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Sarah Palin was right about those death panels, y'know

Okay, so the "standing before a Government Panel, having to defend the life of your baby" is more than a bit hyperbolic, but your creative class betters really do want to cut health care spending by cutting actual care, and they plan to start with the people who depend on Medicare and Medicaid [and the public option too, if that passes].

In his Public Option Undead post below, Lambert linked to this New York Times article criticizing the Dartmouth Atlas. This paragraph struck me:

Dr. Elliott S. Fisher, director of the Center for Health Policy Research at the Dartmouth Institute, said the larger issue was that just because a hospital charges a lot does not mean that it delivers good care. But Dr. Fisher agreed that the current Atlas measures should not be use to set hospital payment rates, and that looking at the care of patients at the end of life provides only limited insight into the quality of care provided to those patients. He said he and his colleagues should not be held responsible for the misinterpretation of their data.

Oh yeah?

Putting out a white paper titled An Agenda for Change, Improving Quality and Curbing Health Care Spending: Opportunities for the Congress and the Obama Administration, authored by Elliott S Fisher and colleagues doesn't constitute even a hint of responsibility for the legislation facing us now? From the preface to the white paper:

Rising health care costs are a major challenge to the American economy, particularly at a time of deepening recession and a renewed commitment to extend coverage to the uninsured. Dartmouth Atlas research on geographic differences in health care delivery and spending points to an opportunity to achieve significant savings in health care costs without compromising health care quality and outcomes. More spending and more utilization do not translate into improved life expectancy for those with chronic illness. The differences in the use of discretionary surgery do not reflect differences in patient preferences and informed patient choice. This paper discusses opportunities for Congress and the Obama Administration to address key shortcomings in our health care system that result in unwarranted geographic variation and uncontrolled growth in health care spending. Success in this effort will not only improve the quality of care, it will make it possible to extend coverage to America’s uninsured without inducing a major increase in health care spending.

This Dartmouth Atlas White Paper was written by John E. Wennberg, Shannon Brownlee, Elliott S. Fisher, Jonathan S. Skinner and James N. Weinstein.

December 2008

Not only does the legislation [all the bills, from HR 3200 onward] contain pilot programs to demonstrate that less care is more for the chronically ill [those hospitals that provide "more efficient care" read: less care are going to be paid more money], it also contains a pilot program [with no-bid provisions, it looks like] for something called "shared decision making" and "patient decision aids", which is essentially a bunch of professionally-produced materials [videos, booklets, etc] that, although they don't explicitly say so, aim to talk patients out of letting their doctors prescribe more expensive procedures when less expensive procedures will [perhaps] do the same job. These measures [it says so explicitly in the final Senate bill] are to be aimed at "preference-sensitive care", which is a phrase from the Dartmouth Atlas, btw.

This is the second or third time I've seen a Dartmouth Atlas researcher using the newspaper-of-record kinds of venues to distance themselves from the actual legislation and I've wondered why. It can't be because they're expecting to profit from the legislation, by any chance could it? And I mean profit as in collecting actual hard cash, not just in having their reputations burnished as pre-eminent policy scholars.

Jack Wennberg [John E Wennberg] belongs to the Foundation for Informed Medical Decision Making that believes in "informed patient choice" and has even trademarked the phrase "shared decision making". And although you'll find that phrase scattered throughout the proposed legislation, as well as the phrase patient decision aids, nowhere will you see it used as a trademark nor will you see either of these phrases attributed to any particular group, but the language and provisions in the bills are straight out of this foundation's writings and Dartmouth group's papers.

Not to mention that Jack wennberg's son David, who is also part of the Dartmouth Atlas group, works for a company called Health Dialog that produces and sells patient decision aids and also uses proprietary algorithms to help insurers figure which of their [potentially expensive] patients to call up and provide "medical decision coaching" to.

Gee, where have we heard of that "proprietary" crap before? Jonathan Gruber and gaussian copulas come to mind.

Health dialog was sold to the insurance company BUPA a couple of years ago for megabucks. David Wennberg is probably already doing well financially as a member of the senior management team of Health Dialog, but I can't help but think that having his company's main products and services written into the law of the land is anything but continued gravy train for him.

Of course, the legislation is written so that the grants for developing these patient decision aids have to go to a non-profit organization, so Jack Wennberg's foundation will probably be eligible for that money, while Health Dialog will make a killing on selling their materials to doctors and hospitals.

