How'd they do that - and how can we do it elsewhere?

John Lumpkin writes about how we might provide better care for less money based on the experiences of 10 communities that have done it successfully.

 

 

I want to start this post with a quick exercise in the geography of health care spending. So to start, please spend a minute with our interactive map of U.S. Medicare spending by clicking here, and then hit your return button.

Back with me? Now ask yourself: Why are some areas of the countries a lighter shade of green than others? If you answered, “because they spend less money on Medicare than the darker green areas,” you are right.

Now ask yourself, “How do they do that?”

That was the question posed to health care leaders from 10 of the light green areas on the map who were invited to a symposium I attended yesterday in Washington called, “How Do They Do That? Low-Cost, High-Quality Health Care in America.”

These 10 “positive deviants,” in the words of one of our hosts, are exemplars of low-cost high-quality care, chosen from 74 such regions across the country, based primarily on the same green-shaded map from the Dartmouth Atlas of Health Care and quality and patient experience data from the federal government.

The event was the brainchild of four of our country’s most prominent thinkers about health care improvement: Donald Berwick of the Institute for Healthcare Improvement; Elliott Fisher of The Dartmouth Institute for Health Policy and Clinical Practice and principal investigator of the Dartmouth Atlas of Health Care, which has put the issue of variations in health care spending on the map, literally; Atul Gawande, the author of the now famous New Yorker article that compared McAllen and El Paso Texas to understand why McAllen was the second most expensive region in the country for Medicare; and Mark McClellan of the Engelberg Center for Health Care Reform at The Brookings Institution.

Like many of us who have looked at the varying shades of green on the spending map, and have studied what it shows about these vast differences in the costs of care, they wanted to understand the multiple factors that may influence these cost patterns—like patient needs, or revenue generation. 

Now, while I do not believe that the vast majority of practitioners make conscious decisions to maximize their revenue at the expense of their patient, regional variations in the cost and quality of care pose a major policy issue that demands solutions.

The symposium was a promising start. From Asheville, N.C., to Everett, Wash., from Portland, Maine, to Sacramento, Calif., these leaders left me hopeful about the willingness of practitioners to confront the issue head on locally even as we struggle to take those lessons to scale nationally.  We've heard these types of stories already from our Aligning Forces for Quality grantees, which represent teams of stakeholders in 15 regions across the country that are taking on some of the thorniest challenges to get to better care, but we always need more stories about more places like this, especially right now. 

Yesterday, the chief medical officer of a multispecialty group practice in Cedar Rapids told how doctors there were startled to discover that they had ordered a whopping 52,000 CT scans in one year in an area with a population of 300,000.  They decided collectively to institute protocols to quit ordering unnecessary scans.

Each team spoke about the cultures, delivery structures and accountability mechanisms that underlie their success. No two are alike – but the way they practice medicine is far more "systemlike" than we are used to seeing in our fragmented U.S. health care “system.” Some patterns: a culture of collaboration to put patients first; considering finances as a constraint, not a goal; the importance of physician leadership; the real or virtual integration of delivery systems across the continuum of care; the importance of strong primary care; the value of electronic health records and the information-sharing it makes possible; and an emphasis on measuring and reporting data on quality and utilization. 

 “The elephant in the room is data.” Without it, “we are flying blind,” said one doctor from Sayre, Penn.  This is a lesson that RWJF has learned again and again through its many investments to improve health care—performance data alone doesn’t solve your quality problem, but it’s a critical foundation. 

The barriers they face begin with the perverse incentives created by our largely fee-for-service reimbursement system. When asked by McClellan who would agree if that is the No. 1 obstacle, nearly every hand in the room was raised. But they are also concerned that antitrust laws can hamstring collaboration and that consumers still want doctors to practice like Marcus Welby despite emerging evidence that large, integrated systems may be our best hope for achieving high-quality, low-cost care.

But it was the question that had most regions stumped for that struck me as the most telling.  “Has anyone complained about rationing when you have been reducing cost by eliminating unnecessary procedures and tests?”   Finally someone said, people aren’t focused on that because they know what they are getting is better quality health care.  It seems to me that the lesson is that when you involve everyday people in the design process they really want better care and they understand that more care is not better care. 

I walked away persuaded more than ever that while we are a nation in search of reform, reform will actually happen one community at a time.  We need these lessons about collaboration that were on display at the symposium, the types of lessons that are also emerging from Aligning Forces.  These communities show us collaboration on reforming health care is not only possible, it’s happening.  We need to clear the obstacles in their path and stand back and learn.

Comments

[Brittanicus]

It tends to make a lot of good people despondent and at the least susceptible, when they read, watch and listen to the maverick storm of media ads, thumping down President Obama's health care initiative? Much of the rambling artifacts are the Simon and Lois ads of the Clinton administration, heavily armed against any revisions in this issue that wealthy insurance companies and subsidiaries won’t tolerate.

They insulted the senior citizens with their propaganda and bald faced lies about the European government run health care system. Being originally an Englishman myself, I guarantee in the 1960's, we had a unique form of medical services, inclusive of eye and teeth. Even government run medical care in Australia was exceptional. It did plummet down somewhat, when business starting recruiting foreign labor from the commonwealth and Northern Europe. Many were out for a free financial ride and got it, along with their large families that British citizens have to support with their limited pounds sterling.

