Dr. Richard Cooper, critic of Dartmouth health study, speaks to the WSWS

Why don’t they go into the middle of Detroit … and say, “Poverty makes almost no difference in health care spending”?

By Joanne Laurier
21 June 2010

On June 2, the New York Times published an article calling into question the research and policy proposals of the Dartmouth Atlas of Health Care. The Dartmouth group has devoted itself in recent years to demonstrating that much of the health care provided by US hospitals is unnecessary and wasted, and that major cuts can be carried out without lowering standards of care. (See “Fraudulent study used to sell Obama health plan”)

This agenda jibes neatly with the drive of the American ruling elite to cut costs, and impose an ever-greater share of the remaining cost burden on the working population. The Dartmouth research was referred to numerous times by Obama administration officials, and the media, most aggressively by the New York Times itself, in the so-called health care debate.

The June 2 article, by Reed Abelson and Gardiner Harris, made no mention of the role played by the Times, which has led the charge against “over-testing” and “over-use” of health care services.

The World Socialist Web Site has documented the shabby nature of the methods and science of the Dartmouth group, which uses statistical sleight of hand to conceal the role that poverty and social inequality play in the current health care crisis in the US.

Dr. CooperDr. Richard Cooper

One of the leading critics of the Dartmouth study has been Dr. Richard Cooper, a professor of medicine at the University of Pennsylvania (see interview).

We spoke to Dr. Cooper last week for his response to the New York Times article and other recent developments.

Joanne Laurier: What is your reaction to New York Times June 2 article?

Richard Cooper: It finally set the record straight. It is a correction of everything the paper has stood for in the past. The Times editorial page and David Leonhardt, the business columnist, have been the publicists for the Dartmouth group, beginning three or four years ago. And so has [columnist] Paul Krugman. And the news stories have followed suit.

The Times has exposed its readers to a constant barrage of Dartmouth double-talk. We all have been sold a bill of goods. The New York Times, more than any other newspaper in the world, has pushed the fallacy of the Dartmouth myth. Despite this, Abelson and Gardiner had the courage to write their article, and to the Times’ credit, they published it.

There were only two letters in response to the Times article: one from Jonathan Skinner [health economist at Dartmouth] and Dr. Elliott Fisher [professor of medicine and Dartmouth Atlas researcher], who are the major perpetrators of the Dartmouth hoax, and the other by Atul Gawande, a physician who has allied himself with the Dartmouth malarkey. [Gawande’s June 1, 2009 article about McAllen, Texas in the New Yorker magazine was frequently cited by the Obama administration and others as proof that health care costs could be curtailed without impairing care.]

JL: Months after the new health care reform bill has safely passed, the Times writes this article. All along they knew Dartmouth was wrong. The paper never solicited your opinion. You have always taken note of the role the New York Times played in promoting Dartmouth and of the Obama health care bill. So what accounts for the paper’s change of heart?

RC: You are absolutely right. I’ve been a Times reader for as long as I can remember. In the old days, if a day went by that I could not read the Times, I could not get through the day. Now it is the opposite. I pick up the paper every morning and my hands are shaking. What malarkey are they going to print about health care today?

It was a terrifying experience to read the Times during the health care reform discussions. And of course I have to wonder what they are reporting in the areas that I don’t know anything about. What about the war? What about energy? What about everything else? As far as I can tell, the Times does not tell the truth about much in health care. I don’t know whether they do the same in areas that I don’t know about.

JL: There were eleven major articles citing Dartmouth in the New York Times in 2009.

RC: Is that all? The reality is that Dartmouth was present in their articles all the time. Even when the Dartmouth group was not mentioned by name, they were there when the paper wrote that you could cut health care costs by 30 percent. By 2009, the Dartmouth mantra was encoded in most of the Times health care articles. You did not have to cite Dartmouth by name anymore. They were there in notions such as “profligate physician behavior.”

JL: So much damage had been done by the time of the June 2 article.

