On June 3rd, NYT writers Reed Abelson and Gardiner Harris bravely published the truth about the Dartmouth Atlas – its use of data is shaky. Writing in the Washington Post last September, I called the Atlas the “Wrong Map for Health Care Reform.” Other than two pathetic rebuttals, one from the perpetrators of the Dartmouth hoax (Fisher and Skinner) and the other from its spinmeister (Gwande), the NYT has yet to publish objective commentary. Given the gullibility of its editorial page, which bought into Dartmouth doubletalk right from the start, it may never do so. And so, my brief response to the NYT follows:
To the Editor:
Abelson and Harris’s critical analysis of the Dartmouth Atlas unmasks the fact that it cannot be taken as a measure of expenditures in relation to quality, and therefore as a measure of value. Yet we are left to wonder, why are expenditures higher in some geographic regions than in others? The answer is that the Atlas’s geography is the geography of poverty. In some cases, poverty encompasses entire regions of the Atlas, particularly in the south, but more often poverty is concentrated within “poverty zones,” such as south Bronx, north Philadelphia or Watts, where it is masked within the Atlas’s units of analysis by the surrounding affluence. Health care expenditures per capita in such poverty zones are double those of their affluent neighbors, and such spending is not masked. As phrased by a colleague, “one persons affluence off-sets ten people’s poverty, but one poor-person’s health care spending in not off-set by even ten who are affluent.” The same pattern applies to expenditures within particular hospitals. Mayo is wrongly thought to be “efficient,” because its per patient expenditures are lower, but no lower than other hospitals in regions where population density is low and poverty rates are even lower. In contrast, hospitals in Los Angeles, which bear the burden of almost two million poor people, are wrongly viewed as “wasteful.” The lesson is that, while much can be done to improve our health care system, all efforts pale in comparison to addressing the higher expenditures required in caring for the poor.