Providing Better Health Care For Less Money
The health care debate in Washington has basically deteriorated into a choice between raising taxes or cutting care. But "that's wrong," says Don Berwick of the Institute for Healthcare Improvement. "There's a third way: It's redesign."
To try to prove his point, Berwick, along with health luminaries Elliott Fisher of the Dartmouth Medical School, Atul Gawande of Harvard and Mark McClellan of the Brookings Institution, brought doctors and hospital officials to Washington from 10 communities around the U.S. where health spending is lower than average and health care outcomes are better than average.
"How many of you, as you've implemented all these reforms in your own systems, have been telling your patients that you're rationing your care?" asked McClellan, a former top health official in the Bush administration. The audience laughed.
But for Dartmouth's Fisher, who has spent most of his career cataloging the differences in care between geographic regions of the country, the fact that many places provide more expensive care yet have no better medical outcomes is no laughing matter.
"Eliminating unnecessary care is not rationing," Fisher said. "Who among us wants to go see a physician when we could have stayed at work or stayed at home? Who of us wants to go to the hospital when we don't need to be there? These communities have shown us that it's possible to avoid that unnecessary care, and that's not rationing."
One of the more hopeful messages that Harvard surgeon Gawande took away from the daylong meeting was that change can happen relatively rapidly. "Half of these communities used to be high cost and transitioned to low cost over the last decade. So they made me hopeful that we could do it" as a nation, he said.
But translating the success of those communities — which ranged from Portland, Maine, to Everett, Wash., to Sacramento, Calif. — won't be easy. "Can you order a cultural change? Can you order cooperation? No, I don't think so," Berwick said.
An even larger problem is that while there is relative consensus that Medicare's current payment system encourages doctors and hospitals to provide too much of the wrong care, no one is quite sure how to revise it to encourage just the right amount of care.
"I guess the way I would put it is even if I was a benevolent dictator for a day, I wouldn't feel comfortable at this point, given the state of knowledge, completely overhauling the Medicare payment system," said White House Budget Director Peter Orszag, who has been studying the issue for several years.
That has led to a conundrum in lawmakers' efforts to try to achieve long-term savings in the health care system. They know that overhauling Medicare payments is a key means to achieving that goal. They also know that if they do it wrong, they could leave the health care system — and the patients it serves — worse off than it is now.
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LINDA WERTHEIMER, host:
It's MORNING EDITION from NPR News. I'm Linda Wertheimer.
STEVE INSKEEP, host:
And I'm Steve Inskeep. On Capitol Hill yesterday, dozens of reporters camped outside the office of Senator Max Baucus. They were waiting to see if a small bipartisan group of senators could come up with a plan to rein in the costs of health care.
But just blocks away, a lot less attention was being devoted to a conference featuring doctors and hospital administrators from around the country, people who actually have figured out how to provide higher quality health care for less money. NPR's Julie Rovner reports.
JULIE ROVNER: The problem with the current state of the health care debate in Washington, says Don Berwick, is that it basically is only providing the public with two choices.
Mr. DON BERWICK (Institute for Healthcare Improvement): Either we're going to do less, cut benefits, you know, make it harder for people to get care, put up new barriers, or spend more, find the revenue, tax the health insurance premiums.
ROVNER: Adds Berwick, who heads the Massachusetts-based Institute for Healthcare Improvement…
Mr. BERWICK: There is a third way. And it's redesign. It's do it right.
ROVNER: Berwick and colleagues from Dartmouth and Harvard invited doctors and hospital officials from 10 communities around the country to talk about how they've provided better than average care at lower than average cost.
David House runs a health care system in Maine. He told the story of one doctor in his early 50s…
Mr. DAVID HOUSE: Who essentially left his office each day with a profound sense of depression because of the enormous pile of incomplete charts, the inability to get patients into his office. Simply an overwhelmed, overworked person.
ROVNER: After House's group helped the doctor install an electronic medical records system and hire a team of professionals to reorganize his practice, his entire workday changed.
Mr. HOUSE: Such that what is coming to him now is that critically important set of activities. Seeing and touching and talking to patients, making decisions that only he can make.
ROVNER: And at a recent meeting, House said, that doctor said that rather than being ready to leave medicine entirely, he was feeling rejuvenated. The critical question, though, is whether the systems that these 10 communities have built can be replicated.
Dr. Atul Gawande of Harvard is known for a recent New Yorker article comparing some of the highest health spending areas of the country with some of the lowest. He said he was particularly impressed by communities that have been able to bring about change recently.
Dr. ATUL GAWANDE (Harvard University): Half of these communities used to be high cost and transitioned to low cost over the last decade. So they've made me hopeful that we could do it.
ROVNER: And he says they did it in spite of payment systems for the huge Medicare program that provide every incentive to keep medical spending up. Elliott Fisher of Dartmouth Medical School says if Congress actually changes the system it would make replicating those community successes even more likely.
DR. ELLIOTT FISHER (Dartmouth Medical School): And I think what is now a barrier - the current payment system - could become an enabler if there were positive incentives created for physicians to come together to work with their hospitals, to work within their communities, to work for the goals that they came to medicine with, you know, to provide better care for their patients.
ROVNER: For example, if doctors can keep patients with chronic ailments healthy and out of the hospital, a new payment system might give them a bonus. But while nearly everyone agrees that the incentives in the current Medicare payment systems are wrong, no one's quite sure how to make them right. And lawmakers are still gun-shy about trying to create a whole new Medicare payment system.
White House Budget Director Peter Orszag addressed the problem in a conference call with health reporters yesterday.
Mr. PETER ORSZAG (White House Budget Director): I guess the way I would put it is even if I were a benevolent dictator for a day, I wouldn't feel comfortable at this point, given the state of knowledge, completely overhauling the Medicare payment system.
ROVNER: As a result, Congress so far is only proposing to test various ways to change Medicare payments. And that's what's led to charges that there's not yet a path towards long term control of health care cost.
Julie Rovner, NPR News, Washington. Transcript provided by NPR, Copyright National Public Radio.
