Wednesday, September 23, 2009

The Validity of the Dartmouth Atlas for Health Care

Some authors have asserted that the waste in our health care system based on the Dartmouth Atlas of Health Care is incorrect. The Dartmouth Atlas uses Medicare data from different regions in the United States comparing the cost of care. The assertion is that if high cost regions spent the same as low cost regions for all patients the savings would amount to about $700 billion per year. Critics question this for many reasons:

1) Medicare data does not include non-Medicare patients for which the results could be quite different.
2) Many expenses for Medicare patients are paid for out-of-pocket and supplemental insurance and thus would not be included in the Dartmouth Data.
3) Medicare reimbursement rates vary by region with some low cost regions receiving high cost region reimbursement because of political influence.
4) Hospitals with more private well-insured patients can more readily cross-subsidize their losses from the Medicare reimbursement schedule and thus are less likely to prescribe more procedures.

So does the Dartmouth Atlas of Health Care using Medicare data reflect on how medicine is practiced for all patients or does it give a false sense of what can be saved by having all regions become low cost? Fortunately there is a completely different assessment of the spending for health care per person in the United States versus many other countries. The McKinsey & Company December 2008 Health Care Report compared the amount spent/person versus gross domestic product. Their conclusion, “The U.S. spends far more on health care than expected even when adjusting for relative wealth”. The estimated excess was about $700 billion. It is to be noted that these other countries have better health outcomes than those in the U.S.

Thus the conclusion is inescapable: doctors in other countries take better care of their patients at significantly less cost. They rely more on history, physical diagnosis and clinical judgment and less on expensive tests. I believe the time has come for physicians in this country to assume their share of the responsibility for our excess health care expenditures.


Michael Kirsch, M.D. said...

Nice post, Ken. Every medical test, prescription, consultation, scan occurs because an individual physician orders it. We control the spigot and billions of medical dollars of unneeded care. We don't need Dartmouth to tell us what we all know. There is too much trigger pulling and not enough aiming. Our profession, with a little help from tort reform, could find the money to cover the uninsured, with some spare change left over for comparative effectiveness research.

Doctor Kenneth Fisher said...

I would also add that we need a physician support mechanism to help each other practice a more rational style of medicine. Thank you for your comments, Kenneth A. Fisher, M.D.