The New York Times changes the Dartmouth Atlas narrative

Several have asked me to comment on the New York Times versus Dartmouth Atlas spat.

In summary, the Dartmouth Atlas comprises of studies showing variation in care for Medicare recipients.  Their main, take home message is that high-spending areas of the country sometimes had poorer outcomes than lower-spending ones.

Their work has been influential with the current administration, and among progressive health reformers.  Last week however, the New York Times published a front page story critical of their conclusions.

Predictably, left-leaning bloggers, like Matthew Holt, Jonathan Cohn, Kevin Drum, and Maggie Mahar, were critical of the Times’ piece.  Mr. Holt, for instance, called it a “dreadful article.”

I’m not a policy maven, so I’m not going to comment on the specifics.  Read the Times’ piece, then the Dartmouth rebuttal, and come to your own conclusions.

I will, however, comment on how this affects the overall narrative — which is what’s important in the end. Face it, most of the public aren’t astute health policy analysts, rendering the point-counterpoint debate between the Times and Dartmouth largely inconsequential to most people.

But progressive commentator Kevin Drum made a comment that caught my eye:

By the time their piece is done, they’ve basically only got two things left. First, the Dartmouth researchers admit that, on occasion, they might discuss their findings more broadly than they should when they’re talking to a lay audience. Second, there are individual bits and pieces of their dataset that other researchers have disputed. Just as there are with any large, complex dataset.

I actually think the first point cannot be dismissed.  Narrative matters to the lay audience. And when the current administration is clearly influenced by Dartmouth, conclusions that are overstated cannot be ignored:

In interviews, Dr. Fisher and Mr. Skinner acknowledged that there was no proven link between greater spending and worse health outcomes. And Dr. Fisher acknowledged the apparent inconsistency between his statements in interviews with The New York Times and those made elsewhere, saying that he was sometimes less careful in discussing his team’s research than he should be.

More expensive care may not be better — but the emerging narrative that “cheaper care is better,” is certainly not always the case.

To be clear, I’ve always supported the Dartmouth work, and find their efforts instrumental in trying to convince patients that more medicine isn’t always in the patient’s best interests.

But we can’t base health policy on the faulty notion that “cheaper medicine is better” either.

The Times, if anything, re-directed the Dartmouth narrative to a more realistic trajectory. And I don’t see how that’s a bad thing.

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  • Leonardo Fontenelle

    From my experience with the Brazilian public health care system, the government expends more where people need more. The outcomes are poorer because people are more socially challenged, not because money makes them sicker.

  • Doc D

    The American Association of Physicians and Surgeons (the AMA alternative) has a nice list of “Health Care Reform Myths,” which you can read at their website and make your own decision. Myth 33 deals with the Dartmouth Atlas.

    All advocacy groups will frame their beliefs with selective judgment (at best–some are just vile). AAPS gives an alternative perspective to the progressive advocates listed above.

  • Marc Gorayeb, MD

    From NY Times article: “Dartmouth researchers also created a company, Health Dialog, to consult for insurers and others on Dartmouth’s findings. Valued at nearly $800 million, the company was sold to a British insurer in 2007 and still helps to finance the Dartmouth work.”

    Anyone see a conflict of interest here? Anyone? Don’t be shy.. Keep in mind how tenuous the relationship is between their population-based Medicare spending data and the actual quality of care being delivered at the individual patient level.

    Ironic, eh? The narrative that supports their pre-conceived notion – that financial considerations drive up health care utilization – cannot possibly drive their own agenda. Think of the proportionality: A specialist in the trenches performing ‘unecessary’ procedures allegedly to make an extra $50-100K or so, while these angelic Dartmouth characters can’t possibly be influenced by a desire to keep their $800 million company humming….

    It’s amazing how words on a page can generate odors.

  • maggiemahar


    Here’s the problem: The Times story misrepresents what Fisher and Skinner said. Kevin Drum assumes that the reporters can’t be making this up. But in fact, they are.
    (Otherwise, Kevin’s posting was excellent.)