RC: I’m sure there were a lot of letters submitted in response to this recent article, including one that I sent in. But none were published. Only the Fisher-Skinner letter and Gawande’s letter, both on June 11. Both were pathetic. Just reiterating Dartmouth doubletalk.

On June 18, Abelson and Gardiner responded to the Fisher-Skinner letter on the Times blog, showing that, time after time, the Dartmouth crowd fabricated and twisted the truth. With the precision of skillful surgeons, these reporters cut though Dartmouth’s doubletalk and exposed the duplicity of their research. They showed that the notion that greater spending indicates waste is wrong.

But what still is not adequately appreciated is that the major cause of excessive spending in areas that spend the most is the high health care costs of poverty. We just completed a study that shows that health care costs for non-elderly adults in Los Angeles are 40 percent higher than in the Sacramento-San Francisco region because of the prevalence of poverty in Los Angeles.

JL: The New York Times article did not mention poverty.

RC: That was very disappointing.

JL: The new health plan will mean lots of pain—perhaps this was one of the motivating factors in the article.

RC: I really don’t know if this article indicates a change of heart for the New York Times. We’ll have to see.

JL: What do you think of Obama’s health plan?

RC: Those who crafted this legislation don’t understand that what really is at issue is the disintegration of our society—widening income inequality and its consequences. The health care reform bill makes believe that poverty is not really happening. The point I’ve been trying to make for a decade is that we cannot afford the high health care costs of the poor. And the only way this can be addressed is to get rid of poverty.

JL: In our previous interview with you, you brought out the ties between Dr. John Wennberg [pioneer and leading researcher] of the Dartmouth Atlas and a company he started called Health Dialog. The Times article also cites the direct financial incentives for Dartmouth’s research results.

RC: Profit is the motive. Health Dialog is a company begun by Wennberg and others. One of the new mandates in the health care reform bill is “shared decision making” [patient-doctor], a term that is actually a registered trademark of the Foundation for Informed Medical Decision Making (FIMDM), which is funded by Health Dialog and which funds the research of the Dartmouth group and like-minded investigators.

Shared decision making is routine for doctors. But the government’s way of doing “shared decision making” is that doctors can only get paid by using software of the sort that is produced by Health Dialog! Wennberg’s son is the president of the data division of Health Dialog.

This is like Exxon having a role in an energy bill that mandates that everybody who has a car must have a certain device that Exxon manufactures and sells. And worse. It’s not transparent. The financial interests of the Wennbergs have not been stated in their testimony to Congress, in op-ed pieces in the Times, and in articles in important journals, such as Health Affairs, whose editor is on the Board of Trustees at Dartmouth, or the Annals of Internal Medicine, whose former editor is on the board of the FIMDM.

In the 1970s, we began to talk about the “Medical-Industrial Complex.” This term was invented by Arnold Relman, who was chair of medicine at the University of Pennsylvania (I was in his department) and who went on to become the distinguished editor of the New England Journal of Medicine. The term referred to the pharmaceutical and medical equipment industries. It’s not that pharmaceuticals or medical equipment are bad. It’s just that, in order to know whether they’re really good, we have to know whether the experts who are telling us so have financial interests. Well, now there’s another industry. It’s called “quality.” And there’s a new complex. It’s called the “Quality-Industrial Complex,” and it includes Health Dialog.

Don Berwick, whose enterprise, the Institute for Healthcare Improvement, is also a player, has recently been nominated to lead the Centers for Medicare and Medicaid Services (CMS), which administers Medicare. He has said that health care reform must have rules invested with authority. Well, we had better know who will profit from the rules. “Quality” is a spawning industry. Already, there are more than 100 organizations involved with measuring or aiding in the pursuit of quality, and many are proprietary companies.

So here you have a health care reform bill that is full of regulation. It’s telling doctors how they have to practice. And there is an army of people that is forming to serve as consultants to beleaguered doctors and hospitals who have to cope with all of this “quality” regulation. And they all will consume precious resources. Yet there are too few resources for the care of the poor.

