World Socialist Web Site wsws . org An interview with Dr . Richard Cooper , critic of the Dartmouth Atlas of Health Care research

Content Provider	Semantic Scholar
Author	Laurier, Joanne
Copyright Year	2013
Abstract	Dr. Richard Cooper, a professor of medicine at the University of Pennsylvania, is a proponent of health care reform that addresses the needs of low-income families and a critic of the Dartmouth Atlas of Health Care. JL: Could you touch on some of your differences with the Dartmouth studies? RC: There are basically two problems with the Dartmouth group’s approach. One is methodological and the other is ideological. Although they are quick to point out that they have published 100 papers, these are based on only a few methodologies—and each is flawed. I’ll get into what’s wrong with their methodology later. But even if they were right, they’re burdened with another problem—ideology. It’s not unusual for policy research to be burdened in this way. In the case of Dartmouth, it’s to an extreme. And, worse, through Peter Orszag, director of the Office of Management and Budget, their ideology has become the cornerstone of health care reform. It was John Wennberg and his associate, Elliott Fisher, who led Orszag and others to believe that studies of geographic variation prove that doctors and hospitals over-treat and over-charge, to no benefit. And it was they who proposed the 30 percent solution, claiming that the money needed for health care reform was easily available—no new taxes would be required (as President Obama had promised). If only health care were “more efficient,” the nation could save 30 percent of health care expenditures, $700 billion annually. And to create that “efficiency,” all that was needed was to force all providers to function like the Mayo Clinic (which cares predominantly for white, middle-class patients) and to utilize more primary care physicians (which Mayo doesn't). That’s what I call the sin of commission—the tragedy of misleading the process of health care reform. There’s a second sin—the sin of omission, or obfuscation. It’s not simply that the Dartmouth work on geographic differences is methodologically wrong and its conclusions incorrect, nor simply that its policy implications misdirected health care reform. It’s that there is another explanation for the geographic differences, which has to do with differences in the distribution of poverty. So all the while that they talked about saving money by reducing wasteful geographic variation (by providing less care where it’s actually needed), the fundamental needs of the poor and the large added costs of caring for them were ignored. It’s actually worse. Poverty was denied, because it couldn’t be both ways. Either the Dartmouth group was right and the high costs in some areas were because of too many specialists and hospitals doing too many unneeded things, or this higher spending was due to the added costs of caring for the poor. The truth is that it is the latter. Therefore, the only way to really save money is to make a long-term commitment to ameliorating the high health care costs that are a result of poverty and other social determinants of disease. Not that there aren’t inefficiencies. But physicians have been dealing with inefficiencies as long as I’ve been a doctor—which is 50 years—and certainly before that. As medicine evolves, there are always more inefficiencies to deal with, but as fast as we deal with them, new ones emerge. So constant diligence is necessary. But is medicine more efficient than in 1960? You bet it is. And is poverty a bigger problem for health care spending now than it was then? You bet. We seem to know how to make things more efficient. But as a nation, we aren’t very good at reining in poverty. It just grows. JL. What’s wrong with Dartmouth’s methodologies? RC: In the beginning, nothing. The Dartmouth group, or at least John Wennberg, started out in the 1970s by looking at practice differences among physicians or physician groups within and between cities. One group of doctors may treat a disease one way, another group another way. This tends to occur most often with diseases where nobody knows which treatment is best—prostate cancer, for example. There are a half a dozen ways to treat prostate cancer. It’s treated differently by different physicians and in different locales. It was very important for Wennberg to point this out. It made people more conscious of such differences and undoubtedly emboldened health care leaders to look for ways to minimize such differences. That’s where practice guidelines came from. Wennberg encouraged a new way of looking at things. Not that studies comparing treatments hadn’t been going on. One example is the national cooperative cancer research groups that began in the 1960s. But Wennberg helped to create a culture that’s lasting. Then things began to go wrong. Wennberg and his colleagues wanted to connect these observations to population health, spending and outcomes. That’s real health policy. And to do that, they needed larger units of analysis and a broader set of medical conditions. And, so, studies of geographic variation in health care were born. The fundamental problem with studying geographic differences is that poverty is geographic, and poverty is the major factor that influences population health, health care costs and outcomes. Low-income patients are sicker, they cost more and their outcomes are worse. The Dartmouth group uses three different levels of analysis. One is hospitals, and we know that some serve poor populations. A second one is states, and we know that there are rich states, like Massachusetts, and poor ones, like Mississippi. But it’s more complicated than that. Some states, like New York and California, are wealthy on average but include areas of dense poverty. The third level is made up of about 300 hospital referral regions in which most of the patients use hospitals in the region most of the time. These are the building blocks of the Dartmouth Atlas. But averages can be
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