SEATTLE The American health care system and the public's understanding of the health care reform effort are both deficient, according to Dartmouth Medical School professor Elliott Fisher, director of The Dartmouth Institute's Center for Health Policy Research. Fisher, in a speech here on Saturday, said he is still hopeful that the health care reform legislation being debated in Congress will prompt needed long-term changes to the U.S. health care system.
Fisher was the keynote speaker at the annual meeting for Group Health Cooperative at the University of Washington in Seattle. Group Health, a consumer-driven nonprofit health care system, has often been mentioned during the reform debate in Washington, D.C., as a possible model to be implemented nationally.
Fisher criticized the national dialogue on health care that has taken place in recent months, saying that many politicians and ordinary citizens have not even begun to discuss key issues that reform needs to address.
"To describe the public discourse about health care reform recently, I think a technical term would be, well pathetic," Fisher said.
He went on to say that although he has been highly disappointed with the public conversation, "there is reason to hope" that the legislation currently being debated in Congress will greatly benefit the American health care system's long-term prospects for success and sustainability.
While Fisher said he believes productive health care reform could occur this year, he made it clear that this does not mean the current American health care system is sustainable or well designed.
"Currently, we're on the Titanic, and it's sinking," he said. "The Medicare trust will be bankrupt by 2017, the quality of primary care is collapsing and the integrity of health care professionals and of academic medicine are both in jeopardy."
Fisher referred to the Dartmouth Atlas of Health Care, which he has worked on, to justify his comments.
The Dartmouth Atlas divides the United States into 306 health care markets for analysis. The system has allowed Dartmouth researchers to analyze how a region's health care practices correlate with patient outcomes.
The group's findings demonstrate what Fisher termed a "paradox of plenty." In a variety of studies looking at a wide range of ailments and treatments, The Dartmouth Atlas demonstrated that in regions where more money is spent, outcomes are not noticeably different, even when controlling for factors such as the overall health of each market's population.
Fisher said that to help understand how this might happen, he has broken down health care into three different subsections: effective care, in which the benefit is clear and most doctors would come to the same conclusion; preference-sensitive care, in which the amount of care administered depends on the values of doctor and patient; and supply-sensitive care, which refers to care that is avoidable without added risk to the patient.
The Dartmouth Atlas found that low-spending regions tend to do a better job of delivering effective care, providing preference-sensitive care in similar amounts and with comparable quality to high-spending regions. The only significant difference was in supply-sensitive care patients in high-spending regions received much more of it.
"This would be all well and good if patients who received higher amounts of supply-sensitive care, such as more time in a hospital or more frequent visits to specialists, saw better outcomes then patients in low-spending regions who didn't have those things," Fisher said. "But over and over, we see that survival rates and the quality of care are no different."
These findings refute what many Americans believe about health care, Fisher said.
"People throughout the country think that More is better,' and they are provided with inadequate information on the risks and benefits of many expensive procedures and treatments," he said.
Fisher explained that when low-spending, high-quality organizations such as Group Health market themselves, they talk about their positive outcomes and high patient satisfaction, not their low spending. Fisher said this feeds the public perception that "more expensive" health care is tantamount to "better health care."
The "fragmented nature of the U.S. health care system and the current payment systems" is a significant barrier to effective reform, he said.
Fisher said that this problem could be addressed through the creation of accountable care organizations, which would centralize care within a region, connecting various health care providers and making them responsible as a group for the quality of care and for patient outcomes.
Such a system would increase the coordination of care, eliminate gaps in the quality of complex care such as surgery and recovery, and help providers identify redundant services that could be reduced to lower costs in their region.
Fisher praised Group Health, saying that the group demonstrated how his findings could be used "not as an abstract model, but as a way to care for real people."
