A Quick Summary of Arguments Against the Dartmouth Atlas and Why They May Come Up at the White House Reform Meeting

Like two large ancient armies, the Democrats and Republicans are grimly getting ready for their Feb. 25 White House Health Reform 'dialog.' Around the distant camp fires, rhetorical pikes, speaking point axes and argument maces are being distributed up and down the line, while plans and counter-plans are being prepared in the pursuit of total victory.

The Disease Management Care Blog will leave it to the far more connected commentariat to provide minute-to-minute analysis of the unfolding order of battle. However, the DMCB figures that one issue that may figure prominently in the televised verbal jousting is the issue of 'unnecessary' or 'wasteful' healthcare variation, a.k.a., the Dartmouth Atlas. This says, but for the export of the efficient care of places like the Mayo Clinic to the rest of the country, we could be saving a LOT of money. According to years of research (much of it based on Medicare beneficiaries in the last two years of life), there are considerable geographic variations in the national healthcare cost landscape that cannot be explained by quality or any other outcome variable. In fact, the Atlas data suggest the opposite: that the more money is spent, the worse the outcomes.

Regular DMCB readers, however, know that the Dartmouth Atlas has not been without controversy. The DMCB is pleased to review its prior posts and offer this efficient and linked executive summary of the reasons why the Atlas folks may not be entirely correct. In the coming televised verbal combat, look for one or more of these five arguments to be used by the reform opponents:

1. It's Local Patient Poverty: critics charge that the variation in the observed cost of care correlates with the degree of local poverty, which leads to a higher burden of (especially chronic) illness, more readmissions and longer lengths of stay with greater intensity of care. This interesting post contends that when chronic illness is backed out, white the Colorado suburbs end up looking a lot like the infamous McAllen, Texas.

2. And Hospital 'Poverty' Too: it's also been pointed out that areas of high poverty tend to have poorer hospitals that can't afford the quantity and caliber of nurses or state-of-the-art technology. They're probably getting more than their fair share of Medicaid patients, which is a notoriously poor payer. The degradation in efficiency and inability to provide additional programs also results in more readmissions with complications.

3. 'Bring Out Your Dead!': this article shows that when you look backwards at the patterns of care for Medicare patients that have died, you're excluding the patients that are still alive thanks to pricey health care resources. In contrast, looking forward reveals that higher costs and longer hospital lengths of stay can be associated with survival. This opinion piece in the New England Journal concurs, pointing out that it's important to not only examine the costs for patients that have died, but the severity of illness as well as the outcomes for all patients receiving care.

4. The Underlying Assumptions: this same opinion piece in the New England Journal points out that hospitals don't necessarity control all health care costs in the two years leading up to death.

5. It's Medicare: it's also been pointed in the Journal that the Dartmouth Atlas looks only at fee-for-service Mecdicare. A better gauge of hospital costs would be to examine all charges on all patients. What's more, the charges for FFS Medicare has poor correlation with overall hospital efficiency.

Why care about this? One cost-saving proposal in the pending legislation is to examine the possibility of using economic sticks and carrots to reward hospitals on the basis of Atlas-style efficiency. So, while there is debate about its underlying scientific merits as well as the leveraging of any argument that could upend Obamacare, there is something far more political here. Since hospitals are large employers in many Congressional districts nationwide, the DMCB predicts the Republicans will attempt to use this as a classic "wedge issue' to peel away the Dems that are from districts with allegedly high cost hospitals. Look for it on the 25th.