Monthly Archives: February 2010

An important article appeared in today’s NYT, describing a new paper by Peter Bach, which is in today’s NEJM. Peter’s paper (“A Map to Bad Policy“) debunks the Dartmouth Atlas and cautions against its use. As I said in the Wash Post in September, the Dartmouth Atlas is the ”Wrong Map for Health Care Reform.”

More damning even than Peter’s analysis was Elliott Fisher’s reply: “Dr. Fisher 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.” Really? It was someone else’s interpretation? OK, Elliott, you’re not responsible. Just stand in the corner.

Peter is not the only leading epidemiologist to debunk Dartmouth in recent days. There’s also the report this week from the U of Wisconsin and RWJ by Pat Remington (another leader), showing that people who have the poorest health (and, therefore, the highest health care costs) live in the poorest counties (see my blog report and an earlier discussion of poverty and health care). And there’s the recent paper by Ong and Rosenthal (co-authored by Jose Escarce, editor of HSR, the leading health services research journal), showing that, when all care is measured (not simply end-of-life care, as measured by Dartmouth), hospitals that provide more have lower mortality, which was confirmed in the current issue of Medical Care by Barnato and associates at the U of Pittsburgh. When it rains, it pours.

What’s doubly important about the death of the Dartmouth Atlas is that it was the cornerstone of health care reform. Right from the start, Peter Orszag, director of OMB and the administration’s architect of health care reform, accepted Dartmouth’s ideological principles that health care spending was driven by doctors and hospitals who over-treated and over-charged, to no benefit. The funds for health care reform were readily available by simply getting rid of geographic differences. That alone would save 30% of health care spending ($700B). And that could be accomplished by making everything look like Mayo (white, middle class and efficient) and by having more primary care physicians (which Mayo doesn’t). And best of all, it could assure that no new taxes would be needed, just as President Obama had promised. 

The problem is that it didn’t make sense. Voters knew it, even if they didn’t know the methodological details. And the CBO figured out. And congressmen had to scramble to find ways to pay for health care reform without actually paying for it, because it was supposed to be for free – the 30% solution said so, and folks all over Capitol Hill cited it.  And now the spiral of hypocrisy has finally unraveled. Like Madoff’s investments, the Dartmouth Atlas was shadows and mirrors. But this time, the price tag is more than the $50B that Madoff cost. It’s the likely loss of health care reform. But don’t worry, Elliott. We won’t blame you.

A new study from the University of Wisconsin and RWJ identifies the five counties in each state with the poorest health (also the five healthiest). According to Marketplace, the research concludes that economic status may be even more important than access to care. The map from this study is reproduced below. Beneath it is a map showing counties with the most (and the least) poverty. Circles identify counties that appear on both maps. There is a remarkable degree of overlap between the very poorest counties and the sickest counties. Note a similar relationship between the wealthiest and the healthiest.

The lesson is that poverty is geographic, poor health tracks poverty and expenditures track poor health. If we’re going to do health care reform again, let’s get it right. No more ”30% solution” this time. But a lot of attention to the links between poverty, health status and health care spending.

In a letter that was organized by Reps. Reyes (D-TX), Lewis (D-GA) and Schakowsky (D-IL), 104 members of the House urged Speaker Pelosi to ensure that the final health reform bill does not lower Medicaid and Medicare Disproportionate Share Hospital (DSH) payments more than in the House-passed bill, which already is too much. “To retain our health care safety net’s stability, we believe that future DSH payments must continue to recognize financial losses sustained by these providers due to Medicaid reimbursement shortfalls and uncompensated care,” they wrote. The House bill would cut DSH payments by $20 billion over 10 years, while the Senate bill would cut $43 billion, approximately 25% of what otherwise would be paid. The rationale for lowering DSH payments is that more patients will be insured. But half or more of them will have incomes low enough to qualify for Medicaid, even at the Senate’s eligibility level of 133% of poverty (the House bill calls for 150%). And it’s because the costs of caring for low-income patients are so high that DSH now subsidizes hospitals that provide a lot of it. So the last thing anyone should want to do is cut DSH as more poor patients are brought into the system.

Who would be most hurt? The map below shows the amount of DSH paid by Medicare on behalf of poor patients in the various counties, expressed as DOLLARS per POOR POPULATION (individuals below the poverty level). Note: orange is the most, dark blue is next, pale blue is least. Areas with the densest concentrations of poverty, such as in the south, northeast and California, receive the most, and they will lose the most. The northwest and upper-Midwest win again. Of course, the Dartmouth Atlas tells us that these latter regions are “efficient” and deserve to be rewarded. That’s malarkey! Paying for health care reform on the backs of the poor is poor social policy.

Map by Matthew Cooper

Commenting on the President’s budget, an editorial in the Times on Feb 2^nd juxtaposed three of our nation’s dilemmas: the deficit, jobs and health care.

“President Obama got his priorities mostly right. The deficit, compared with what it could have been, is $120B. That’s a lot of money. But it’s not too much at a time of economic weakness, when deficit spending is needed to put Americans back to work.”

“Medicare and Medicaid will cost $788B; that should be another reminder of why the country needs health care reform.”

The fundamental question about health care spending is, therefore, what does it mean for jobs?  Approximately 15 million people work in health care, and that doesn’t count jobs at the 140 companies that specialize in constructing health care facilities or 56,000 pharmacies or the dreaded health insurance companies, nor does it include all of the jobs of people supplying goods and services to the 18 million folks engaged in health care in these various ways.  But a more important question is, where is the job growth? The answer is health care. Over the past decade, the growth in health care jobs has equaled the total growth of jobs. Many are high-skilled, but many are entry-level jobs that help to move people out of poverty. So we had better be careful in measuring the impact of health care. Quite apart from its beneficial effects on well being, it just may be the engine of the economy.