More on the Dartmouth Atlas, Courtesy of the New York Times

The Disease Management Care Blog has written lots on the good, the bad and the ugly of the Dartmouth Atlas (here, here and here). Now we have an excellent article in the New York Times by Reed Abelson and Gardiner Harris that reviews the strengths and weaknesses of their data. As the DMCB has suspected, it appears that the heady excitement from being quoted by Presidents and Senators may have lead the researchers to sometimes portray their findings as more than they really are. Kudos to these reporters for actually reading the research for themselves.

The Tea Baggers Just May Have a Point About Health Care.....

Back in the 1960s, the Twilight Zone regaled television viewers with fantastic stories from a place between 'science and superstition,' that lay 'between the pit of man's fears and the summit of his knowledge.' Approximately thirty years later, popular culture was introduced to an even more surreal place in the 1979 film The Black Hole. Disney's state-of-the-art special effects portrayed a space environment dominated by a distant, visually compelling and vaguely sinister hyper-gravitational spinning black hole. As testimony to their commercial success, the terms 'twilight zone' and 'black hole' remain instantaneously recognizable today, describing situations where the usual laws of gravity, time and common sense are unpredictably and variably suspended.

Since thirty years have passed, it may be time to recognize another fantastical environment, described in this Health Affairs web exclusive, titled 'Prices Don’t Drive Regional Medicare Spending Variations,' by Daniel Gottlieb, Weiping Zhou, Yunjie Song, Kathryn Gilman Andrews, Jonathan Skinner and Jason M. Sutherland.

Basically, the authors examined critical three factors in the regional variation of Medicare's per capita health spending: 1) the additional money allocated for teaching hospitals, 2) the additional money allocated for the care of the socioeconomically disadvantaged and 3) local differences in the cost of living, which influences pricing of medical services. The bottom line is that when these elements are mathematically 'backed out,' per capita variation in health care spending is only dampened sightly and is still all over the board.

How can this be?

While it's still up to readers to decide if some of the variation can be explained by local poverty and its effect on hospital quality, the Disease Management Care Blog is still struck by Medicare's surreal distortion of the time-space fabric of the health care market universe and how easily the viewer can be sucked into this logic-defying time-space of contractors, DRGs, RVUs, ineffective cost controls, inefficient mainframe-style central planning, political zg zagging, cumbersome denials, attacking the inevitable outliers, provider gaming and a sprawling $911 billion bureaucracy.

There is plenty of blame to go around for this dysfunction and, let's face it, Medicare and Medicaid have led to unparalleled health benefits for the poor and elderly. Yet, persons looking into the distorted market of two to threefold cost differentials with no discernible impact on quality must be puzzled by how the black hole can bend a line of reasoning toward greater government involvement.

The DMCB not suggesting the CMS be cancelled, any more than it can cancel black holes: both are embedded in our time-space continuum.

But it also cautions against tut-tutting those wacky cranky Tea Baggers and their common sense look at 'government style health care.' The cognitive dissonance of 'getting government out of Medicare' belies a deeper reality: once you step outside the Twilight Zone and away from the Black Hole, it's pretty obvious that government's management of the program is not of this earth.

Atlasians vs. Cooperites: Poverty and the Dartmouth Atlas

Dr. Richard Cooper continues to generate controversy on the Kaiser Health News site and in the latest issue of Managed Care Magazine. Of course, regular readers of the Disease Management Care Blog are unsurprised, because they were given a heads up about this tempest in a theoretical teacup, this duel of dons, this locking of learned horns, this wrestling of wonks months ago.

The DMCB efficiently explains.

The Dartmouth Atlas folks are holding firm to their assertion that regional variations in Medicare spending cannot be explained by demographic factors or the regional burden of illness. Since healthcare in many areas of the country cost more and have nothing to show for it compared to cheaper areas, the Atlasians assert this otherwise unexplained discrepancy must be due to subjective patient and physician preferences. These unecessary preferences are bankrupting the country.

