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H. Gilbert Welch Headshot

Are the Dartmouth data wrong?

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I have never worked on the Dartmouth Atlas of Health Care. However, in the interest of full disclosure: it is the work of many of my closest colleagues - and, in fact, my closest friends. Furthermore, these data have informed both my research and teaching for the past 20 years at Dartmouth.

So naturally I was more than a little shaken when one of my students emailed me the New York Times link, "Data used to justify health savings can be shaky." Many policy experts and commentators quickly responded on the web: pointing out factual errors, misinterpretations and quotations taken out of context.

But it's still the New York Times, right? They must know what they're doing.

The article raised serious questions: Are the Dartmouth data wrong? Is geographic variation in expenditures really just about the cost of living in different regions? Was the case for health care reform made on faulty premises? And the most fundamental question of all: Is there really waste in American medical care?

Yes, Virginia, there really is waste in American medical care.

Geographic variation has been a fact of life in US medical care for decades. Anyone who has looked, has found it. There are dramatic differences in amount of health care used in different regions of the country. And its not about price, its about the number of services.

The fundamental question is to what extent is the observed variation warranted (different areas need different amounts of care) vs. unwarranted (different areas simply have different practice styles). Sometimes the answer is readily apparent. No one would invoke need as an explanation for why doctors in one town in Vermont performed tonsillectomies in children at 10 times the rate of another town 60 miles south. Similarly, no one would argue that elderly men in the Pacific Northwest needed to undergo radical prostatectomy at twice the rate of their counterparts in the Northeast. Instead these differences clearly reflected physician practice styles.

But moving from individual procedures to the intensity of medical care in general makes the question more challenging. While pharmacology researchers can do true experiments to see if a drug works, medical care epidemiologists can't randomly expose some patients to medical care in Miami and others to medical care in Minneapolis. Nevertheless multiple methodological approaches have been developed to isolate unwarranted variation, although the jargon can get pretty arcane: indirect age-sex-race adjustment, Charlson co-morbidity indices, implicit price deflators, longitudinal cohorts, migration get the picture. Frankly, it's understandable why some might see it as a black box - and thus "shaky".

But for more than 30 years my Dartmouth colleagues have subjected their work to the time honored process used to assess the veracity of all scientific findings.

It's called peer review - the process of having the methods, findings and conclusions scrutinized by experts at other institutions. The outside experts are selected by medical journal editors and grant funding agencies for their methodological expertise and their independence from the investigators. And for 30 years the fact of unwarranted geographic variation has passed this test - being published in the world's most prestigious medical journals.

If I had any critique of the Dartmouth approach it would be this: wasteful expenditures are inferred as the difference between high and low spending areas. In this there's a not too hidden assumption: low spending areas don't waste money.

This assumption doesn't pass my laugh test.

There's waste everywhere in medicine, even in the low rate areas. All over the country we are buying expensive new drugs, when less expensive medicines would do just as well (not to mention have a more established safety record). All over the country we are paying the cost of administering multiple insurance programs (not to mention paying the provider's cost of dealing with them). All over the country we are paying to make the most fundamental life events - birth and death - into a routinely medicalized experience. And all over the country we are paying to look hard at those who are well in an effort to find something, anything, wrong. Its enough to make you sick.

It's good to question science, but the fact that questions can be raised doesn't mean the science is wrong. What proportion of health care expenditures are wasteful? 25%? 30%? 35% 33.3%? Let not kid ourselves, there's no one exact estimate. But practicing physicians across the United States know these Dartmouth estimates aren't too high, if anything, they're too low.

Sure, I work at Dartmouth. So don't believe me, ask your doctor.