Talk about your death panels, yes, they're in the legislation, even if they're only a collection of nudges toward making you want less care, rather than actual sitting panels that you have to stand before and defend yourself from.

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Submitted by lambert on

Except where we had Neil Bush just coincidentally profiting from NCLB with curriculum materials, we've got Dartmouth Atlas cronies profiting from "patient decision aids"? And the "creative class" profiting from the web site, the brochure design, the training....

* * *

Also, a nudge becomes a shove quite rapidly. ALthough it's hard to believe the law would rig the choices so that all the nudges went in a particular direction... Or not.

Submitted by hipparchia on

i meant to put that baseline scenario link in the post and then forgot. thanks.

i'd completely forgotten about neil bush and his cows. and yeah, it does look like the dartmouth atlas and friends are going to profit from the hcr cowpie.

Submitted by cg.eye on

the geeks:

The big idea is this: A person's health doesn't happen all at once; it's a consequence of years of choices - some large and some small, some good and some bad. His book looks at the choices that advances in genomics, self-monitoring, new screening techniques, and collaborative health tools are giving the average patient. The trouble is, there's so much information available that it's really, really hard to interpret it all. What to do? According to Goetz, the answer is to make a decision tree.

How high technologist of them. Chart it, and it's done.

Submitted by hipparchia on

yep, the Chart it, and it's done types have taken over health care 'reform' but i was glad to see all the rebuttals in the comments, ranging from the uber-geeky

Using decision tree is a great way to search for root causes. However health, and the physical processes that define it, is a complex system and acts multicollinear.

It's our western preference to approach issues like this in a deterministic way. Unfortunately this leads to blindsight or suboptimalisation at best.

See also how this can effect cancer treatment at:
http://www.ted.com/talks/lang/eng/david_...

to the ultra-snarky.

The "preventive math" site tells me that getting screened for alcohol abuse will add 40 days to my life. No. It won't.

Crap. There goes my plan to get screened for alcohol abuse every 39 days.

that one is my favorite.

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Submitted by nycweboy on

I think there's some confusion here about the point the Atlas is trying to make versus what the Obama Administration wants to draw from it versus fears of reduced care. The Atlas shows how the omney spent on Medicare doesn't correlate to quality of care or healthcare outcomes: Louisiana, which is one of the highest states for Medicare usage, has some of the worst life expectancy rates, a clear indication of overutilization (similar to what Atul Gawande found in The New Yorker article about Texas). The Obama Administration is arguing that you can use information like that to determine better ways to set Medicare reimbursements; perhaps, but that tends to miss the point: the problem has to do, more broadly, with the incentives created by fee for service, and until that's addressed, you would, as the Dartmouth team suggests, be penalizing good care. And yes, this does come down to what care is necessary... but Medicare overspending is not, ultimately, about refusing end of life care or procedures that could extend life... it's asking why people near death are in hospital, having tests and unnecessary procedures. There's a lot of waste to be examined before we get anywhere near anything like looking at end of life (which, to remind everyone, Sarah Palin was utterly wrong about anyway) care and decision making by individuals about how they want to be treated. The Dartmouth Atlas is an imporatt, key study to understanding the problems with health care policy in the US. It would be a shame to dismiss it based on complaints by doctors who have a vested, monetary interest in not seeing reforms in Medicare that would make the program more financially sound.

Submitted by hipparchia on

I think there's some confusion here about the point the Atlas is trying to make versus what the Obama Administration wants to draw from it versus fears of reduced care.

not on my part.

The Atlas shows how the omney spent on Medicare doesn't correlate to quality of care or healthcare outcomes: Louisiana, which is one of the highest states for Medicare usage, has some of the worst life expectancy rates, a clear indication of overutilization (similar to what Atul Gawande found in The New Yorker article about Texas).

no, it's a clear indication that old people in louisiana are more expensive than old people in some other areas of the country.

The Obama Administration is arguing that you can use information like that to determine better ways to set Medicare reimbursements; perhaps, but that tends to miss the point: the problem has to do, more broadly, with the incentives created by fee for service, and until that's addressed, you would, as the Dartmouth team suggests, be penalizing good care.

canada, france, japan all have systems that utilize fee-for-service at least as much as ours does [and probably more], so that's a bogus talking point and it serves the interests who want to keep prices high and control spending by lowering utilization. international comparisons are tricky, but indications are that our utilization, even in the 'profligate' medicare system, is lower than other countries.

the dartmouth team has been talking out of both sides of their mouths basically on on whether and what payment reforms would or would not penalize good or bad care [and yes, this sentence, while grammatical, makes little sense, much like the dartmouth team's weasel words on payment reform].

yes, if we had really good electronic records and used them correctly we could probably identify patterns of over-, under-, and mis-utilization of care, but the dartmouth atlas methodology is useful for broadly calssifying geographical areas by spending, but it is really really crappy for investigating and confirming the WHY of the spending variations.

