The two scientists go on to point out several factual errors and misrepresentations in the article.  Among the errors: the Times claims Dartmouth data does take into account quality of care; Fisher and Skinner show that the atlas does indeed contain quality data.  The article also claims that “neither patients’ health nor differences in price are fully considered by the Dartmouth Atlas”; the scientists respond that risk adjustments are included in their studies.  As for price, they point out that because their investigations focus on actual measures of utilization, price adjustments are not necessary, though fully price-adjusted expenditure data is also available on the Dartmouth Atlas Web site, just the same. 

Rather than the Times article, which cites “critics” of Dartmouth’s work but fails to present any substantial criticism (or at least none that can hold up to scrutiny) and Skinner and Fisher describe as “superficial,” the researchers urge readers to take the time to read their initial but very thorough responses to the reporters’ questions, which the Times posted as a sidebar. 

In an article that ran in the Dartmouth campus newspaper, Fisher reiterated that the Dartmouth Atlas findings – essentially, hospitals that spend more on high-intensity health care “are less likely to deliver safe and effective care” – remain largely undisputed in the scientific community.  

“All of this research and all the findings they cite [in the Times’ article] are consistent with ours,” Fisher said. “The Times is not helping advance the public’s understanding of what’s going on.” 

Fisher went on to say that the potential remains to save “about 20 to 30 percent of health care spending” if more hospitals engage in “better performance measures, greater accountability and payment systems that reward improved performance.”

Like the scientists at the Dartmouth Atlas, IHA and Iowa’s hospitals are committed to understanding variations in health care delivery for the purpose of ensuring access to high-value health care.

 The New York Times, meanwhile, appears less interested in improving health care and more interested in creating controversy where there is none.

Dartmouth is a natural for this sort of endeavor primarily because it is home to the Dartmouth Institute for Health Policy and the Dartmouth Atlas of Health Care, which have been studying variation in health care delivery and spending for a couple of decades.  But while the Atlas gives Dartmouth the data, the college’s home state, New Hampshire, isn’t exactly a shining example of health care value. 

At more than $7,800 per Medicare recipient per year, New Hampshire spends nearly 20 percent more than Iowa ($6,686).  Of course, that’s not nearly as bad as nearby Massachusetts ($9,568) or New York ($9,995), both of which should provide convenient laboratories for what not to do for value-based health care delivery. 

This is worth noting because of something Dartmouth’s president, Jim Yong Kim, mentioned when the center was announced over the weekend.  According to Associated Press coverage of the story, Kim and state leaders have “discussed using the center to make New Hampshire a model for innovative health care.” 

This brings one thought immediately to mind: Why not Iowa? 

Obviously, Dartmouth has every right and reason to focus on its home state.  But this deserves serious consideration in Iowa, where IHA has made “value” a health care watchword.  Certainly, the tools and the people are there. The Iowa Healthcare Collaborative has united hospital and physician interests under the value flag and, like the Dartmouth Atlas, has become a vast data collector.  

The University of Iowa (UI) and Des Moines University both offer excellent schools of health care administration and medicine with easy access to not only urban medical centers but also nearby rural referral centers and Critical Access Hospitals, many of which are on the cutting edge of innovative health care delivery models.  The schools of engineering at UI and Iowa State, along with major businesses (including hospitals) that have adopted ideas like Lean and the Toyota model of process improvement, offer expertise and laboratories for systems analysis. 

What Iowa doesn’t have is seed money, like the $35 million that was anonymously donated to fund the Dartmouth center.  Perhaps if we can broaden our state leaders’ views on what drives a healthy economy (hint: it’s more than wind turbines and gambling halls) and quality of life (more than good schools and smooth roads) to realize the impact of high-value health care, some investment capital might emerge.

He immediately trots out the tired old arguments about how the high cost of living and large number of impoverished patients drive up health care costs in certain places.  He doesn’t say exactly where those places are, so I’ll assume he means very large cities, like Manhattan, where his hospital is located. 

The problem with this argument is that there are other, similarly high-cost and high-poverty urban areas where health care costs are notably lower.  For example, according to the Dartmouth Atlas of Health Care, which has studied geographic variation in health care costs – specifically in the Medicare program – for decades, hospitals in Manhattan spend an average of $81,143 on each Medicare patient during the last two years of life (at Presbyterian, it’s $91,113).  In Los Angeles, the cost is $77,411.  In Chicago, it’s $62,565.  In Boston, it’s $57,057.  (In Iowa, it’s $33,864.) 

