Wednesday, August 12, 2009

Hidden Insight in the Dartmouth Atlas of Health Care

Many quote the Dartmouth Atlas of Health Care ( as suggesting we spend about $700 billion/year on inappropriate non-beneficial care. This approximate number is also supported by the McKinsey Global Institute which demonstrated that other industrial nations spend more per person on health care as their gross domestic product (GDP) increases. They made a graph plotting spending per person on the Y-Axis versus GDP on the X-Axis. The result is a tight curve with all countries bending upward toward the right except for one country that is way above the curve. That country is ours, the United States with excess expenditures of about $700 billion/yr. It should be noted that our results in healthy lives are among the worst.

The Dartmouth map demonstrates that the sites spending the most with no additional benefit, with a few notable exceptions, are our major teaching centers. In the need to perform procedures to generate the necessary cash to cover their considerable overheads, these centers are training our young doctors to do, not to think! It is startling to realize that seats of learning have abandoned their basic principles under their need to tout the latest gadgets to attract patients and meet their needs for funds. Our major medical centers are in a technological arms race with each other. They are in competition for cases that need intensive care units, complex testing and therapies requiring ever increasing expensive technologies. Many great things are accomplished for many patients. However, the ability to discern who will or will not benefit is being lost in many of our great institutions. That is the hidden secret of The Dartmouth Atlas of Health Care.

In the Sunday July 26, 2009 New York Times David Leonhardt wrote, “Even when doctors order costly treatments with serious side effects and little evidence of their being effective, as studies find is common, patients are loath to question the decision. Instead of blaming such treatments for the rising cost of medicine, many people are inclined to blame forces that health economists say are far less important, like greedy insurance companies or onerous malpractice laws”. I believe it would be beneficial if our political leaders would read and reread these words.

Physician fees have to be adjusted on an individual case by case basis. The cardiologist who gets up at 3:00 am to do a cardiac catheterization and stenting for a patient in the midst of a heart attack is doing a fine service saving heart muscle and should be well compensated. The same cardiologist who at 10:30 am is doing the same procedure on a patient with stable mild chest pain (angina) should not be reimbursed because medical therapy has been shown to be equally effective, thus the need to individualize each case.

My suggestion to address this issue of appropriateness is thorough peer review. This review would have as one of their functions, sporadically reviewing cases for the appropriateness of their care. After an initial warning, payment would be withheld for care deemed non-beneficial. Doctors and hospital administrators are smart; they would quickly learn to limit their inappropriate non-beneficial care. Some of the saving could be used to reform the Medicare payment schedule to hospitals so that the massive cost shifting now taking place (see posting The Mayo Clinic: A Model for Appropriate Care, But Can it Survive as Such) need not occur.


Michael Kirsch, M.D. said...

This was a very fine post. You are endorsing comparative effectiveness research to cull out the excessive and unnecessary medical tests and treatments that all physicians, including me, generate. It will create a 'civil war' in the medical community if this effort ever gets airborne. The stakeholders will adopt all legal means to defend their existence. The important Dartmouth data threatens careers and industries. Those who are taregeted will erupt and will make the rowdy town hall meetings on health reform seem like afternoon tea.

Kenneth A. Fisher, M.D. said...

We physicians must learn to individualize each case and use our therapies only for the benefit of our patients. It is now obvious that frequently that is not now happening. Our credibility as a profession is at stake. I believe that sooner our later our colleagues will understand this and accept help from other physicians. Kenneth A. Fisher, M.D.

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