Health reform's next test

By Jim Yong Kim and James N. Weinstein
Monday, May 17, 2010

Health insurance reform is now law, giving millions of Americans access to the full resources of our health-care system for the first time. The question becomes: How can we ensure that they -- and all of us -- receive value-based and high-quality care?

It is well known that U.S. health-care costs, as a share of our economy, are the highest in the world but that compared to other industrialized countries, our results are the worst. The Dartmouth Atlas has documented the enormous waste in our system and shown that spending more money and performing more medical procedures do not equal better outcomes for patients.

Americans deserve health care that is coordinated across physicians and health systems, and that is effective, appropriate and safe. As a nation, we have a moral and a fiscal responsibility to ensure that all patients receive value for health services. While the achievement of health insurance reform was historic, it is time to focus on the next step: improving quality while bending the unsustainable cost curve significantly.

We are physicians and researchers; one of us is now a college president, and the other head of a leading academic medical center. We share a history of work in medicine, science, policy reform and education. We also share the view that throughout history, our most difficult problems have found scientific solutions.

We propose the rapid expansion of a new field to tackle the twin problems of how to provide high-quality health care while lowering costs: health-care delivery science.

This new field will work with the recognition that truly reforming health care requires more than the efforts of one entity. We cannot blame government or insurers or physicians for the complex and multilayered problem. No single group or entity created the puzzle that is our health-care system; it is not reasonable to expect one group to solve it.

What will lead to improvements is a multidisciplinary approach that brings the best minds to focus on the problem. Experts in management, systems thinking and engineering, sociology, anthropology, environmental science, economics, medicine, health policy and other fields must join together to apply a laser focus to fixing the delivery system.

Why? Consider the moving pieces of a patient-health system encounter. A patient comes into the emergency room. Immediately, judgments are made about how sick she is and what treatments she needs. There is no universal medical record for that patient, so the provider has no idea about her medical history, medication use or preexisting conditions. Incomplete information is relayed through layers of nurses, physicians, specialists and the shifts of personnel who replace them. In the absence of real-time information, tests are ordered and treatment decisions made. Perhaps after an overnight stay, barring complications from drug interactions or perhaps an unrecognized underlying condition, she is discharged, with no further transfer of information to a provider and, more important, no follow-up to see whether the treatment was effective. The symptoms were treated; the patient was not.

The best insurance in the world will not fix this problem. We need a whole new cadre of people committed to applying their expertise to the challenge of health-care delivery.

We have begun building that cadre at Dartmouth with the establishment of a Center for Health Care Delivery Science. But it is our hope that many more institutions will work together to generate the needed evidence on health-care delivery solutions, to disseminate that knowledge and to train the current and future professionals who will put solutions into practice. We envision a network of centers across the country that will marry research and implementation from the start -- finding and testing delivery solutions with practitioners and patients on the front lines.

The recent health legislation establishes an implicit covenant with the American people. The spirit of this covenant goes far beyond insurance. In exchange for new public and private investment in the health system, Americans expect access to effective, high-quality care within a financially sustainable system. With a robust science of health-care delivery, this goal can be achieved.

Jim Yong Kim is president of Dartmouth College. James N. Weinstein is president of the Dartmouth-Hitchcock Clinic.

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