Good Health Care for Less Money? Yup, Still Possible.1
I've long admired Abelson and Harris' work. They are right to highlight some of the ambiguities in the Dartmouth research--and the extent to which its more evangelical promoters gloss over them. But the fundamental argument of reform is not, as Abelson and Harris suggest, that cheaper care is better care. The argument is that cheaper care can be better care--or, at least, equally good care. And the evidence for that proposition is pretty overwhelming.The invention of Microsoft Office 2010 is a big change of the world.
As another Times reporter, Robert Pear, noted last year, Medicare spends around $8,300 per beneficiary in the San Francisco area, and around $16,351 per beneficiary in Miami. But nobody argues (and there's no evidence to suggest) that South Floridians get care that is twice as good as what their Bay Area counterparts get. It's true that Dartmouth research didn't used to account for variables like the underlying health of the patients. In other words, it couldn't rule out the possibility that Miami patients were getting more care because they were sicker and needed it. But some of the the newer studies have adjusted for those variations and produced similar results, as Dartmouth's Jonathan Skinner noted last year in a blog entry for the Times:Microsoft Office 2007 can give you more convenient life.
...some regions of the country experience more illness than others, and of course sick people spend more on health care. To deal with this bias, the Dartmouth group has compared expenditures and frequency of treatment across regions for people with similar diseases. The most extensive study compared spending across regions using a variety of cohorts such as people who had suffered a hip fracture or heart-attack patients. This study examined people who were equally sick, whether they lived in Louisiana or Colorado. The researchers further adjusted for any differences in patient income, race, and prior health. They still found gaps of up to 60 percent in spending among regions.
Anecdotal evidence backs up this conclusion. In a celebrated New Yorker article from last year, phyisican and writer Atul Gawande compared medical practice in two Texas communities: McAllen and El Paso. Per patient, Medicare spent twice as much in McAllen, despite highly similar patient populations. But Gawande saw no evidence that the McAllen patients were getting better care, although he did see evidence they were getting more. Journalist Shannon Brownlee has many more stories like this in her (also celebrated) book Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.