But it’s not just about how much it costs to provide health care, it’s also about how much health care is provided and whether or not it’s necessary.  The first part is about intensity, and one measure of intensity is the number of days a patient spends in the hospital.  In Manhattan, the typical Medicare patient spends nearly 35 days in the hospital during the last two years of life.  In Los Angeles, it’s 28 days.  In Chicago, it’s 26 days.  In Boston, it’s 21 days. (In Iowa, it’s about 16 days.) 

But doesn’t more time in the hospital – more health care – mean healthier patients?  The studies say no. 

Rather than making excuses about high-cost health care, hospital leaders should follow Iowa’s example by learning what creates high-value health care and then implementing it.  And Medicare should recognize and reward that value.

Providers (especially large academic medical centers) in high-cost areas are opposed to this provision, explaining that because they treat sicker and poorer patients and provide medical education as teaching institutions, their costs are inevitably going to be higher than non-teaching hospitals in non-urban areas.

However, a recent Health Affairs study showed that there is no correlation among patient characteristics including race, socioeconomic status or severity of illness that contribute to such huge regional disparities.  The study concluded that, in fact, the opposite is true.

The study showed that hospitals considered to be more efficient (low-cost, high-quality) providers like the University of California-San Francisco (UCSF), Cleveland Clinic and University of Chicago Medical Center are actually treating more black and low-income patients than the less efficient medical centers like New York University Medical Center (NYU) in Manhattan and Cedars-Sinai in Los Angeles.  The study noted that only 4 percent of NYU’s patients and 9 percent of Cedars-Sinai’s patients are African American, compared to 69 percent for the University of Chicago and 28 percent for the Cleveland Clinic.

Removing race from the equation and focusing solely on poverty yields similar results.  The study found “there is no relationship between the number of days patients spend in the hospital and the proportion of patients who are poor” as shown in the chart below.

(The association among academic medical centers between the number of days spent in hospital during the last six months of life and the percentage of low-income Medicare patients.) Source: Health Affairs

These findings certainly counter the providers that continue to rely on their patient mix and demographics to support their inefficiencies and overutilization.  The report also highlights a recent study published in the New England Journal of Medicine that also found that poverty and race had virtually no impact on increases in utilization or cost.

Hospitals in Iowa provide some of the highest quality of care in the nation at some of the lowest costs.  However, Medicare reimburses Iowa hospitals at a much lower rate than other less efficient hospitals that simply cannot continue to justify their waste.

Rewarding efficiency based on true value (high quality, low cost) should remain a top-priority during the remaining debate on health care reform, and once and for all put an end to overpaying for waste and inefficiency in health care, but rather put the resources to a better use and reward those providers that have the best outcomes at the lowest cost.

As many Iowans know, our state’s hospitals spend far less (and receive far less) Medicare funds than most other states.  The Dartmouth Atlas of Health Care has documented that higher-spending hospitals and states are not providing any better care and, in fact, much of that extra spending is simply wasted.  The White House and much of Congress is in agreement, and this is making some high-spending hospitals nervous, the New York Times reports: 

The issue pits hospitals in more rural states like Iowa and Minnesota, where spending tends to be lower, against those in areas like New York City and Los Angeles, and revolves around a question that has bedeviled the medical establishment for decades: how much money do hospitals need to provide adequate care for patients…

Urban hospitals are countering that they serve poorer, sicker patients.  But that does not explain why similar hospitals – such as highly regarded academic medical centers in urban areas – have extraordinary differences.  Take a look at the table below (this information all pertains to Medicare patient averages during the last two years of life): 

These hospitals all happen to appear at the top of U.S. News & World Report’s “Best Hospitals” list and they all serve very urban populations.  Yet the differences are stark and raise many questions.  Why, for example, are patients spending 10 more days at UCLA Medical Center then its sister institution in San Francisco?  Why are 26 more physician visits needed at New York-Presbyterian than Johns Hopkins? 

Now, just for perspective, here are the numbers for Iowa’s major medical centers, along with the overall U.S. average: 

One last thing:  Though it’s convenient from a media perspective, this is not necessarily an urban vs. rural issue.  There are, as the tables above show, urban hospitals that are providing value to the Medicare and there are rural facilities that are extreme outliers when it comes to Medicare spending.  The point is it is time for Medicare, as a health care consumer, to seek out and reward value – wherever it is found.