Lead Author: John E. Wennberg
Co-Authors: Elliott S. Fisher, David C. Goodman, and Jonathan S. Skinner
The Dartmouth Atlas of Health Care 2008
Nowhere are the system’s failings more apparent than in the care of the chronically ill. More than 90 million Americans live with at least one chronic illness, and seven out of ten Americans die from chronic disease. Among the Medicare population, the toll is even greater: about nine out of ten deaths are associated with just nine chronic illnesses, including congestive heart failure, chronic lung disease, cancer, coronary artery disease, renal failure, peripheral vascular disease, diabetes, chronic liver disease, and dementia. Treating chronic disease is both enormously costly and not particularly effective. Most patients with chronic disease are treated in episodic fashion by multiple physicians, who rarely coordinate the care they deliver. As chronic disease progresses, the amount of care delivered and the costs associated with this care increase dramatically. Patients with chronic illness in their last two years of life account for about 32% of total Medicare spending, with much of it going toward physician and hospital fees (Medicare Part A and Part B) associated with repeated hospitalizations.
This edition of the Dartmouth Atlas will focus on disentangling the phenomenon known as “unwarranted variation,” or variation in different regions of the country that is not explained on the basis of illness, patient characteristics or preferences, or the dictates of evidence-based medicine. Like the last edition, it focuses on supply-sensitive care delivered to chronically ill Medicare beneficiaries in the last two years of life.
Given the complex, entangled web of economic incentives and false assumptions that currently operate in today’s health care system, is it possible to successfully address the underlying major structural problems behind the unwarranted variation phenomenon: poor science, poor coordination of care, and overuse of care, particularly of acute care hospitals? The first step, we suggest, is to understand the causes and consequences of variation in the way chronic illness is managed from state to state, from region to region, and from provider to provider. Much of this edition of the Atlas has been devoted to this task. The next step is to implement reforms that can address unwarranted variation. In this chapter, we have outlined a general approach to reducing variation. The end game is the establishment of science-based, cost-effective, and coordinated management of chronic illness through care that is also sensitive to patient preferences and supported by adequate infrastructure. An adequate infrastructure includes the personnel and technology that serve as the means for both guiding and monitoring quality and efficiency. Eventually, reimbursement should be determined on the basis of these measures.
A strategy for improving the scientific basis of clinical care
Today, there is virtually no clinical research that focuses on variation in care intensity. The nation needs a crash program to transform the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation and Medicare spending can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care.
The support of such research needs to be the responsibility primarily of federal science policy. It makes no sense for the government to invest in biomedical research (such as most of the research funded by the National Institutes of Health) without complementary research aimed at determining how new and existing treatments affect the outcomes of care, the lives of patients, and the efficiency of clinical practice.
How hospitals might respond
Using the Dartmouth Atlas database, hospitals can learn quickly where they stand on the relative efficiency scale, and those with acute hospital resource inputs and utilization that are substantially in excess of efficient practice benchmarks set by providers like the Mayo Clinic and Intermountain Healthcare will understand that in the long run, CMS may penalize them for providing high-cost, high-intensity, chaotic care. Under the shared savings model, CMS would offer a strong financial incentive for hospitals to organize their care.
How physicians might respond
The primary care “medical home” could provide a model for coordinating care among sectors and ensuring that patients’ transitions between sectors run smoothly. In this role, primary care physicians would have an advantage, because in today’s health care markets, most primary care physicians do not have entangling owner relationships with acute care hospitals, skilled nursing facilities, or long-term care facilities. They are thus in a better position to help reduce the remarkable variation among these sectors of care. We believe that CMS should develop strong financial incentives for primary physicians to assume a leadership role in coordinating care and reducing overuse of acute care hospitals.
The Dartmouth Atlas of Health Care 2008:
Don McCanne, MD
Uwe Reinhardt has said that for the past few decades John Wennberg has been howling in the wind. So what is the noise all about? It is about the hundreds of billions of dollars that we are wasting on poor quality, intensive high-tech care that does not improve outcomes.
Wennberg’s group tends to dismiss national health insurance as being an inadequate response to our needs, instead suggesting solutions such as deciding that “that only accountable care organizations capable of providing evidence-based care would be eligible for Medicare reimbursement for routine management of chronic illness.” Such an approach would not only perpetuate our highly-flawed, fragmented system of financing health care, but would further compound the fragmentation of our health care delivery system.
That is not to dismiss the very great importance of the contributions of John Wennberg and his associates. They have provided us with a data base that provides an opportunity to shift spending from wasteful, poor quality excesses to higher quality care that benefits everyone. They have demonstrated the importance of establishing a primary care medical home.
To achieve that goal, we really do need to reform our health care financing system. Just imagine how effective a single payer national health program would be in “transforming the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care.”