The Dartmouth Atlas Project – The Health Care Blog

The Return of Conservative Medicine

Dec 1, 2018

By Kenny Lin, MD

Forty years ago, Dr. Jack Wennberg and colleagues at Dartmouth Medical School published the first of a series of groundbreaking studies of medical resource utilization and practice variations that would eventually become the Dartmouth Atlas of Health Care.

They found huge variations in how often elective surgeries such as tonsillectomies were performed in different parts of New Hampshire, even in neighboring cities and counties.

These geographical variations could not be explained by differences in the demographics or health of patient populations, and outcomes in areas with more surgeries per capita were no better, and sometimes worse, than in those with fewer surgeries. Subsequent studies identified similar unwarranted variations in many other procedures and treatments paid for by Medicare, leading to a consensus among policymakers that the U.S. health system spends hundreds of billions of dollars each year on medical care (termed “waste”) that has no health benefits and often harms patients.

To my profession’s credit, physician organizations are finally taking unprecedented steps to confront the problem of waste in medicine. The American Board of Internal Medicine Foundation’s Choosing Wisely campaign, which asks each partnering group to identify 5 commonly performed tests or treatments that should be questioned by physicians and patients, has signed up more than 50 specialty organizations to date, with more to come in the next several months.

This week, screening and diagnostic experts from all over the world gathered at Dartmouth to discuss strategies for Preventing Overdiagnosis, a problem that is largely created by physicians looking too hard for diseases with imperfect tests that lead to many false positive results and more invasive procedures, such as biopsies. (Even if the tests themselves were perfect, they are often performed in patients who could not possibly benefit from the results, such as patients with terminal cancer.)

But if the problems of medical waste and overdiagnosis are familiar to doctors, most patients are still in the dark about the basics. Continue reading…

Measuring What Matters for ACOs

Feb 4, 2014• 9

By Fisher, Schpero & Corrigan

More than 55 percent of the U.S. population now lives in a local area with an accountable care organization (ACO), in which a group of providers is held accountable by a payer for the total cost and quality of care for a defined set of patients. The spread of ACOs, however, by no means ensures their success.

Significant questions remain about whether the goals of the model—better care at lower costs—will be achieved.

There are some signs that the ACO model—by rewarding provider organizations for implementing high quality mechanisms for care delivery that lower overall costs—is driving innovation in the marketplace. For example, the Montefiore ACO in New York City is using special scales in the homes of patients with congestive heart failure to monitor for changes in weight that could indicate trouble.

Walgreens has formed three ACOs and is using its retail pharmacies as low-cost care centers. In addition, the Beth Israel Deaconess Care Organization created a high-touch care management system in which nurse practitioners visit the ACO’s sickest patients at home to reduce the number of hospital readmissions.

Yet, there are also challenges inherent in the adoption and implementation of the ACO model. There have been several wide-ranging proposals on how to enhance accountable care, especially in Medicare, but we believe that developing policies to standardize measurement is an important first step.

First, we need to promote adoption of a core set of effective measures across payers. Current measures, such as screening for high blood pressure, are limited in scope and fail to incorporate important dimensions, including health outcomes meaningful to patients and the total cost of care for those within the ACO. Proposals for more advanced measures have been developed but not yet adopted, in part because of provider concerns about being held accountable for aspects of performance they do not fully control.

These issues could be addressed by operationalizing the concept of “shared accountability” through patient engagement and partnerships, as with local, multistakeholder community health coalitions, and embracing a core set of more challenging and meaningful metrics, such as functional health and total costs per capita.