Just as the anti-governmental health care extremists have been pounding the airwaves, the open border, globalist is now subjecting the American people to a torrent of inflaming immigration polls. But like all polls they can be intentional manipulated, in exactly how the questions are worded? Sure they can keep their co-pays, deductibles and pre-existing small-print clauses, squeezing every penny from a hurting economy, but tell the--BLOODY TRUTH!

It's a sad fact that you cannot trust the Liberal slant regarding this searing problem, although not all Liberals are favorable to another AMNESTY? The Democratic leadership, hiding liberal views behind closed drapes tried to annihilate any good, workable illegal immigration enforcement laws. In an earlier session of the Senate an error was made with E-Verify, so it's was fortunate to survive Sen. Reid and Pelosi’s notion? Anything that has an impact on removing illegal immigrants is intercepted by business oriented free traders.

GOOGLE---illegal immigration--to find out their sinister intention, to just throw open the gates, ports and airline entrances to cheap labor, that also become the downfall of the European Union. the polling I have seen has been calculatedly --ENGINEERED--to get results, that they can brandish around, declaring the majority of Americans believe in a path to citizenship and open borders? Already the Democrats are ready to flag the Save Act, 287(g) local police enforcement to weaken these laws.

Currently both issues have heavy fallout, and you the voter should let your Senator or Representative know your opinion on either matter at 202-224-3121---BEFORE IT'S TOO LATE. Both have massive consequences in costs and quality of life in your future and generations to come.WE MUST SAY NO AMNESTY! SEAL OUR BORDERS AND NO MORE FREEBIES TO ILLEGAL ALIENS. THEY ARE THE CRIMINALS, NOT AMERICANS WHO SACRIFICE TAXES? GOOGLE--NUMBERSUSA for details our government and the media have a nefarious talent, for keeping facts under wraps?

[Brittanicus]

It tends to make a lot of good people despondent and at the least susceptible, when they read, watch and listen to the maverick storm of media ads, thumping down President Obama's health care initiative? Much of the rambling artifacts are the Simon and Lois ads of the Clinton administration, heavily armed against any revisions in this issue that wealthy insurance companies and subsidiaries won’t tolerate.

They insulted the senior citizens with their propaganda and bald faced lies about the European government run health care system. Being originally an Englishman myself, I guarantee in the 1960's, we had a unique form of medical services, inclusive of eye and teeth. Even government run medical care in Australia was exceptional. It did plummet down somewhat, when business starting recruiting foreign labor from the commonwealth and Northern Europe. Many were out for a free financial ride and got it, along with their large families that British citizens have to support with their limited pounds sterling.

Just as the anti-governmental health care extremists have been pounding the airwaves, the open border, globalist is now subjecting the American people to a torrent of inflaming immigration polls. But like all polls they can be intentional manipulated, in exactly how the questions are worded? Sure they can keep their co-pays, deductibles and pre-existing small-print clauses, squeezing every penny from a hurting economy, but tell the--BLOODY TRUTH!

It's a sad fact that you cannot trust the Liberal slant regarding this searing problem, although not all Liberals are favorable to another AMNESTY? The Democratic leadership, hiding liberal views behind closed drapes tried to annihilate any good, workable illegal immigration enforcement laws. In an earlier session of the Senate an error was made with E-Verify, so it's was fortunate to survive Sen. Reid and Pelosi’s notion? Anything that has an impact on removing illegal immigrants is intercepted by business oriented free traders.

GOOGLE---illegal immigration--to find out their sinister intention, to just throw open the gates, ports and airline entrances to cheap labor, that also become the downfall of the European Union. the polling I have seen has been calculatedly --ENGINEERED--to get results, that they can brandish around, declaring the majority of Americans believe in a path to citizenship and open borders? Already the Democrats are ready to flag the Save Act, 287(g) local police enforcement to weaken these laws.

Currently both issues have heavy fallout, and you the voter should let your Senator or Representative know your opinion on either matter at 202-224-3121---BEFORE IT'S TOO LATE. Both have massive consequences in costs and quality of life in your future and generations to come.WE MUST SAY NO AMNESTY! SEAL OUR BORDERS AND NO MORE FREEBIES TO ILLEGAL ALIENS. THEY ARE THE CRIMINALS, NOT AMERICANS WHO SACRIFICE TAXES? GOOGLE--NUMBERSUSA for details our government and the media have a nefarious talent, for keeping facts under wraps?

[cheap soma online]

Our leader in each sector even in small towns must provide a much greater effort on our healthcare system. A bigger budget must be provided in each towns for this to happen.

[Affordable Health Insurance Quotes]

They dark areas are area's know for their high health care costs because of the diet they choose. It's not fair to everybody who chooses to be healthy. Hopefully the proposed sugar tax will pass. Those who choose poor diets and poor life choices should be held accountable and be responcible for paying for healthcare reform.

[Health Policy Prof]

Hopefully, the proposed sugar tax will NOT pass. I understand the problem obesity causes, but we cannot ignore the problems other eating disorders like anorexia causes, There is no such thing as unhealthy food: only unhealthy eating. The government's role is not to play "food police," taxing certain foods, labeling them as "bad;" requiring restaurants to include all sorts of calorie information for a patron's single meal at that restaurant. The proper role of the government is to provide information to its public - on nutrition and the benefits of exercise - and possibly on the private medical providers in the area --- and to run nutrition and exercise programs for the public. The government can compliment the private medical system to fill out our system to make it a true health care system. Our public health care system can be transformed to more fully accomplish its goals.