Dartmouth Atlas’s Skinner on high-cost hospitals
On Tuesday, I wrote about a new Massachusetts Institute of Technology study suggesting that more expensive hospitals in New York provided higher-quality health care. Those results seemed to contradict findings from the Dartmouth Atlas of Health Care, which has produced a stream of research suggesting that more spending doesn’t correlate with better-quality care. So I reached out to Dartmouth’s Jon Skinner, a researcher with the Atlas, to get his take.
Skinner had nothing but kind words to say about the MIT researcher who authored the study, Joseph Doyle, whom he describes as a “Grade-A, stellar researcher.” And he points out that his colleagues at Dartmouth have published research showing that in Canada, higher spending also correlates with better outcomes.
“If you treat the results the way that [Doyle] does, you can identify high-cost hospitals as delivering higher costs,” says Skinner. “But I don’t think that means we should be allergic to cutting any costs.”
From Skinner’s perspective, the two studies are looking at pretty different data. MIT focused exclusively on ambulatory care, looking at what happened when patients ended up in an emergency room. The Dartmouth research, meanwhile, has looked at overall cost of care for specific regions of states. That means, for instance, that the Atlas captures both the economic cost and negative health-care impacts of a patient getting re-admitted to a hospital after a medical error.
“Doyle’s work is about what happens in the emergency room,” he says. “It’s not about what happens in the hospital, post-discharge. That’s things like, are there readmissions? Is this person treated effectively the first time, or do they come back?”
Because the MIT study looks only at data from the emergency room, it’s impossible to know what happens after that initial episode of care and whether the higher spending would continue to translate into better quality.
Skinner also contends that there’s also a bit of a chicken-and-egg situation going on in higher-cost hospitals: Because they have a better track record on outcomes, they’re able to demand more money for the services they provide. That, in turn, may allow for more investment in getting even better — and, again, allow for their prices to rise.
On the flip side, hospitals that don’t earn enough money can certainly see their ability to treat patients impeded. “It’s certainly true that there are some cases where small, poorly reimbursed hospitals have trouble providing quality care because they don’t have adequate staff or finances,” says Skinner. “The irony of the United States system is we’re spending twice as much as anyone else on health care, but some places still don’t have enough.”
Skinner and Doyle did agree on one key point: We’re not going to get better health-care outcomes by simply throwing money at low-cost hospitals to make them high-cost hospitals. Skinner likens that to him being given $1 million, and being told to become a world-class golfer.
“If somebody offered me a huge incentive to be a good golf player, it wouldn’t matter, I just couldn’t do it,” he says. “But if you sent somebody to teach me how to do golf, if I knew what I was doing, then I might have a shot.”
The same, Skinner says, is true for health care: We do have examples of high-quality hospitals providing care at low prices. It’s likely their lessons, rather than lump sums of cash, that will get us to a place where that kind of medicine is the new normal.