Jack Wennberg & The Dartmouth Atlas Project
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I got a call last week from a reporter at the Boston Globe who was working on a story, published today, about the latest report from the Dartmouth Atlas Project at Dartmouth Medical School. This report, like the many that have been issued before it, illustrates, in typical Wennbergian fashion, the extraordinary differences in resource use associated with health care that’s provided by health care organizations during the last two years and last six months of a patient’s life. For the past forty years or so, Wennberg and his colleagues have been publishing study after study after study on the enormous differences in practice patterns and practice styles that exist across the health care system. More importantly, I think they’ve proven beyond any reasonable doubt that these differences don’t translate into better health care.
To quote one of the Project’s Policy Briefs, “Regions and academic medical centers with greater overall spending rates do not have higher quality of care; nor, perhaps surprisingly, do they have higher rates of discretionary surgery. The greater spending is largely the result of the providers in these regions using more supply-sensitive care: more physician visits, hospitalizations, stays in ICUs and diagnostic testing and imaging. The remarkable variation in the frequency of use of these services among regions demonstrates the role capacity plays. For example, rates of primary care visits vary by a factor of about three, visits to medical specialists by more than six, and hospitalizations for cancer, chronic lung disease and congestive heart failure by more than four.”
This variation is expensive. A few years ago, The Atlantic Monthly published an article about his work that indicated that if the entire country practiced health care using the same practice style embraced by the people at the Mayo Clinic, Medicare spending would drop by thirty percent. This decline, of course, would be large enough to cover the entire uninsured population without spending any new money on health care.
But as I talked to the reporter from the Boston Globe, I pondered this curiosity. All these studies over all these years, and still — as much variation as ever. Maybe more (due to the rapid growth in clinical technology over the same period of time). Why?
I concluded it might be because Wennberg and his gang are kind of an island of inquiry. Almost no one else plays in their space, and their work — while peer reviewed and impeccable — hasn’t changed the hearts and minds of the practicing physician community. Interesting, yes — but able to move the mountain that is modern medicine toward a more systemic approach to care delivery? No — not yet anyway.
What a shame.
I was glad to see the new Dartmouth study motivated you to speak to your blog audience after periods of relative quiet. I also think it’s a terrible shame that this dramatic evidence seems to always fall on deaf ears. I believe however that even if doctors were moved by this data - and typically, they aren’t even aware of its existence - they still wouldn’t know what to do about it. Its not within the hands of individual practitioners to change the supply-side economics but rather more in the control of the policy-makers and others who more directly impact market conditions, including, of course, private influential business leaders like you.
I don’t understand why CMS and/or private insurers have not done more to change the incentives in the system. For example, why isn’t there more publicity identifying which specific hospitals (and perhaps doctors) are high utilizers (by national as opposed to local or regional standards) and which are not? Why can’t doctors and hospitals be grouped into tiers (like drugs are now) with those who earn a spot in the preferred tier either paid a premium or charge the patient a lower copay? Perhaps the most egregious high utilizers should even be eliminated from the network altogether. So far, it looks to me like hospitals and doctors do not suffer any adverse consequences for high utilization. Indeed, it is more profitable for them to practice that way. Incentives matter. It’s not rocket science.
Leanne - Thanks for writing. I do think it’s difficult for health plans (the bad guys) to influence the provider community (the good guys) to change - based on this, or any other data. My own view on this - which I kind of stated above - is that this falls into the “heal thyself” category for the provider community. No one disputes there’s variation, and I doubt most people in the medical community would even dispute the notion that more care doesn’t mean higher quality. Nonetheless, we - the payors - have limited capacity to change this. This has to come from within the provider community.
Barry - the best example I know of that follows the path you outline above is the MA Group Insurance Commission, which provides health insurance to about 250,000 state employees and retirees and their families. The health plans that do business with the GIC have to use tiered networks, based on cost and quality. We manage one of the plans that’s offered through the GIC, and it’s a tiered network plan that tiers specialists. Primary care providers are all first tier, and then select groups of physicians are tiered (one, two and three) based on cost and quality measures. The GIC approach has been in place for three years, and seems to be making some headway.
It will be interesting to see what happens when folks like us start making this product available to the rest of the employer community in MA - which for us, will be true on July 1st, 2008, and January 1st, 2009.