And yes, this does come down to what care is necessary... but Medicare overspending is not, ultimately, about refusing end of life care or procedures that could extend life... it's asking why people near death are in hospital, having tests and unnecessary procedures.

there are recent papers in the peer-reviewed literature suggesting, among other problems, that the dartmouth atlas methodology has [1] significantly overestimated utilization; [2] significantly overestimated spending in the highest-cost ares; [3] inadequately measured positive outcomes; [4] inadequately measured 'quality'; [5] inadequately controlled for degree of illness. that's not a comprehensive list of all the criticisms btw.

There's a lot of waste to be examined before we get anywhere near anything like looking at end of life (which, to remind everyone, Sarah Palin was utterly wrong about anyway) care and decision making by individuals about how they want to be treated.

sarah palin was both right and wrong on the end-of-life counseling: the intent behind the end-of-life counseling provision was originally a humane one. it is something that should be provided and paid for and many patients would welcome it, and yes, many patients would prefer to not be subjected to heroic measures and intensive care and dying in the hospital. but for now, the rise of palliative care/hospice/end-of-life counseling suffers from the same range of badly- and well-utilized services and some of the same perverse monetary incentives that the rest of our [non]system suffers from. iow, convincing people to die [and then caring for them] somewhere other than in the icu is becoming a booming business.

the biggest driver of waste, in human lives for sure, and in money too probably, is the insane administrative tangle that has grown up around the for-profit insurance and hospital industries.

as a lifelong 'consumer' of expensive medical care i can tell you from personal experience that hospital cleanliness standards used to be pretty good but are now verging on abysmal. the same for would care. the rise in the number of medical personnel hasn't really kept pace with the population increase, but the number of administrative persons has skyrocketed [i used to have a link for this, can't find it now], and i'd venture to guess that the number employed to mop the floors and do laundry has dropped significantly. the readmissions for [and deaths from] hospital-acquired infections has risen abominably, and i'd venture the opinion that hospitals are skimping on the cleaning personnel [and supplies] and maximizing the admin personnel.

but the layers of bureaucracy don't involve hiring just an army of low-paid clerks, it's sucking up more and more time that doctors and nurses should be spending with patients, not arguing on the phone with insurers. we're already somewhere near the bottom of the international list for number of doctors per capita and near the top for unhealthy people, but one of the insane conclusions drawn by the dartmouth group is that we have too many doctors now and need to reduce those numbers.

The Dartmouth Atlas is an imporatt, key study to understanding the problems with health care policy in the US. It would be a shame to dismiss it based on complaints by doctors who have a vested, monetary interest in not seeing reforms in Medicare that would make the program more financially sound.

agree with you that we should not buy, unexamined, the complaints of some greedy docs [and hospital execs], but after poking around in the dartmouth atlas data and papers for a couple of years now, i think they've managed to demonstrate only one thing: that there are both expensive and not-so-expensive populations of old people in the country. their attempts to account for the spending differences appear to strongly reflect the researchers' ideological positions and reflect reality less strongly, and furthermore, they just plain appear to be methodologically unsound. early on, jack wennberg made some good discoveries, but over the intervening years, it looks like the dartmouth researchers have devolved into a bunch of dweebs who are in love with their mathematical models.

speaking of those who stand to make money, both shannon brownlee and maggie mahar have written books blaming our poor quality and high costs on overutilization, and both used the dartmouth atlas as their basis for their theses, and therefore they probably both have a vested interest in the dartmouth group's being held up as a primo go-to source on health care policy. just sayin'.

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Submitted by nycweboy on

it's a clear indication that old people in louisiana are more expensive than old people in some other areas of the country.

