Less-is-More Approach Now Under Heavy Fire

John Marcille

An analysis in the New England Journal of Medicine (http://bit.ly/c2keSV) February 18 about how the Dartmouth Atlas of Health Care rates hospitals has caught many eyes. Peter S. Bach, MD, a physician at Memorial Sloan-Kettering Cancer Center, posits that the Atlas uses flawed methodologies in suggesting that less is more. Dartmouth Atlas officials defend their methods in an addendum.

“Say Hospital A and Hospital B each has a group of patients with a fatal disease,” Bach writes. “Hospital A gives each patient a $1 pill and cures half of them; Hospital B provides no treatment. An Atlas analysis would conclude that Hospital B was more efficient, since it spent less per decedent. But all the patients die at Hospital B, whereas only half of the patients die at Hospital A, where the cost per life saved is a bargain at $2.”

In our cover story about disease management one of that industry’s boosters makes a similar point. Ariel Linden, DrPH, MS, a widely published researcher of DM outcomes, says that he is unable to find the extravagant savings that some DM vendors tout.

Linden favors a DM approach where the patient is managed in a primary care setting in an intensive — and expensive — manner. “Whoever said it was going to be cheap? I can’t understand this reasoning. Chronically ill patients are difficult, they’re sick, and they’ve spent most of their lives with unhealthy behaviors.”

Researchers are asking the same thing about hospital care. A University of Pittsburgh study finds that patients live longer at hospitals that offer the most intensive care (http://bit.ly/9LS9Ua).

Is that the choice? Save lives or save money? Managed care will surely be drawn into this debate about where to draw the line.

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