Comments on: The Dartmouth Atlas Controversy

By: The Right Takes Up Dartmouth Debate | Kaiser Permanente Health Insurance Help

Mon, 14 Jun 2010 03:20:34 +0000

[...] John Goodman compares the debate to that over public education, and says: I think the work of Elliott Fisher and Jonathan Skinner is very important. But behind the very public to and fro about their work is a very important policy issue that all sides allude to and none are confronting directly. To wit: Can we (meaning the government) use statistics on Medicare spending to force the health care system in general, and Medicare providers in particular, to deliver more efficient, higher-quality care? [...]

By: TGGP

TGGP — Sun, 13 Jun 2010 05:39:00 +0000

Have you read James Q. Wilson’s “Bureaucracy: what government agencies do and why they do it”?

By: John R. Graham

John R. Graham — Thu, 10 Jun 2010 16:51:23 +0000

I like the comparison to government schools as well, but I can go one better. Where does the government have an even greater monopoly, along with the added benefit of unquestioned constitutional authority to exercise it? Plus a culture of shared values unequalled in our society and a degree of central command and control reinforced by punishment unacceptable to most of us?

The answer, of course, is the military. But nobody would assert that every infantry regiment operates with the same “quality” as every other infantry regiment in the Army, nor that every destroyer operates with the same “quality” as every other destroyer in the Navy, etc. These units are bound by rules and regulations, but the result is not equal outcomes. It comes down to leadership, which can never be equally distributed.

By: Alyn Ford

Alyn Ford — Thu, 10 Jun 2010 12:35:14 +0000

John, great post here… Given a patient’s hospital stay is defined by a few very important events separated by vast expanses of nothing valuable (TV watching, wandering around, etc…), I think there is an argument that iterative clinical efficiencies could be easily eclipsed by simple operational improvements. Hospitals, after all, can be likened to extremely inefficient factories (raw goods in are ill patients… finished goods out are healthy ones)… But they are silo’d and the awareness of one care provider’s actions and status is often a mystery to the others in the hospital. I’ll bet an operational transformation could not only greatly eclipse the fiscal benefits of iterative clinical improvements but could actually sustain or advance clinical quality. Without a quantum change in the operating efficiencies of hospitals generally, quality will inevitably decline.

By: H.Carroll

H.Carroll — Thu, 10 Jun 2010 02:46:24 +0000

The simple truth is that none of these references to cost and value studies and measures has much meaning at all in the absence of a valid external, objective metric for measuring what the heck any medical procedure “costs,” let alone figuring what it is “worth.” Bill masters and Medicare schedules are worthless tools for establishing how any delivery system, methodology, practice model, or other reimbursement scheme actually produces in savings or relative efficiency. The only thing that can do that is “fixing the background metric” to borrow a physics analogy. A more-or-less free market system wherein balance billing is a “normal” feature and there is price rationality, transparency, and consistency is the only mechanism that I believe can provide this in the absence of totalitarianism in medical care (universal provider), which is what “Medicare for all” would be, and where ObamaCare leads us to.

By: David R. Henderson

David R. Henderson — Wed, 09 Jun 2010 21:33:22 +0000

John,
Touche.
Best,
David

By: Charles H. Keys

Charles H. Keys — Wed, 09 Jun 2010 21:00:51 +0000

I couldn’t resist sending this hyperlink to you. Another example of responsible leadership and management in the health insurance industry – I think not - blue cross further demonstrates their arrogance! See that’s why health insurance continues to rise and rise (I’ll admit to this being one of the reasons) for the consumer – to further the greed of insurance company leadership. I believe this salary beats Aetna, Humana, United Health and most of the others.

By: Frank Timmins

Frank Timmins — Wed, 09 Jun 2010 20:28:33 +0000

Linda Gorman writes,

“So much for the Dartmouth and ObamaCare claim that higher health spending is simply wasted.”

I don’t know that they (Obama and the ilk) are not telling us what they really believe in this situation. In their world anything spent over the specified budget is “a waste”. I don’t think decreased mortality that you note in the higher spending facilities is a consideration for the Leftists.

By: John Goodman

John Goodman — Wed, 09 Jun 2010 20:26:57 +0000

Response to David Henderson: Good catch, but you’re not quite right. The four or five largest school districts in Texas probably spend the most per student and probably have among the worst results. But this doesn’t mean that there will be a negative correlation between spending and results for the 1000 + districts statewide.

Response to Chuck R: I do not regard common sense buying as telling doctors how to practice medicine.
Steering employees away from high-cost, low-quality institutions is common sense. But that’s not the same thing as figuring out how to replicate excellence.

By: Chuck R.

Chuck R. — Wed, 09 Jun 2010 20:01:40 +0000

One significant error in this post. There has been SIGNIFICANT demand-side impact on the health care supply chain in at least four of these markets: Rochester, Portland, Asheville and Everette…and likely some of the others. The best results in health care happen when the buyer is clear about the value they want to buy, and works collaboratively with suppliers who organize to reduce waste and align processes to value creation. Sometimes, health care leadership is strong enough to drive superior value without reciprocation from purchasers, but those providers will be the first to tell you that it is far more sustainable to have purchasers reward quality and value with their benefit policies. And, in other markets, employers are pushing for value and–finding it lacking in their own market–they seek it elsewhere. A very recent example is the reasonably high-profile move of an employer group in Las Vegas, telling local hospitals it would transport employees to Utah to get care if they could not figure out how to improve quality.

Do not count employers out. When they manage their supply chain, they are very, very powerful.