Okay... but why? Is Louisiana that exceptional? Does some aspect of providing or accessing care justify that level of expense? If so... why do people seem to struggle to come up with a good explanation? And why ignore the most obvious explanation - which carries over to the state's problems with Medicaid - that there are significantly higher levels of fraud and abuse of the payment systems?

canada, france, japan all have systems that utilize fee-for-service at least as much as ours does [and probably more], so that's a bogus talking point and it serves the interests who want to keep prices high and control spending by lowering utilization. international comparisons are tricky, but indications are that our utilization, even in the 'profligate' medicare system, is lower than other countries.

There's almost no apples-to-apples comparison of either utilization or payment methods between us and any of those countries you cite; that's the argument, which I agree with, for moving to single payer. Our utilization is theoretically lower in a system which penalizes many people for doing just that. And our utilization is probably higher than others, given that we encourage medicalizing many problems that should probably not involve doctors, hospitals, or, say, emergency rooms. Almost everyone looking at this suggests that if we expand the availability of insurance the first thing that will happen is more utilization, based on pent up demand. And the bottom line is... we have a fee for service problem, that stems from Medicare's model, which serves as the basis for private insurance. I have no interest in keeping prices high; but the combination of profit motive and a system that rewards doing more service with more money creates the incentives that cause the problems we have. That doesn't seem hard, or complicated... or bogus.

sarah palin was both right and wrong on the end-of-life counseling: the intent behind the end-of-life counseling provision was originally a humane one. it is something that should be provided and paid for and many patients would welcome it, and yes, many patients would prefer to not be subjected to heroic measures and intensive care and dying in the hospital. but for now, the rise of palliative care/hospice/end-of-life counseling suffers from the same range of badly- and well-utilized services and some of the same perverse monetary incentives that the rest of our [non]system suffers from. iow, convincing people to die [and then caring for them] somewhere other than in the icu is becoming a booming business.

If Sarah Palin had anywhere near the nuanced take you present here... then yes; she doesn't, and I think that's been well borne out since she made the absurd "death panels" claim. End of life care - like ICU care - is expensive; thus, it wouldn't be a huge surprise that insurers are trying to drive decisions away from it; obviously, that's deeply troubling. But still. We want to encourage more thinking about end of life care, not less, ask questions about heroic measures, and make a reasonable point: even with heroic measures, many patients won't survive. One of our biggest problems in healthcare is that many Americans don't understand, or necessarily like, science - especially when scientific research doesn't bear out our emotional, often anecdotal, instincts. We don't want people to die; we want to believe that any and all options should be explored rather than admit defeat and let death come. And sometimes, it makes sense to try... but when it doesn't... we should also face that. This is hard stuff. At the very least we should have these discussions in public, and out loud. That, more than anything, is the kind of conversation Sarah Palin's statement was meant to cut off. So yes... wrong, and absurd.

after poking around in the dartmouth atlas data and papers for a couple of years now, i think they've managed to demonstrate only one thing: that there are both expensive and not-so-expensive populations of old people in the country. their attempts to account for the spending differences appear to strongly reflect the researchers' ideological positions and reflect reality less strongly, and furthermore, they just plain appear to be methodologically unsound. early on, jack wennberg made some good discoveries, but over the intervening years, it looks like the dartmouth researchers have devolved into a bunch of dweebs who are in love with their mathematical models.

I disagree; it's not the populations that are expensive... it's the geographies, and what's going on in them: why is New York so expensive for Medicare? Could is be a glut of hospital beds in New York City and traditional practice models that encourage more stays of longer duration and more procedures? Why can't Florida seem to develop any economies of scale? It's easy to dismiss "mathematical models" as cold, but... that's the point of data and scientific research. You go where the data takes you, and then you see where you are. I don't know that we're actually that far apart in the end: I think the Dartmouth Atlas is valuable data... but shouldn't be used, as many want to, to extrapolate too much about what would work better. What it tells us is why what we're doing now doesn't entirely work; finding out what will work better... will take more, and different types of work. We will struggle to measure "quality" and "outcomes" because, outside of surgical procedures, those questions are hard to define. What's a "best outcome" in the treatment of depression? How long does it take? What defines "quality care" of schizophrenia? Of recovery from a brain injury? What's the "best practice" for rehabilitation from a stroke? This isn't simple, and I'd agree, we can't leap to institute policies that try too hard, and too fast, to regulate medical care when we're still learning what works. But where we do know things - about overutilization, about excessive use of unnecessary procedures, about practice models that can, and should be changed - why not try to move the needle? The Dartmouth Atlas, for its flaws, does give us data that helps us figure some of that out. And I think it's unwise to dismiss it entirely. Or to give those who oppose its most basic observations about excessive spending to much credence in ignoring what it says.

