The path to better – and cheaper – health care

About this blog: Is more care better for your health?  Dr. John Wennberg has been asking that question for 40 years and has conducted meticulous research to discover the answer. In “Tracking Medicine: A Researcher’s Quest to Understand Health Care,” published last year by Oxford University Press, Wennberg reveals that the most expensive technologies, surgeries and treatments do not necessarily provide the best results for patients. Here, Wennberg explains.  

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The difference wasn’t due to illness.  It traced directly to the opinions of the local specialists about the value of the procedure. The Stowe physicians were very enthusiastic about tonsillectomy, the doctors of Waterbury more skeptical.

When it comes to health care, geography is destiny.

But it wasn’t just surgery that varied. I found costly differences in the use of hospitals, nursing homes, home health care and physician visits, particularly among patients with chronic illnesses. These differences were directly associated with the supply of medical resources, not the needs of patients.

These findings have had profound implications for both the quality of care that patients get, and for controlling costs. Many conditions – chronic back pain, an enlarged prostate, arthritis of the knee and hip, inguinal hernia, stable angina, and silent gallstones – can be treated with surgery or drugs. Which treatment patients receive depends upon where they live, largely because of differences in local medical opinion.

Patients should be informed of all their treatment options, and participate actively with their physician in choosing the treatment that’s right for them, a process known as shared decision making. 

When patients are given a chance to know their options and share the decision, they often make choices that are different from what their doctors recommended.

Studies show that patients tend to want less surgery.

In one study, men who had enlarged, not cancerous prostate, were advised to have surgery to ease problems with urination.  But when the men were informed about the risks and benefits, including that surgery would adversely affect their sex lives, most of them opted for watchful waiting.  Their physicians were surprised that patient preferences differed from their own opinions. They thought surgery was in the best interest of most of their patients.

When it comes to controlling costs, the supply of medical resources is even more important.  At Dartmouth, we’ve found that patients living in communities with lots of care did not do better than those with less care. 

Indeed, the evidence seems to point in the opposite direction – the outcomes are often worse.  This suggests that patients are getting a lot of unnecessary and even harmful care in many parts of the country.

American health care is at its best when it is organized and coordinated.  Patients served by organizations such as the Mayo Clinic and Intermountain Healthcare in Utah, need fewer visits, referrals, laboratory tests and MRIs and are hospitalized less.  Such organizations use fewer hospital beds and fewer physicians in treating their chronically ill. Medicare spending is lower and yet patients who receive consistent care in organized facilities do better.

The Affordable Care Act supports several initiatives that promote organized care and shared decision making – essentials to reining in the expensive chaos of American medicine.  My concern is that these reforms will take a long time – longer than we have to avert a catastrophic increase in medical spending.

We now pay for more care, not better care. Penalizing high cost hospitals in high cost regions would surely dampen enthusiasm to build more hospital capacity.  

But growth in spending also closely follows growth in per capita number of physicians, particularly specialists.  Through its more than $9 billion annual payments for training of medical residents, Medicare has the power to “bend the cost curve” by reducing the number trained. 

We don’t need to ration care: we already have more than enough physicians and hospitals to provide Mayo-style medicine for all Americans. 

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