Friday, September 11, 2009

Expanding Medical Education

Interesting article by Richard Cooper in favor of eliminating the caps on funded residency positions, the limiting factor in preventing the expansion of graduate med education. He argues that the reason this change is not broadly supported is due to the systemic myth that more specialty physicians leads to worse health outcomes, which is an artifact of faulty statistics. In reality more spending leads to better outcomes, especially among higher-income patients, because the care consists of a broader spectrum of services. Cooper indicates as much in in this interview.

Here's one particularly juicy segment of his article, discussing the methods of the Dartmouth group's “30% solution” study:
The surprising observation was that outcomes were the same in all of the quintiles. The lowest-spending quintile was like the highest. How was that possible? The answer lies in a third problem—the aggregation error. By including a diverse range of hospital regions with diverse total health care spending (despite similar Medicare spending) and a diversity of subpopulations in each, the averages within each quintile regressed to the mean. The extremes of affluence and poverty in the highest-spending quintile came to resemble middle America. However, had meaningful subpopulations within each quintile been compared, striking differences in utilization and outcomes would have been observed, and their strong relationship to communal wealth, individual income, and clinical risk would have been appreciated.

The Dartmouth group apparently saw no need to disaggregate their quintiles to reveal the effects of income and risk. They were content with the knowledge that nothing was “necessarily better,” nor was anything worse. And, because nothing was better in the highest-spending quintile, the added spending was assumed to have been wasted; and because this waste was unexplained, it must have been due to the excess use of “supply-sensitive services”; and these services must have resulted from an oversupply of specialists.
This may seem esoteric and ivory tower-esque, but it's not--this Dartmouth study is the research cited and supported by the CBO, NYT, and lots of politicians.

In his interview, Cooper favors the creation of an insurance system that includes everyone and leaves the rest of the system alone. But he notes that this will likely lead to a doctor shortage as in Massachusetts, which leads us back to the need for expanding graduate med education.