16 replies »

1. One more thing. I think that there are numerous travel insurance web pages of reliable companies that permit you to enter holiday details and have you the prices. You can also purchase the particular international holiday insurance policy on the internet by using the credit card. All you have to do is to enter your current travel specifics and you can see the plans side-by-side. You only need to find the plan that suits your financial budget and needs after which use your credit card to buy the idea. Travel insurance online is a good way to take a look for a dependable company regarding international travel cover. Thanks for expressing your ideas.

2. What’s bugging me is that the government has added laws and its getting crazy. I do hope that this medical reform will work out. People are already getting confused with the new things.

3. Matt,
   Your June 25, 2009 post RE: Dan Gilden’s analysis of a “Tale of Three Counties” was predictive of a huge risk that we now face. Gilden’s insights were spot on. The fact is as you said “Finally it’s worth noting that if his conclusions are true this has huge implications for overall health care policy”…Matthew Holt.
   I think the NYTimes got the last word for those late viewers, and they finally reported what needed to be said the first time around. And BTW, the data that Dartmouth uses will NOT be released, so we will have to rely on approved CMS researchers to validate the claims for us all. When they do we should all listen and not criticise the messenger.

4. A variety of new technologies have been developed over the past decade to assist in this goal.

5. Utah doc, healthier people is not a significant factor in the Dartmouth results because it has been controlled for in many of the Dartmouth studies. I am sure that you are right that cultural factors play a major role in practice patterns. But the Dartmouth researchers never deny that, do they? Similar cultural factors also play a role in Minnesota and other states where costs are lower. But cultural factors show themselves in the practice of medicine.
   If someone argued that financial incentives were the only significant variable making some areas high cost and others low cost, you would be right to criticize. But (almost) everyone who knows that research also knows that the variation occurs for different providers that are paid Fee For Service. FFS is a factor, but only in conjunction with other factors. Atul Gawande’s article on El Paso and McAllen comes to mind.
   To say others should practice more like Intermountain to save money is to express a goal supported by evidence. It is not a method or a set of operational guidelines. Who really thinks otherwise? True, the goal will be difficult or impossible to achieve without cultural change, which is something that many of us (on the left and right politically) have been saying for a long time.

6. The Dartmouth research has helped raised important questions about regional variation and possibly unnecessary health care. But the conclusions drawn from their data are often a stretch.
   In Utah the Dartmouth data shows that the lower cost of care is similar across the four major hospital systems that operate here. And CMS Hospital Compare data shows that none of those four systems is systematically outperforming the others on quality metrics. Furthermore the rate of increase in health care premiums in Utah is the same as elsewhere.
   But Intermountain is always highlighted by Dartmouth and others as an innovator in cost and quality. When Dartmouth Atlas founder Jack Wennberg asked by a local NPR radio interviewer to explain why all of Utah’s health care systems had low costs his response was that “Intermountain has taught the others how to do it.” This shows a susceptibility to Intermountain’s PR that is unworthy of such a critical thinker.
   The more likely hypothesis is that Utah has healthier people, conservative physicians, strong family support systems that allow older people to be discharged more quickly to home, and a religious population that does not push for extreme and expensive measures to prolong death when it is inevitable.

7. Anyone who has seriously published in NYT knows, they triple-check something this big. This is just the tip of the iceberg.

8. “Dartmouth is far from perfect and could use so questioning, clearly academic exercise from people not involved in healtcare. If they are forced to explain and back up their results it can only help them.”
   Yes. Along with “I’m from the government, and I’m here to help.”
   NYT would never have gone with that story, unless it was double-checked by several editors and a few statisticians. This is just the tip of the iceberg. Look for more — a lot more.

9. “There’s lots more work to be done here, but this article doesn’t help.”
   Are you taking the global warming stand her Matt? Don’t dare question the science we don’t have time to prove ourselves. Sience is built on questioning, vast majority of which are wrong but by proving so you establish the facts. Unless your pushing propoganda over science you shouldn’t fear 1 poorly written and reserached article. Seeing what a couple questions have done to the global warming politics I can see why you would worry though.
   Dartmouth is far from perfect and could use so questioning, clearly academic exercise from people not involved in healtcare. If they are forced to explain and back up their results it can only help them.

10. My main criticism of Dartmouth work and especially some of the use it has been put to is its mostly ignoring (and then being used to deny by others) the real problem of the UNDERserved. With its focus on inpatient care and those who have already managed to get their way into care, it misses (and is then used to deny) the issues the lack of acces to primary care, the existance of medically underserved areas and populations, health professional shortage areas. Hence we get the emphasis on the “overtreated” as a convenient way to cut costs while ignoring health disparities.
    If you are not familiar with shortage areas and related issues, see:
    http://bhpr.hrsa.gov/shortage/
    http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesignationAdvisor.aspx
    http://bhpr.hrsa.gov/healthworkforce/default.htm
    For more on the progressive critique of Dartmouth see:
    http://pnhp.org/search/google/dartmouth?query=dartmouth&cx=015249405663905105964%3Aebn8t4lcngk&cof=FORID%3A11&sitesearch=#913
    Nevertheless the NY Times article really sucked: it appears to have been a preconceived hatchet job, got the basic facts of it critique wrong, and misquoted folks.