Quality is a good idea, just like pharmaceuticals are a good idea. Energy is a good idea. These are all good ideas. The “quality movement,” however, is becoming subordinated to profit, and as that happens, “quality,” as defined by regulators and entrepreneurs, is becoming a bad idea.

JL: So Dartmouth provided the bad science for a bad bill, but it is also a matter of money.

RC: I learned early in my career that academic battles are not fought over ideas. They are fought over money. I always wondered why the Dartmouth group was so aggressive in fending off criticism. Academic disputes are more like a sport. It’s how we sift through ideas. Dartmouth has not been involved in a sporting event. It has waged war.

Until recently, I wondered where the money was. And I believe that I found much of it. The money is called Health Dialog. The initial investors sold the company for $772 million, giving them an 880 percent profit, and the cash keeps rolling in. David Wennberg remains a division president and John Wennberg is somehow involved financially.

There is no public information about just who the investors were, but if the Dartmouth Atlas is to be believed, and if the FIMDM is to have credibility, and if we are to have confidence in “shared decision making,” which was recently endorsed by MedPAC (the committee that advises the government about Medicare policy), but which is trademarked by the FIMDM, there has to be transparency.

Were any of them affiliated with the Dartmouth group’s research? Were any associated with journals in which that research was published? It’s not in the public record. There should be a call for the public release of the names of those who invested in Health Dialog. We do know that some of the people associated with the FIMDM and the journals mentioned have been staunch defenders of the Dartmouth Atlas. I think the public is entitled to know who is supported by the money that comes from Health Dialog, either directly or through the Foundation, and who has profited directly from Health Dialog.

Dartmouth College recently received an anonymous gift of $35 million to fund a new health care policy institute along the lines of interest expressed by Wennberg and his colleagues. Where did that money come from? Anonymous gifts are not unusual. That’s a big one, and most universities announce the donors of major gifts. Where did all of that money come from? And what’s the big secret?

The “quality-industrial complex” needs transparency. And the Dartmouth program, with all of its extensions, is simply not transparent.

JL: Their research is also directly funded by the insurance companies.

RC: Now you’ve got the loop. Independence Blue Cross [Southeastern Pennsylvania’s largest health insurer] licenses the Health Dialog software under a program they call “Connections.” They market their version of shared decision making using their module, which as far as I can tell is basically the Health Dialog module repackaged for the insurance carrier. We need to know who profits from quality.

JL: The New York Times article repudiating Dartmouth, although the authors don’t say so, is a vindication of your criticisms.

RC: I don’t believe I need vindication. I don’t need vindication from the attacks by the Dartmouth group or their groupies. As I mentioned previously, I did write a letter to the paper about the article that exposed Dartmouth’s duplicity. The Times has never published any of the dozen or so letters, as well as three or four op-ed pieces, that I have written over the years. I doubt that they’ll publish my letter, unless the paper really has seen the light.

JL: Could you comment on the role of the WSWS versus the mainstream media?

RC: I think it’s been a really important voice. The notion that poverty matters is not being picked up by the Times or the Washington Post. The Dartmouth group takes the position that poverty does not matter. How remarkable. They don’t even take an intermediate position, like poverty is important, but there are a lot of other factors. But, in fact, they deny that poverty is a factor in health care spending.

A New England Journal of Medicine article by Dr. Jason Sutherland, Fisher and Skinner in September 2009 said that poverty has almost no impact on health care spending. What a terrible thing to say to poor people. Why don’t they go into the middle of Detroit and into one of the hospitals that cares for a lot of poor people? The Dartmouth people should look some of those folks who are really suffering in the eye and say to them, “Poverty makes almost no difference in health care spending.” I’d like to see if Skinner and Fisher have the guts to confront the poor and not hide behind the New York Times and the New England Journal of Medicine.

The World Socialist Web Site has the guts to do it and you’re out there saying it. And I think that’s important. The gauntlet has been thrown down on these issues. And the WSWS has been instrumental in making that happen.

For more information, see buzcooper.com.