I have seen the future of health care here at the Spine Center of the Dartmouth-Hitchcock Medical Center.
It is not that Jim Weinstein and his colleagues have any breakthrough cures for back pain. What they do have is a revolutionary model for how doctors and patients interact that improves medical care while saving money.
It all starts in the waiting room, where patients use wireless computer screens not simply to provide the usual information about age, insurance and allergies, but also to answer a series of questions about the nature and severity of their symptoms.
That information, supplemented by conversations with doctors and therapists and updated from the patient's home over the Internet, becomes the basis on which a treatment plan is devised and monitored. When aggregated with the same data from other patients here and at participating clinics, it becomes the vehicle for learning what works and what doesn't.
After a brief visit with a doctor, the next stop is down the corridor at the Center for Shared Decision-Making, where patients watch a 45-minute video that lays out the anatomy of the spine and, in unbiased terms, provides the latest information on the potential risks and benefits of spine surgery. Cost is never mentioned, but what is noted is the fact that while surgery has a good chance of bringing quick relief to severe back pain, after a year it's not a lot more effective than a regimen of drugs, physical therapy and small lifestyle adjustments. And guess what? After watching the video, patients elect not to have surgery 30 percent more often than patients who consult their doctors in the traditional manner. At $60,000 a pop, and with spine surgery among the fastest-growing areas of medicine, that means real money.
There are several other crucial elements to the Spine Center's system. Many of the doctors are on salary, eliminating the endemic bias in American medicine toward more care. Rather then sending patients to a series of independent specialists, they are all right there, talking among themselves and working off the same data, backed by software that helps avoid common errors and tracks patient progress.
The Spine Center has been so successful that, despite some physician resistance, the model is being expanded. Belatedly, the National Institutes of Health has begun to fund outcomes research. And thanks to Sen. James M. Jeffords (I-Vt.), the recent Medicare reform bill has money for demonstration projects that sound suspiciously like what's going on here.
That this should be happening here is no surprise. More than 20 years ago, Jack Wennberg of the Dartmouth Medical School found that medical spending in Miami and New York is nearly twice that of places like Minneapolis and Portland, Ore., with worse outcomes. Since then, Wennberg and his colleagues have figured out that behind those numbers are differences in practice patterns by local doctors that, as much as anything, are driven by having too many hospital beds, specialists and sophisticated equipment -- an excess supply that leads to excess demand, which leads to even more excess supply.
The only way to break that vicious cycle, they now believe, is to use the persuasive power of hard data on medical outcomes, the pull from better-aligned economic incentives and a strong push from the government, insurers and various medical societies to get doctors and other providers to reorganize the way they deliver health care. Their approach is laid out in a series of papers to be published this week in the journal Health Affairs.
This isn't brain surgery. Breaking down departmental silos, organizing processes around customers, using information technology to benchmark quality and cost, paying for performance -- with the exceptions of education and newspapering, this is the sort of reengineering every other industry underwent years ago. Now, Dartmouth-Hitchcock has shown that those principles can be applied to a huge segment of the economy that is growing three times as fast as everything else -- not because it is so productive, but because it is so wasteful.
Pearlstein will host an online discussion at 11 a.m. today at www.washingtonpost.com.