Jack says cover the uninsured & spend less!

It’s no secret what the Dartmouth group’s solution for the health care system has been — reduce practice variation, get surgery and physician resource use rates similar to the Mayo Clinics’ of the world, and take the huge savings that would be generated to cover the uninsured. In fact Wennberg, Skinner, Fisher & Weinstein, now joined by “gone native” journalist Shannon Brownlee, have a new White Paper out—their own open letter to Obama’s mob.

Along the way that requires demand-side reductions (achieved by shared decision making) and supply side changes.

And there’s the rub. The Dartmouth gang logically point out that we
don’t need more doctors, and of course in their perfect world we
wouldn’t. But if we were to remake the world in (say) Mayo’s image,
we’d need a whole lot less of certain specialists and hospital spending
than we have now, and therefore a whole lot of specialists and
hospitals would be spending a whole lot of time telling Congress that
patients were going to be denied care.

Now, the Dartmouth gang have some chance of getting their message
across. As of Jan. 20, Peter Orszag will control White House bean
counting—and he’s a Dartmouth devotee. But realistically I can’t see
any of the logical policy initiatives that would flow from this
analysis coming as part of the new Obama/Daschle/Baucus initiative.

They’ll need too much help in Congress to get pay or play, the new
Medicare/Medicaid expansion, and the national connector up and running
(not to mention going after AHIP) to savage the doctors and hospitals
big time. And anyway, we don’t care about not spending money now—in
fact spending more money is good! (As Bush said, the government should
just go shopping!)

Of course (as regular commentator JD has been saying) once if we’ve done the coverage thing, and once if there is one organization (e.g. an expanded Medicare) that controls much of overall spending, and once
if Congress starts caring about government spending levels again, then
the Dartmouth ideas will suddenly become relevant like the scribblings
of some defunct economist. Around 2015, my guess.


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bruce quinnMark Reiboldtjdbev M.D.R.K. Pandey Recent comment authors
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bruce quinn
bruce quinn

The implications of the Dartmouth Atlas is not usually fully grasped, although their current detailed white paper moves in that direction. The point of the Atlas is that if the other 47 states gave healthcare with similar effectiveness and intensity to the care in Minnesota, Iowa, and Oregon, US healthcare costs would drop by a third. From this perspective, the cost issue is not a billion-dollar comparative effectiveness institute, a billion dollar electronic health record plan, etc. The question boils down to, what are the three fastest and most effective ways to make healthcare in 47 states look like the… Read more »

Mark Reiboldt

Mr. Holt, I think this issue relates to a much larger question of how hospitals are trying to overcome hurdles placed by the inefficiency of the system while also trying to navigate through a challenging financial crisis like every other business/industry out there. The credit crunch has especially hit hospitals hard, which has only added fuel to the fire of the burden hospitals feel for providing uncompensated care. This care increased 8% just in the 3Q of 2008. I wrote up some thoughts on it here:


bev, what you say is true: specialists could retrain. However, why would they want to? Doing so would in general result in a big pay cut, it would require some to go back to school and to some extent start over. Specialists also tend to have a lot more control over their time than primary care physicians and to look down on them (consciously or not). So while they could retrain, they will not want to and their lobbies will fight fiercely and effectively to ensure that they don’t have to. Matt, I really hope you’re wrong that we won’t… Read more »

bev M.D.
bev M.D.

As for too many specialists, there is such a thing as re-training and, if they don’t have any business, some specialists will select this choice. Those who are specialists in non-surgical specialties already trained in internal medicine, which can provide primary care (exclusive of pediatrics and ob-gyn, but I don’t think we should go back THAT far to the country doc days.) And many specialist surgeons started out with a general surgery residency and specialized from there – and guess what kind of surgeon is becoming a rare species these days? General surgeons! See, it’s not so hard if there… Read more »

R.K. Pandey

The saving in healthcare is by focussing on wellness, reducing the wasted (overcare), reduction in number of bureaucrats, etc. to name the few. I am not sure if there is really a shortage of doctors..while I agree there may be problem with the distribution. Did you know that over the years, numbers of hours worked by doctors have gone down while the salaries have gone up! No solution to healthcare is possible if we focus narrow pieces. We have to have someone facilitate the discussion around total scope. Otherwise, these distracted and destructive discussions on pointing fingers will continue without… Read more »