Tracking Medicine: A Researcher's Quest to Understand Health Care by
Book Description
August 26, 2010 0199731780 978-0199731787 1
Written by a groundbreaking figure of modern medical study, Tracking Medicine is an eye-opening introduction to the science of health care delivery, as well as a powerful argument for its relevance in shaping the future of our country. An indispensable resource for those involved in public health and health policy, this book uses Dr. Wennberg's pioneering research to provide a framework for understanding the health care crisis; and outlines a roadmap for real change in the future. It is also a useful tool for anyone interested in understanding and forming their own opinion on the current debate.
Editorial Reviews
Review
"There are many books on healthcare reform, health delivery, or systems research, but none that combine the science with practical experience like this one does." --Doody's
"The cost crisis now facing the
"Tracking Medicine should be required reading for all health care professionals, and indeed for all who are intrested in truly reforming health care... Highly recommended." --Choice
"The title of this book hints at a personal history:'researcher's quest . . .' Yet, John Wennberg has been the dominant force over several decades in studies to describe and understand American medicine. Thus, this personal narrative is also an excellent summary of our current understanding of US health care." -- American Journal of Epidemiology
About the Author
John E. Wennberg, MD, MPH, is Peggy Y. Thomson Professor (Chair) in the Evaluative Clinical Sciences, and Founder and Director Emeritus of The Dartmouth Institute for Health Policy and Clinical Practice.
CUSTOMER REVIEWS
An excellent book by the pioneer in medical utilization analysis, May 17, 2012
By Gaetan Lion
John Wennberg's pioneering work on the geographical variation of medical utilization was well documented in the first chapter of Shannon Brownlee's excellent book: Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. Nevertheless, it is fascinating to get the scoop from the horse's mouth.
Wennberg plays an instrumental role in the history of modern medicine. He is the pioneer who showcased that we do a lot of medical procedures that often hurt patients. He has documented and updated his findings extensively at his Dartmouth Atlas of Healthcare website.
Wennberg is a brilliant polymath, an MD with a degree in epidemiology. He also completed the course work towards a doctorate in sociology. And, he studied in depth the classic on the subject Introduction to Mathematical Sociologyby James Coleman. Thus, Wennberg is well equipped to handle related complex data analysis.
He categorizes health care in three categories:
1) Effective care. It is scientific based and necessary. There is no uncertainty in utilization here. This type of care accounts for only 15% of Medicare spending.
2) Preference-sensitive care. Here there are different treatment options (including no treatment `watchful waiting'). The science is not settled. This care accounts for 25% of Medicare spending.
3) Supply-sensitive care. The decision for care is made by a primary physician who refers patients to a specialist. The primary physician will utilize the specialist resources to their fullest capacity. Thus, utilization is very sensitive to health care supply. The more surgeons in a specific city, the more surgeries. The main issue is the geographical variation in frequency of care. Also, medical utilization is often negatively correlated with quality of outcome as confirmed by tracking Medicare patients. This care accounts for 60% of Medicare spending.
The improvement in health care efficiency entails focusing on 2) and 3) that account for an amazing 85% of Medicare spending and much of it is discretionary (wasted).
Wennberg uncovers the causes of geographical variation in utilization. One of them is health care supply (supply-sensitive care). Another cause is lack of consensus on treatment. The weaker the consensus the greater the divergence of a specific treatment utilization rate (preference-sensitive care). See fig. 4.1 on page 39 showing the wide range of utilization rates for Hysterectomy vs the narrow range fo Appendectomy for hospitals in three different states in 1975.
Wennberg uncovers that in health care less is better than more. This is true for many cancers. For curing breast cancer, Lumpectomy (just removing a breast tumor) combined with radiotherapy is better than the more invasive radical Mastectomy (removing the entire breast and underlying muscle tissues). Mastectomy rates are 8 times greater between the region with the highest rate vs. the region with the lowest rate (fig. 4.2 pg. 50). The PSA test to diagnose prostate cancer is a failure. It generates way too many false positive. The FDA approved the test to assist in monitoring prostate cancers that had already been diagnosed. When the PSA test was used as a preventive prostate cancer screening diagnostic used on a healthy population with very low incidence rate; the test in a Bayesian fashion generated a huge false positive rate. Even when a positive PSA test is accurate, a patient is often better off not treating his prostate cancer and opting for watchful waiting as this cancer typically progresses very slowly and does not affect lifespan. Wennberg states that 50% of older men have prostate cancer. But, 97% of men die of something else. Meanwhile, prostatectomy (removing the prostate) is associated with high rates of impotence and incontinence. Wennberg uncovers this operation is also ineffective in treating BPH (by triggering side effects worse than the condition). Prostatectomy rate in the highest region is 19 times greater than in the lowest region (fig. 4.2 pg. 50). Moving on to Hysterectomy, utilization rates are far higher than cancer treatment would justify. And, variation in such rates is huge (fig. 4.1 pg. 39).
