In their continuing quest to convince politicians that health care reform can be financed by greater “efficiency,” Dartmouth Atlas leader Elliott Fisher and a small band of sympathizers cited ten “model regions” in their recent New York Times op-ed (August 13). By their description, they include “towns big and small, urban and rural, North and South, East and West.” Here’s their list: Asheville NC, Cedar Rapids IA, Everett WA, La Crosse WI, Portland ME, Richmond VA, Sacramento CA, Sayre PA, Temple TX and Tallahassee FL. Big? Well Sacramento has more than 400,000 souls, but it’s the largest, and none of the others reaches 200,000. Small? Well, yes. Sayre weighs in at 5,400. The average of all ten is 131,000. Are these representative of America? Hardly. No more than Grand Junction CO (population 50,000), where the President sojourned this weekend to teach us how medicine should be practiced. Even if Medicare was a valid metric, can we design health care reform based on health care spending in these communities? You’re kidding! The major challenges are in the big urban centers, where affluence and poverty intersect, and in the old Confederacy, with its broad swath of poverty and accompanying poor outcomes that put the US at the bottom of the pack internationally.
The Dartmouth Atlas has led policy-makers to believe that future expenditures can be off-set by small town efficiency. Their route to efficiency is through “pay-for-value,” which would reimburse doctors and hospitals more if they spent less but had good outcomes, like in small towns. On the surface, this makes sense. We’ll pay more for cars that run better. But patients aren’t cars, and south Los Angeles is not Grand Junction, and Medicare spending is not even a valid measure of value. The worst outcomes are among patients who are sickest and need the most, and they cost the most, and disproportionate numbers of them are poor. Pay-for-value would cut reimbursement to hospitals that readmit more patients, most of whom are poor, and penalize physicians who provide more services to patients, most of whom are also poor. If America truly wants health care reform, it will need a new map, one that can distinguish the eastern megopolis from open plains and the poverty belt from the rust belt. The Dartmouth Atlas is a map to nowhere.