Tag: Dartmouth Atlas

Connecting value to coverage: a first glimpse

MPainterWould you take a virtual walk with me across the Dartmouth Atlas map on RWJF's web site?  Just follow the link.  Now, move your cursor first over, say, anywhere in Minnesota.  There, you'll see that 2006 Medicare reimbursements were roughly $6,700 per beneficiary.  Now, move your cursor across the country, way over to Massachusetts–specifically, Boston, for instance.  There, 2006 Medicare reimbursements were almost a whopping $3,000 per beneficiary higher.  You'd sure think that the quality of care in Massachusetts must be extraordinarily better for that extra $3,000 per person–but, guess what?  It's not–it's roughly the same–maybe even worse in some cases.  Plus, Massachusetts has embarked on its own universal coverage experiment.  First in its class, Massachusetts is providing the rest of us with a real-world unfolding example demonstrating how health care cost, quality, value, and coverage intersect.  If Massachusetts could figure out how to pay for high-quality care at the level of, say, Minnesota, their coverage experiment might just get exponentially easier.

So, are our national leaders taking this unfolding lesson to heart?  We're beginning to learn.  Last week the Senate Finance Committee released a set of policy options on transforming the health care delivery system.  Their statement is really the first glimpse we've had at how our national leaders might (or might not) be linking value and coverage.

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Are We Mature Enough to Make Use of Comparative Effectiveness Research?

Thanks to White House budget director Peter Orszag, a Dartmouth Atlas aficionado, $1.1 billion found its way into the stimulus piñata for “comparative effectiveness” research. Terrific, but – to paraphrase Jack Nicholson – can we handle the truth?

In other words, are we mature enough to use comparative effectiveness data to make tough decisions about what we will and won’t pay for? I worry that we’re not.

First, a bit of background. Our health care system, despite easily being the world’s most expensive, produces (by all objective measures) relatively poor quality care. Work begun 3 decades ago by Dartmouth’s Jack Wennberg and augmented more recently by Elliott Fisher has made a point sound-bitey enough for even legislators to understand: cost and quality vary markedly from region to region, variations that cannot be explained by clinical evidence and do not appear to be related to health care outcomes. In other words, plotting a 2×2 table with costs on one axis and quality on the other, we see a state-by-state Buckshot-o-Gram.

Three key conclusions flow from this “variations research”:

  • Lots of what we do in health care is costly and ineffective
  • We must somehow goose the system to move all providers and patients into the high quality, low cost quadrant on that 2×2 table; and
  • Better evidence about what works would help with such goose-ing.Continue reading…


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