Submitted by lambert on

.... or people in their personal networks are now running businesses based on the ideological conclusions drawn from this (flawed) study is a huge red flag.

Submitted by hipparchia on

although i was wondering about their data and the conclusions they were drawing long before i knew of the possible business entanglement.

nycweboy's picture
Submitted by nycweboy on

I would agree... but the fact that they're very open in sharing the Atlas itself tends to mitigate some of it, at least for me. And I wouldn't necessarily disagree that a researcher with a profit motive is to be looked at with some skepticism (however, I worked in medical advertising, and it's safe to say that almost everyone is a bit dirty under this standard). I'm not sure that makes the Atlas itself suspect, but I don't look to the Atlas researchers for policy solutions. As I said, I think their strength lies in defining and providing scope to our understanding of the problems in American healthcare. Beyond that, I take their suggestions with a serious grain of salt.

Submitted by hipparchia on

I don't look to the Atlas researchers for policy solutions.

it doesn't matter if you do or not [although various pundits told us to]. the president and congress did, and dartmouth group put themselves forward as policy experts in areas where the bills are [perhaps] going to benefit them.

and furthermore, it's not even good policy that they're putting forth.

Submitted by hipparchia on

It's easy to dismiss "mathematical models" as cold, but... that's the point of data and scientific research. You go where the data takes you, and then you see where you are.

yep. i've got degrees and experience in stuff like biostatistics and mathematical modeling and geospatial analysis. that's how i got interested in the dartmouth atlas in the first place, all the pretty maps, and the scads of data.

Okay... but why? Is Louisiana that exceptional? Does some aspect of providing or accessing care justify that level of expense? If so... why do people seem to struggle to come up with a good explanation? And why ignore the most obvious explanation - which carries over to the state's problems with Medicaid - that there are significantly higher levels of fraud and abuse of the payment systems?

first off, they state right in one [and probably more] of their papers that yes, the people in louisiana are sicker than the people in colorado, so this is going to account for part of the difference in spending. and yes, some populations really are sicker than others, even the dartmouth group says that.

what else? you mention fraud, and as it turns out, the dartmouth group didn't take this into account in any of their calculations. so yes, i can readily believe there's fraud, even rampant fraud, in louisiana, but that doesn't necessarily translate into more care, since providers could be submitting totally bogus bills without providing any of the care they bill for. this is, in fact, quite possible, as the record-breaking medicaid and medicare fraud cases in miami and los angeles [two 'high-spending areas, according to dartmouth] have demonstrated. i don't remember the details about los angeles, but in miami, the fraudsters were submitting bills in the names of doctors who had been dead for years, so you know those doctors were providing zero care [and i'm not sure what you mean about florida not being able to scale, does this answer your question any?]

speaking of billing, did you know that most of the dartmouth atlas is built from billing data, and that the researchers only inferred from the billing claims what treatment the patients got? for most of their work, they didn't actually look at treatment data. in one of comments on the nejm article cirticizing the dartmouth atlas, there's this:

Second, the measure of hospital volume as hospital days, when Medicare pays by PPS, is bizarre. Third, conclusions about the Cleveland Clinic’s organizational superiority miss the fact that the Clinic’s costs in the study are nearly identical to those of University Hospitals, a mile (at most) away, which was organized very differently. It’s Cleveland, not the Clinic’s structure.

the point about cleveland doesn't quite fit into the discussion of billing here, but it was in the comment and it supports the idea that spending varies by population [yes, i know, it can also be used to support the idea that spending varies by "practice"]. anyway, medicare pays hospitals, in large part, on the prospective payment system [pps], which means that if person abc goes in for treatment xyz, medicare automatically assumes they'll need to stay in the hospital for 6 days. if person abc gets well quickly, they might go home after 4 days, or if they linger on, they might end up staying for 7 days, but how would you know this from the billing data? answer: you don't. this introduces another source of error into their estimation of how much care people are getting.