    The Times’ reporters write: “In interviews, Dr. Fisher and Mr. Skinner acknowledged that there was no proven link between greater spending and worse health outcomes. And Dr. Fisher acknowledged the apparent inconsistency between his statements in interviews with The New York Times and those made elsewhere, saying that he was sometimes less careful in discussing his team’s research than he should be.”

    Look at the first sentence: “Fisher and Skinner acknowledged . . .” Did Fisher and Skinner speak in unison? Clearly this is inot a direct quote. It is a paraphrase of what they said. Secondly, it suggests that in the past they have suggested a proven link between greater spending and worse outcomes, and are now acknowledging that this is not true.

    Fisher and Skinner have Never suggested that greater spending leads to worse outcomes. They understand that this would be completely untrue, and that if one of them said such a dumb thing, it would undermine their credibility. They have repreatedly said than when spending is higher “sometimes outcomes are worse.”

    The reason there is no direct quote here is because the reporters are putting words int their mouths. They didn’t say what he wanted them to say so he paraphrases what he wants them to say.

    I spoke to most of the sources the Times interviewed–incluidng Skinner. They all say that the article distorted what they were saying ripping what they said out of context, and putting it in a context where they seem to be criticizing the Dartmouth research. (See this post on HealthBeat and part 2 of the post here:

    Now look at the second sentence in this pargraph from the Times. It doesn’t tell you what statements he made in interviews with the Times or elsewhere . . Statements about
    what? The placement of the sentence leads you to believe
    that he’s talking about “statements about whether more spending always leads to worse outcomes.”

    That isn’t what Fisher was talking about. Again, he’s never made any statements suggesting a proven link between greater spending and worse outcomes.

    Finally, I didn’t correct the misinformation in the Times’ story because I’m a “left-leaning blogger.” I’m perfectly happy to be described as left-learning, but I defended the research because I hate to see anyone in the media spreading
    misinformation–whether it’s FOX or the New York Times.

    If one source says he was misquoted–or that what he said was put in a context that completely distorted the meaning–that’s one thing. If three sources tell you that– and a fourth shows you e-mails that he sent to the Times reporter warning him that he was “jumping to conclusions” that are not true and “comparing apples to grapefruit” this calls the whole article into question.

    As one source told me: “He had a storyline and didn’t want to hear anything that didn’t fit the story-line.”

    Marc– The company “Health Dialog” does not support Dartmouth’s work. It distributes videos and pamphlets that support work done by the “Foundation for Informed Medical Decision-Making, a non-profit corporation that provides patients with objective information about their treatment optoins using interactive media. Patients are given videos and pamphlets outline the risks and benefits of treatments–for instance, mastectomy vs. lumpectomy–so that patients can make an infomed decision — rather than passively giving ‘consent.” Jack Wennberg, the father of the Dartmouth reserach, co-founded this non-profit Foundation.

    Health Dialog is a for-profit company that manufactures and disributes these pamphlets and videos which are purchased by hospitals as well as health plans.

    The non-profit Foundation for Informed Medical Decison Making didn’t have the money needed to manufacture the videos and pamphlets. It had a team of doctors who woule write the pamphlets and videos, updating them constnantly as we learned more about various treatments, adn interviewing patients who appeared on the videos expalining why they chose a particular treatment option.

    A 2004 article in Health Affairs explains how they finally resolved the problem:
    After numerous false starts with various
    potential partners, in 1997 the foundation entered
    into a new commercial arrangement
    with Health Dialog, a privately held, for-profit
    venture founded by George Bennett and Chris
    McKown that offers health coaching (nurse
    call service), decision support, and chronic
    disease management services to health plans,
    employers, and provider organizations. In return
    for exclusive marketing rights to the
    foundation’s decision-support programs (now
    predominantly in linear videotape format),
    Health Dialog pays royalties to the foundation
    based on its gross revenues. The foundation
    develops andmaintains editorial control of the
    content for the programs, which are produced
    and distributed by Health Dialog.
    In the current fiscal year, the royalties from

