr. Cooper's perspectives may gain some traction is because smart hospital Boards usually have good relationships with their Congressmen. If they're doing their job, they'll remind their a Representative or a Senator that this is the perfect excuse to secure better funding for the local Deficit Memorial Hospital.

One reason why the DMCB likes Dr. Cooper's perspective is not just because it rings true, but because the Atlasians turned to the 'preferences' hypothesis to explain the 'unexplained' variation. While there may be evidence for the former, the hypothesis that patient and physician preferences explain the rest seems convenient, makes sense but unproven. Dr. Cooper fills the some of the unexplained void by pointing out that regional poverty hasn't been fully accounted for.

Maybe they're both right with an answer somewhere in between, but the DMCB wants to see this statistical skirmishing, this clash of the savants continue.

Tally ho.