one more thought on louisiana. over the past couple of decades or so, the average length of stay in the hospital here in the us has dropped from about 10 days to about 5 iirc. this is due in part to a lot of improvements in the way we do things, but still, some people just need to stay in the hospital for days or weeks longer than the average person. medicare's pps isn't set up for these people, and most hospitals now aren't either, so now those patients are transferred from the hospital at the end of their 6 days or whenever to longer-stay hospitals [which are often a hospital-within-a-hospital] and as it turns out, medicare pays these hospitals a percentage more than they would have paid for the same patients to stay extra days in the normal hospitals. turns out there are a fair number of these special hospitals in louisiana. we know that the people there are sicker, so the population can probably support at least some of these hospitals, and now the question becomes: does the extra payment attract more of these hospitals than are necessary? given that at least some [maybe all, i forget] of these hospitals are for-profit, the possibility for it is there. certainly the incentive is. meanwhile, there was an article on these hospitals in the nyt recently, an expose of sorts, suggesting that these hospitals are taking [sometimes grievous] shortcuts in patient care. did the dartmouth group take either of these confounding factors into account then calculating how much actual care that patients in louisiana are getting? i dunno.

new york. nyc has a bunch of top-notch academic medical centers, aka teaching hospitals. medicare gives grants to these hospitals to train brand new doctors. lots of grants. turns out, the dartmouth atlas calculations for new york [and other teaching hospitals] were adding these grants in as part of the total expenses of treating patients in these places. probably these grants should be counted as something that benefits all the rest of us [we get more trained doctors] and not counted as elderly new yorkers are soooo much more expensive. when you redo the calculations without these grants factored in, spending in new york [and some of the other areas] drops by 20-40%. this still leaves new york somewhere near the head of the pack in spending, but they're no longer out in the stratosphere.

ok, it's getting late, this comment is way too long, and i've still got stuff to say about el paso-mcallen-harlingen, detroit, san francisco, and rochester mn, home of the much-vaunted mayo clinic. not to mention that there's still more on ffs vs pps. later, dude.

Submitted by lambert on

"... what treatment the patients got?"

That's a humongous methodological flaw, and surely somebody (other than you, Hipparchia) has pointed it out?

A billing classification (coding) system (taxonomy, ontology) is not at all the same as a medical classification (coding) system (taxonomy, ontology). (Imagine trying to reverse engineer the blueprints of an automobile from the billing records of an auto mechanic's shop!)

Mapping from one ontology to another must be done with formal, documented methods, and is extremely difficult and expensive, and even then, there will be a residue of material that is not mapped. (And that's even before we get into the issues of whether medical billing coding maps consistently to medical treatment across institutions and jurisdictions.)

Hipparchia, is there any sign at all in the Atlas methodology that such mapping was done?

Submitted by hipparchia on

they make 1- or 2-sentence references to this in their papers and reports. if they've published a report or paper describing in detail how they did it, i haven't run across it yet. but...

  • - they appear to have over-estimated both the spending and the actual care in some of the high-spending areas [cf the fraud estimates and teaching center grants mentioned above].
  • - they assert that ~30% of spending variation results from possibly-unexplained geographic differences; medicare recently did a study that suggests this variation might be more like 20%.
  • - they assert that poverty level doesn't adequately explain spending variations, but richard cooper says that the methods they used to measure poverty are faulty.
  • - they assert that the levels of healthcare spending by the private sector closely mirror the levels of medicare spending, so therefore we can use medicare spending to estimate the amounts of care that everybody in the nation gets [cooper calls bs on this too, and a cursory examination of publicly available data on the web, from reputable sources, suggests that he is right and they are wrong].
  • - they assert that more care translates to worse outcomes, but that study done in california that was published recently suggests that more care leads to better outcomes [i think i linked to it in one of my earlier posts]. heck, just poking through their own data, what they've made available on the web anyway, suggests that more care leads to better outcomes [but my mad statistical and modeling skillz are rusty and i haven't yet figured out how to get hold of some of the kinds of data that would be needed for proof of that].

all of which suggests that maybe somebody should also take a closer look at how they've been mapping billing data to treatment data.

Submitted by lambert on

This is a huge methodological issue!

NOTE In a way, using billing data as a proxy for treatment data replicates the conceptual difficulty at the heart of the issue: Confusing health insurance with health care.

Submitted by hipparchia on

bingo!

otoh, just because i haven't discovered an in-depth report or paper yet doesn't mean it doesn't exist. case in point: it took me months to track down the paper where they go into greater detail linking more care --> greater mortality. after reading it and digging through the appendices, i think their methodology still sucks on that one, but i'm just a blogger with too many cats so now i have to track down something in the peer-reviewed literature [most of which is behind very expensive paywalls dammit] to use for rebuttal.