replying re: NEJM debate on hospital efficiency and policy

My impression is that the opinion piece, "A Map To Bad Policy: Hospital Efficiency Measures in the Dartmouth Atlas", by Dr. Bach not only questions policies that would identify high and low efficiency hospitals, but also questions the Atlases' methodology of assigning costs to a particular hospital, and the definition of efficiency in the Dartmouth data(paragraphs 3,4,5). I read with interest the response and counterpoints regarding their methodology by Drs Skinner, Staiger, and Fisher in the NEJM. The authors write that the fragmentation of care can make some hospitals "appear so expensive in the Dartmouth data". This question of methodology is separate, but related to, the policy issue of whether or not to reward efficient hospitals. The Times' article brings up a valid point that the methodology of ranking hospitals in the Dartmouth data was questioned. It highlights a healthy debate in the best ways to measure efficiency and costs of care, and that policy makers may be best served by a "buyer beware" approach to healthcare data, i.e. it needs close examination of its methodology, and often can be interpreted in different manners. I disagree with Dr. Gawande's implications that the data that he drew on has not been disputed, and the implication that the Dartmouth data is verified by its decades of citation. Criticism of decades of fundamental findings can be helpful, and I appreciated a debate on the pros-cons of methodology more than reference to the longstanding nature of data. We need look no further than the sea change on the benefits hormone replacement for an example of longstanding data that was eventually seen in a new light-- and may have benefited from an earlier analysis of methodology. I enjoyed the debate and Times coverage. I have the imp! ression that ongoing research will continue to better define hospital efficiency, and policy makers are in store for alternative views on where the best value in health care is found.

 

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