The U.S. health care system can be reformed to cut costs and improve quality, Dartmouth Medical School professors Elliott Fisher and Gerry O'Connor told an audience of over 300 community members at Spaulding Auditorium on Tuesday. Their speech was part of the Institute for Lifelong Education at Dartmouth's summer lecture series, "Positive Solutions."
Fisher currently serves as director of the Center for Health Policy Research at Dartmouth, which has for the last 20 years used Medicare data to track the wide variations in the cost of health care throughout the country.
Based on this data, Fisher said, high-spending areas could reduce their costs without reducing their quality of care. Disparities in spending cannot explain differences in the effectiveness of care patients receive, Fisher said. Patients in areas where more money is spent on health care on average receive less effective care, he said.
Differences in spending also do not affect the amount of elective care that hospitals offer, Fisher said. Elective treatments, such as heart bypass surgery, which will not cure a patient but could improve quality of life, are equally common in high-spending and low-spending hospitals.
Variations in the cost of health care, Fisher said, are due to differences in "supply sensitive services." These services, which include consultation with specialists and diagnostic tests, are largely determined by a region's medical resources, according to Fisher. Regions with more hospital beds, for example, use each bed more frequently, he said.
There is no evidence that the capacity to provide more medical services increases the quality of health care, Fisher said. High-spending regions may actually have slightly worse results, he said, with 5 percent higher mortality rate for heart attacks. This may occur because the involvement of a large number of doctors and specialists in treating a patient increases the likelihood of medical error.
If high-spending regions such as Miami or southern Texas adopted the policies of low-spending regions like northern California, health care spending would decline by over 30 percent and the Medicare trust fund would last an additional 25 years, Fisher said.
"We could theoretically send 30 percent of the U.S. health care workforce to Africa and in theory improve the health care of both countries," he said.
Fisher advocated transforming hospitals in the United States into "accountable care organizations," in which all of the doctors in a region would be integrated into their local hospitals. Each accountable care organization's performance would be measured as a whole, Fisher said, and shared savings would be distributed throughout the system. This would encourage doctors to work together, better integrating their care and reducing the amount of resources they use, he said.
"We need patient reform that rewards value, not volume," Fisher said.
O'Connor shared his experience in treating cystic fibrosis patients to show how Fisher's principle of care coordination and accountability, if put into practice, can have dramatic results. He found a wide variation in patient treatment and outcomes for cystic fibrosis clinical care centers throughout the country.
Using quality benchmarks and blind data sets, O'Connor and his colleagues determined which centers were achieving positive results and which were not. He then developed and implemented standard guidelines and data-reporting procedures for the nation's 150 cystic fibrosis care centers.
Within seven years, the median age of surviving cystic fibrosis patients jumped from 28.6 years to 36.9 years, according to O'Connor. He said he hopes the rest of the health care community can learn from the successful reform of cystic fibrosis care.
"You have to change process to change outcome," he said. "There is nothing about this approach that is [cystic fibrosis] specific. It can be applied to a whole bunch of things in health care."
