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replying re: NEJM debate on hospital efficiency and policy
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| Written by Barrett Levesque |
| 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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from health care summit comments
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| Written by Barrett Levesque |
| on prevention:post on huffington post - Jay Bhattacharya, a Stanford Health Policy Professor and health economist
If there's one area where both Pres. Obama and the Republicans seem to agree is that one key route to reducing health care costs is to increase the amount of disease prevention. It is true that there are many worthwhile preventative care interventions that ought to be applied more widely (both among children and adults). The unfortunate fact is that, according to the health economics literature, even if we expanded prevention substantially and according to the best available evidence, total health care expenditures would not decrease and in many cases would increase.
This is for two reasons. First, preventative interventions, by their very nature, needs to be applied to a broad population to be effective. Most of that population will derive little benefit from those interventions because they would never get the disease even in the absence of the interventions. Childhood vaccines are a good example of this. Of course, the extent to which is true depends on the particular intervention being considered, but the principle applies to all preventative activities. In order to prevent one person from getting sick, we need to apply the intervention to more than that one person. This fact greatly increases the costs of prevention.
Second, no matter how successful prevention is in reducing disease, no such intervention confers immortality. Everyone will eventually die of something. This obvious point has an important corollary, which is best illustrated with an example. Suppose we could find a way to prevent cancer entirely. Such an intervention would without a doubt increase the incidence of heart disease since more people would be alive to get heart attacks. This consideration is obviously most important for prevention applied to older people. In some simulation work that I have done, I have found that even if we found a way to prevent all cancers for free (and we are far from such an incredible technology), Medicare costs would fall by only a small amount.
None of this should be taken to mean that we shouldn't expand prevention. It's just that the benefits of such an expansion, which in some cases could be considerable, will not come for free. |
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Growing Gtube
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| Written by Barrett Levesque |
| Fellows- You are looking for web training videos-- looking for job opportunities-- or are you a resident interested in checking out GI fellowship programs-- we are the website poised to grow as a complement to your networking, media sharing, and education.
Sign up! We are growing, and each fellow can have a significant impact on the shape of this site-- "of the gastroenterology fellows, and for the gastroenterology fellows"..
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