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Richard Cooper has shown a positive association between health care quality and "total spending" at the state level, but he does not appear to understand the limitations of this total spending measure; simply adjusting for median age causes the significant positive correlation to disappear. Cooper also finds that some third factor-we think that it is "social capital"-is the key to explaining health care quality. Cooper may believe that this result challenges three decades of research by the Dartmouth group. Instead, it supports the group's view that improved efficiency-and not more doctors and hospital beds-is central to improving quality.

The Elusive Connection Between Health Care Spending And Quality