    Health Dialog are expected to reach $6 million,
    enabling the foundation to expand its library
    of programs to twenty-one by the end of
    2004, support a cadre of fourteen academically
    based medical editors (to develop content for
    decision aids and assure that it remains upto-
    date with research developments), and to
    fund a small portfolio of research related to decision
    aids (studying issues such as framing effects
    and evaluating the impact of decision aids
    on patients’ decision making).
    Health Dialog’s success in the marketplace
    has greatly expanded the reach of decision aids
    (with more than 20,000 video programs distributed
    to patients and their families in the
    past year), and this creative business model
    has gone a long way toward addressing the
    need for sizable, ongoing financing.
    You’ll find this in Health Affairs here
    Sorry to go on at such length but as you can see the NYT Story is misleading on this point as well.

    • Leonardo Fontenelle

      Just for the record, reporters do it a lot. Then have the story ready, and then try to get something to sustain such story.

  • Gardiner Harris

    Thanks for the blog. We have posted yet another explainer on this issue at ( that goes through many of the technical issues. It shows conclusively that the Dartmouth researchers have mischaracterized their own research. This is rare.

    But I wanted to respond to some of Maggie Mahar’s points, the most improbable of which came when she wrote, “Fisher and Skinner have never suggested that greater spending leads to worse outcomes.” First, in our story we pointed out that Dr. Fisher made this very point in testimony before Congress last year. This point — that there is a negative correlation between spending and outcomes — is also made throughout the Dartmouth Atlas website (as our piece showed). Remarkably, they made this point AGAIN in their rebuttal to our piece, which Ms. Mahar also posted on her own blog ( But perhaps most importantly, Ms. Mahar herself wrote an extensive piece about the Dartmouth work that is all about their negative correlation thesis ( A representative quote is this: “There is a stark correlation between reduced utilization and better outcomes.”

    Ms. Mahar has made a habit of claiming that we misquote sources. She did so after a Feb. 18 piece about the Dartmouth work even though the quote that I used from Dr. Fisher came directly from an email that Dr. Fisher sent me. How, exactly, can you misquote someone when the quote was lifted whole cloth from an email from the source? Ms. Mahar is also upset that we used data from a Wisconsin group that didn’t want their data used. Since when should journalists allow sources to decide whether we should or should not use their data or quotes?

    She claims that the data resulted in an “apples to grapefruit” comparison. That was the point of using that data, to show that hospital rankings differ substantially if quality data are included, which Dartmouth does not do.

    Why is Ms. Mahar such a fierce defender of the Dartmouth work? Maybe it is not her left-leaning politics but rather because the Dartmouth research underpins so much of her own work, including her book.

    –Gardiner Harris

  • run75441

    Mr. Harris:

    Lets get the rest of the quote in context from Maggie:

    “‘Study after study has proven the case. Just last spring, for example, Fisher and Dartmouth economists Jonathan Skinner and Douglas Staiger published a study in Health Affairs revealing that while there have been tremendous gains over the last 20 years in survival rates following an acute myocardial infarction (commonly known as a heart attack), survival gains have stagnated since 1996—even as spending has continued to climb—suggesting that we may have hit a point of diminishing returns. And once again, the results contradict the conventional wisdom that more care is better care: the gains in survival rates have been the smallest in regions like Southern California, where patients received more expensive, intensive care, and the greatest in areas like Minnesota, where they received more conservative care.

    Meanwhile, the citizens of Minnesota contribute the same share of their paychecks to Medicare as do workers in California. But, on average, Medicare spends far more per beneficiary in Southern California than in St. Paul.

    ‘Minnesota pays for the hospital building boom in California,” observes HealthPartners’ Isham. “And as long as the number of representatives in Congress coming from high-cost states [like New York and California] exceeds the number of representatives coming from low-cost states [like Utah and Minnesota], this will continue to be the case.’”

    Gardiner, when has throwing money at an issue willy-nilly led to a positive conclusion? It doesn’t, it did not for manufacturing and it doesn’t for meds either.

    You cnflate the issue and are cherry picking it.

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