Not so says the professor from the University of Pennsylvania. When regional variations in the degree of poverty are superimposed on the local health care systems, it turns out that hospitals in poor areas can't attract the human or financial capital to adequately care for persons with and without Medicare, resulting in greater inefficiencies caring for a much sicker population that needs a lot more health care. The Cooperites believe we are getting our money's worth and punishing these hospitals with reduced payments is foolhardy. Not recognizing this will cause hospitals to go bankrupt and risks having providers refuse to see patients with Medicare.

One reason why Dr. Cooper's perspectives may gain some traction is because smart hospital Boards usually have good relationships with their Congressmen. If they're doing their job, they'll remind their a Representative or a Senator that this is the perfect excuse to secure better funding for the local Deficit Memorial Hospital.

One reason why the DMCB likes Dr. Cooper's perspective is not just because it rings true, but because the Atlasians turned to the 'preferences' hypothesis to explain the 'unexplained' variation. While there may be evidence for the former, the hypothesis that patient and physician preferences explain the rest seems convenient, makes sense but unproven. Dr. Cooper fills the some of the unexplained void by pointing out that regional poverty hasn't been fully accounted for.

Maybe they're both right with an answer somewhere in between, but the DMCB wants to see this statistical skirmishing, this clash of the savants continue.

Tally ho.

Even the Dartmouth Atlas Folks Are Worthy of Some Criticism

Think that publishing results in peer review medical journals should be the the 'proof' you need for your approach, your product or your point of view? That having the data appear in print gives you a golden pass? That by including those scientific reprints in your marketing materials, doubts about your company's value-add should fade away like the promise of a well run Medicare physician pay-for-performance payment program?

The Disease Management Care Blog feels your pain. It recalls an encounter with a health system leader at a holiday reception years ago. After having just published a paper on a successful reduction of costs for a chronic heart failure population, he dismissed it as having a 'voodoo' methodology.

By now, most of us in the disease management/population health business have learned the hard way that getting your positive results 'published' isn't the Easy Button you'd think it is. It is the nature of science to constantly scrutinize, challenge, seek additional insight and to be skeptical. The DMCB concludes there are two sides to this coin: on one side is the oxygen-deprived environment of 'therapeutic nihilism,' where nothing can be concluded and everything can be questioned. On the other is the unsettled 'journey-not-destination' of clinical research that helps us be smarter today than we were yesterday.

Both sides of this coin involve some swordsmanship. And if it's a little guy doin' the skepticizing, the spectacle is all that more richer. Which is why the DMCB found the multi-manuscript on-line Health Affairs jousting between Dr. Richard Cooper of the University of Pennsylvania's Leonard Davis Institute and the self-assured giants at the Dartmouth Atlas so enjoyable. Dr. Cooper used State by State quality measures and physician data to conclude that there is a positive correlation between specialist physician supply and quality. Nonsense sniffs the Dartmouth Atlas folks. Dr. Cooper calls their conclusions about a negative correlation a 'myth.' Dartmouth Atlas says they have 30 years of research on their side and that Dr. Cooper is 'incorrect.'

Much of the parrying is over some relatively obscure brain-aching epidemiologic principles, like the magnitude of correlations, the presence of any confounders and the statistical methodologies. Even the DMCB will need to read these papers several times to gain additional insight.

But, in the meantime, the next time you or a colleague are unsuccessfully trying to convince a group of the merits of your program, the worthiness of your product or the value of your outcomes, keep in mind that even the Dartmouth Atlas folks can get beat up from time to time. Remember, according to Wayne's World, only rock star Alice Cooper deserves to be humbly approached on bended knee with cries of 'we are not worthy!'

In contrast, the rest of us in this business are worthy of being criticized. Let the games continue.

Hat tip: HealthHombre.

The Medical Home and a Preference Sensitive Read of the 2008 Dartmouth Atlas on Tracking the Care of Patients with Severe Chronic Illness

The Disease Management Care Blog likes to troll other sister sites to see what there is to see and came across some commentary here and here and here on the 2008 ‘Tracking the Care of Patients with Severe Chronic Illness’ from the folks at the Dartmouth Atlas. Wennberg and colleagues used the same methodology deployed in prior reports by relying on Medicare claims data from the end of life, but this time applied it to persons with ‘chronic illness,’ defined as congestive heart failure, chronic lung disease, cancer, coronary artery disease, renal failure, peripheral vascular disease, diabetes, chronic liver disease, and dementia. There have been news releases, print media reports and even a 'told you so' commentary from the CBO.