11. I do not view the New York Times articles as a hatchet job as much as a critique of the strength and weaknesses of Dartmouth research. It is a little too simplistic to assumption that saving $700 billion annually is as easy as telling high-cost hospitals to merely perform medical services like Intermountain, Geisinger or the Mayo Clinic. Moreover, Medicare may not be a good proxy for non-Medicare health care spending in many areas.
    Thomas Saving, Andrew Rettenmaier and their colleagues at Texas A&M University found that variations in Medicare spending are often offset by non-Medicare spending. For instance, although Texas is fifth highest in Medicare spending per capita, it is 43rd in per capita spending for the state’s entire population. California is 11th in Medicare spending, but 42nd overall.
    Very little savings will come from forcing the rest of the country to adopt the medical practices of the most efficient areas. After adjusting for the different characteristics of the states (age, income, ethnicity, etc.), the potential savings drops to only about 5 percent, which assumes orders are carried without mistakes or bureaucratic ineptitude. Realistically speaking, there are no savings to be expected using this approach.
    Thomas Saving is a former Medicare Trustee and both Saving and Rettenmaier are NCPA senior fellows. Their research was published by the National Center for Policy Analysis. Here is a reader-friendly blog post with links to their work. http://www.john-goodman-blog.com/can-an-independent-medicare-commission-control-health-care-costs/

12. From: “Dr. Steve A”
    Date: June 4, 2010 8:01:45 AM EDT
    Subject: fyi: the real problem with Dartmouth
    My main criticism of Dartmouth work and especially some of the use it
    has been put to is its mostly ignoring (and then being used to deny by
    others) the real problem of the UNDERserved. With its focus on
    inpatient care and those who have already managed to get their way
    into care, it misses (and is then used to deny) the issues the lack of
    acces to primary care, the existance of medically underserved areas
    and populations, health professional shortage areas. Hence we get the
    emphasis on the “overtreated” as a convenient way to cut costs while
    ignoring health disparities.
    If you are not familiar with shortage areas and related issues, see:
    http://bhpr.hrsa.gov/shortage/
    http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesignationAdvisor.aspx
    http://bhpr.hrsa.gov/healthworkforce/default.htm
    Nevertheless the NY Times article really sucked: it appears to have
    been a preconceived hatchet job, got the basic facts of it critique
    wrong, and misquoted folks
    See Dartmouth response:
    http://www.dartmouthatlas.org/downloads/press/Factual_errors_NYT_article.pdf
    http://www.dartmouthatlas.org/downloads/press/Skinner_Fisher_DA_05_10.pdf
    also:
    http://www.tnr.com/blog/jonathan-chait/75289/good-health-care-less-money-yup-still-possible
    also:
    http://delong.typepad.com/sdj/2010/06/new-york-times-fail-gardiner-harris-and-reed-abelson.html
    http://delong.typepad.com/sdj/2010/06/henry-aaron-of-brookings-on-abelson-and-harris-of-the-new-york-times-rarely-have-i-begun-an-article-with-such-high-hopes-th.html
    http://delong.typepad.com/sdj/2010/06/merrill-goozner-is-unhappy-with-abelson-and-harris-of-the-new-york-times.html
    http://delong.typepad.com/sdj/2010/06/why-oh-why-cant-we-have-a-better-press-corps-2.html
    http://delong.typepad.com/sdj/2010/06/are-reed-abelson-and-gardiner-harris-as-big-tools-as-their-attempted-trashing-of-dartmouth-suggests-yes-time-to-shut-the-ne.html

13. Interesting businesses: Dartmouth researchers who have published misleading data and opinion enrich themselves by selling a company they formed to proselytize its dogma; and Don Berwick (CMS Director nominee) wrote the misleading IOM report using flawed methodology and formed a “safety” non-profit company at which he earns nearly $2 million. Hmmm.
    Foundations of health care reform are cracked. Is it no wonder the problems continue while patients suffer?

14. Another gem:
    The researchers also say they have made some of those adjustments in some of their other published work.
    How about actually reading that work and evaluating it? It’s published, so not hard to find.
    It appears that the authors’ sympathies lie with providers and defending the status quo ante of high payments to them. This passage is ripe with insinuation that trying to control costs and utilization is bad because insurers are for it:
    In any case, the more-is-worse message has resonated with insurers, whose foundations now help to finance the Dartmouth Atlas. Dartmouth researchers also created a company, Health Dialog, to consult for insurers and others on Dartmouth’s findings. Valued at nearly $800 million, the company was sold to a British insurer in 2007 and still helps to finance the Dartmouth work.
    Gardiner Harris seems to have written almost the same article before for the Times. So Matthew, this does indeed constitute licking the sores. Reed Abelson has written much better, and seemingly contradictory, stuff for the Times before.

15. This article unfortunately demonstrates how poorly educated most Americans, as represented by reporters, are in understanding basic statistics and how to read charts and graphs.
    It also smacks of the same political machinations practiced by those, including many medical professionals (read, American College of Physicians), who attempted to debunk the IOM’s report on the number of deaths per year from medical errors.
    Make no mistake; these are deliberate attacks promulgated by those invested in maintaining the status quo. See Clayton Christensen’s book on disruptive innovation and how the “establishment” tries desperately to maintain status quo in times of change….

16. It’s peculiar. The writers of the Times article appear not to understand what they have read, or even what they have written.
    At one point, they write:
    But the real difference in costs between, say, Houston and Bismarck, N.D., may result less from how doctors work than from how patients live. Houstonians may simply be sicker and poorer than their Bismarck counterparts.
    At another:
    Dartmouth researchers use data on how much hospitals have billed Medicare for patients with a chronic illness who were in their last six months or two years of life.
    If this were a term paper, I would grade it a B…and that’s for a 20 year-old in the era of grade inflation who spent a few hours trying to form an opinion about something s/he doesn’t yet really understand. As an article in the NY Times, written by adults who are expected to be authoritative, and read by millions, this is a big, fat “Fail.”
    Matthew: I think strictly we should regard this as an outbreak of pustulent sores on the body of the Times. They would have to follow up with a series of articles on this line of thinking before it could be counted as “licking” those sores. For everyone’s sake, let’s hope the editors don’t like the taste of pus so much this time.