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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5 replies »

  1. 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 other 3? Whatever that answer is, it is something that is available today in Minnesota, Iowa, and Oregon.

  2. 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:

  3. 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 overcome the provider lobbies until 2015. I do think I have more than mere hope, in that I’ve been arguing that universal coverage actually creates a mechanism (multiple mechanisms actually) to precipitate the deep reforms to how care is delivered and paid for.
    I’d say that if we all we do is expand SCHIP and add a health insurance connector, then it’s true we won’t have the impetus or leverage to make major provider side changes until around 2015. However, if we actually create a universal health care scheme in the next year I think the following changes will occur:
    1. liberals will turn energy from universal health care to outsized incomes and profits (not just among insurers). The left is well-represented among the thought-leaders for delivery system reform, but they haven’t had much traction with the rank and file because it is obsessed with insurance coverage, rejections of coverage based on underwriting, and claims denials. With standardization of benefits, removal of underwriting and universal coverage, it will become quickly clearer that the large majority of the cost problem lies with providers.
    2. Conservatives will almost overnight turn from defending the current system and its waste to attacking it. There are a few conservatives who do understand the massive inefficiencies of the system, but hardly any elected politician does (or is willing to state it publicly). But once the waste is associated with a government program and subsidized by government, conservatives will attack waste in the system as part of their attack on big government. The trick will be to channel that criticism away from reducing benefits (catastrophic coverage) and towards reducing wasteful, overpriced care.
    3. The middle class and upper middle class will feel the bite of additional taxes for universal coverage more than anyone. Probably not immediately, due to a desire not to raise taxes during the recession, but within a couple of years. This will lead to increased demands for a better bang for the buck from health care, and I think we’ll see a lot more stories on the bloated system and deceptive practices like we’ve begun to see in the NY Times, Boston Globe and other media outlets.
    Obviously, I’m oversimplifying, but I think we do have to consider how universal health care can change the game when it comes to delivery system reform. A greater focus on delivery system reform from any one of the groups above probably won’t speed up reforms, due to the huge power and persuasive ability of provider lobbies. However, if all three groups shift roughly as I’ve described, I think we can see major reforms as early as 2011, not 2015.

  4. 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 is no other choice.

  5. 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 much result.

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