Some of the blog sites linked above make obeisance to Wennberg’s discussion of the “Medical Home.” Interested in knowing whether this was a ‘preference sensitive’ read of the document, the DMCB downloaded all 174 pages. On page 104, there is indeed a 3 paragraph section titled “How physicians may respond.’ It notes patients with chronic illness would ‘presumably’ benefit most from the kind of care coordination under the ‘medical home,’ but (and this is a big but) a) the primary care physicians would need to assemble into networks and b) they’d need to be willing to profile hospitals and use the data to steer patients and c) Medicare would need to execute on shared savings arrangements. The term ‘medical home’ appears 3 times.

How about disease management? While the press releases, print media and sister blogs fail to bring it up, the DMCB fired up the “Search” function in the Adobe reader and found 7 references (mathematically that comes to over twice as many vs. medical home) on the topic. They are pasted below for your reading pleasure. They address a spectrum of care settings and are hardly any less supportive:

• 'Because seriously ill patients are highly loyal to the hospital where they receive their care—as has been shown elsewhere—hospital-specific utilization rates reflect the approach to chronic disease management of the physicians who practice in association with that hospital.'

• 'In the ambulatory setting, for instance, patients with chronic heart failure are routinely hospitalized during acute episodes of the underlying disease that often could have been controlled with better disease management and coordination between physicians.'

• 'More to the point, do patients who receive more supply-sensitive care have better outcomes? Do they live longer? Do they have better quality of life? Such questions have received virtually no attention from academic medicine or from federal agencies, such as the National Institutes of Health, that are responsible for the scientific basis of medicine. With the exception of a few studies of chronic disease management, clinical research that might shed light on the question simply has not been done.'

• 'Care transitions (i.e., “hand-offs”) in particular—between primary care and specialist physicians; between nursing homes and hospitals; between home health care and primary care; and between acute care and hospice and palliative care—are often plagued with miscommunications about the patient’s medical needs and care preferences, leaving patients in the wrong facility or receiving the wrong care. In the ambulatory setting, for instance, patients with chronic heart failure are routinely hospitalized during acute episodes of the underlying disease that often could have been controlled with better disease management and coordination between physicians.'

• 'Over the last 50 years, the nation has invested heavily in such medical resources as specialists, acute care hospitals, intensive care beds, and expensive imaging equipment, much of which is allocated to the management of patients with chronic illnesses. Underlying this investment is the assumption that more intensive management of the chronically ill results in better health outcomes and greater patient satisfaction. That assumption is being challenged by the hospice and palliative care movement, by the growing chronic disease management industry, and by population-based chronic care models that emphasize continuous and coordinated management of patients over time and among sectors of care.'

• 'The cost-sharing provision would create revenue for the provider partner to manage the financial consequences of downsizing its acute care component in the process of creating an organized system. These costs might include the amortization of debts to bond holders and employee buyouts. Savings would also be allocated to pay for the infrastructure required to build organized care, such as the IT systems required, and services for caring for the chronically ill that are not funded under traditional Medicare Part A and B, such as nurse coaches and other key personnel required for active disease management.'

• 'Beginning first with its own physician staff and referring physicians, how would the various components of chronic care management be integrated? A plan would include the specification of new roles for providers in managing chronic illness, perhaps worked out with the support of disease management companies that could help provide some of the missing infrastructure. Special focus would be on filling gaps in care management that result in unnecessary (preventable) exacerbation of underlying disease.'

My read is that Wennberg et al recognize the established positive role of disease management in the care of chronic illness. At the same time, they point out that the medical home also offers distinct advantages, even if the barriers are formidable. They also appear to have independently come to the same conclusion as the DMCB: a combined approach warrants consideration.

The DMCB agrees the Dartmouth Atlas is a critically important document that should better inform the policy debate over the direction of healthcare in the U.S. Let’s hope the politicians, regulators, policy makers and industry leaders closely read the entire document.