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Cedars-Sinai Perspective On Healthcare Reform Posted In Online In New England Journal Of Medicine

White Paper available online: ‘Dead Souls — Comparing Dartmouth Atlas Benchmarks with CMS Outcomes Data’  by Michael Langberg, M.D. and Jeanne Black, Ph.D. M.B.A.

The premise, based on the Dartmouth Atlas of Health Care, that geographic variations in end-of-life Medicare spending can be used to identify wasted resources was popularized by Peter Orszag, director of the Office of Management and Budget, who has said that “30 percent of Medicare’s costs could be saved without negatively affecting health outcomes.”1

This belief has been propagated by well-meaning adherents seeking a means of financing the expansion of health coverage. Institutions such as Cedars-Sinai Medical Center in Los Angeles (where we work) and New York University (NYU) Medical Center have been portrayed as excessively costly,2 while “model systems” such as the Mayo Clinic, Cleveland Clinic, Intermountain Healthcare, and Geisinger Medical Center are lauded.

Less fanfare attended the July 2009 release by the Centers for Medicare and Medicaid Services (CMS) of data on risk-standardized 30-day mortality and readmission rates among Medicare patients with acute myocardial infarction, heart failure, or pneumonia.

These data show that the mortality rate among patients with heart failure at one of the four “model systems” was significantly worse than the national rate, putting the system in the bottom 2% of U.S. hospitals. Two of the four systems demonstrated lower mortality due to heart failure. None achieved a survival rate among patients with pneumonia that was significantly better than the national rate.

In contrast, both Cedars-Sinai and NYU had mortality rates for all three conditions that were significantly better than the national rates, a performance level achieved by less than 1% of the facilities included in the CMS comparisons. Moreover, though lower mortality rates mean that more patients were at risk of being rehospitalized, the rates of readmission within 30 days at Cedars-Sinai and NYU were no different from the overall national rate.

One of the model systems had significantly worse readmission rates for all three of the conditions. The Dartmouth Atlas cannot reveal these important outcome differences among hospitals because its analysis is limited to Medicare beneficiaries who died.

The Dartmouth Atlas approach purports to eliminate the need to adjust for severity of illness — all the patients were equally at risk of dying, because they all died. However, not all Medicare beneficiaries with chronic conditions are at the same stage of their disease. For some, aggressive treatment may extend their lives. A recent study of six California teaching hospitals found that the six-month mortality rate among Medicare patients with heart failure was significantly lower at the most-resource-intensive hospital than at the least-resource-intensive one.3

The need to improve efficiency is urgent, but we must consider meaningful outcome measures if we are to avoid the unintended consequence of cutting resources that are used to save lives.

Michael L. Langberg, M.D.
Jeanne T. Black, Ph.D., M.B.A.
Cedars-Sinai Medical Center
Los Angeles, CA

No potential conflict of interest relevant to this article was reported. This article (10.1056/NEJMopv0908995) was published on November 11, 2009, at NEJM.org.


1. Orszag PR. Increasing the value of federal spending on health care. Washington, DC: Committee on the Budget, U.S. House of Representatives, July 16, 2008. (Accessed November 10, 2009)

2. Pear R. Researchers find huge variations in end-of-life treatment. New York Times. April 7, 2008. (Accessed November 10, 2009) 

3. Ong MK, Mangione CM, Romano PS, et al. Looking forward, looking back: assessing variations in hospital resource use and outcomes for elderly patients with heart failure. Circ Cardiovasc Qual Outcomes, October 13, 2009. (Accessed November 10, 2009)