Less is more for cardiovascular diseases too. To reduce heart attack risk, controlling cholesterol, blood sugar, blood pressure, and avoiding smoking are better than stents. Attacking plaque with stent is no better than treating it with drug alone. This is true in terms of lifespan, mortality rate, and heart attack recurrence. Stenting rates are 11 times greater between the region with the highest rate vs. region with the lowest rate (fig. 4.3 pg. 51).
Rates of surgeries are highly correlated over time. This entails that regions with high rates remain so. However, most surgery rates have gone up between 1996 and 2005. During this period, knee replacement surgery rates have increased by 61% and hip replacement by 37%.
Next, Wennberg leverages the seminal work of his colleague Elliot Fisher (covered in the second chapter of "Overtreated") that indicates that more care is not only wasted; it is dangerous. Fisher found that regions with higher spending on treatments were associated with mortality rates about 5% higher vs. lower spending regions. See the great variation in spending for different cities (Fig. 15.3 pg. 255) that seem almost perfectly correlated to mortality rates (Fig. 15.4 pg. 256) as the two graphs look almost identical. Patients’ satisfaction was also lower within those higher costs regions.
The divergence between the staffing and practices of high spending hospitals vs. low spending hospitals is huge (Table 10.1 page 168). The high spending ones have a lot more specialists, lot more beds, more patient days stay, more doctor's visits per patient, far more different doctors seeing patients. Yet, on all those extra health care resources used the high spending hospitals have a negative return for the patient in terms of higher mortality rates and lower patient satisfaction (Table 11.2 pg 178). Those findings are well controlled for income, demography, health, etc...
In chapter 12, Wennberg outlines all the reasons why we need to reform the way we manage chronic illness. "Doing everything possible" for an extra day of life does not work. It is a recipe for overuse, patient dissatisfaction, and in a counterproductive way earlier death. Reducing overuse is urgent because it is getting worse. Nationwide, the supply of health care has steadily risen (Table 12.1 data over 2001 - 2005 period. pg. 197) with more beds, more medical specialists per 1,000 chronically ill Medicare patient. This has resulted in a commensurate increase in supply sensitive care over the same period (Table 12.2. pg. 199) with a rise in the rate of patient days stay in intensive care, and in the rate of specialist’s visits. Additionally, overuse combined with geographic variation creates inequities. The efficient regions subsidize the inefficient ones from a Medicare financing standpoint. And, the inefficient regions punish their patients with higher out-of-pocket costs.
In chapter 13, Wennberg outlines his health care reform recommendations. They include:
1) Promoting organized systems of health care delivery to reduce overuse. Kaiser and the Mayo clinic deliver superior health care very efficiently. Doctors are salaried employee instead of entrepreneurs motivated by volume of surgeries and expensive treatments;
2) Establishing informed patient choice as the ethical and legal standard for decisions regarding elective surgeries and treatment and care at the end of life. Demand for surgeries would be more patient instead of doctor driven. Overuse in preference-sensitive and supply sensitive care would be lessened;
3) Improving the science of health care delivery;
4) Constraining undisciplined growth in health care capacity and spending. Medicare is to reduce reimbursement rates in high cost regions to reduce overuse of supply side care. It is also to reduce reimbursement rates for elective surgeries and treatments with little benefit (reduce preference sensitive treatment). The Government that subsidizes med schools should exert a greater influence on the regional supply of doctors and the doctor's mix. Both factors have a large impact on supply-sensitive care.
In the Epilogue written with Shannon Brownlee (author of "Overtreated"), they review Obamacare (Affordable Care Act) who had passed in March 2010, just months before the book was published. They acknowledged that on most counts, Obamacare is a step in the right direction as it addresses all of Wennberg's recommendations outlined within chapter 13. More specifically, within the Act the development of Accountable Care Organizations (ACO) would promote organized systems of health care. The Act also establishes a patient choice protocol (reduce overuse of preference-sensitive care). And, it would fund annually $500 million towards comparative effectiveness research focused on drugs and medical devices. And, a new Workforce Commission would monitor health care labor supply (reduce overuse of supply sensitive care).
We will just have to wait whether the Supreme Court passes or strikes down the Act probably within a month after I wrote this review.
Wennberg plays an instrumental role in the history of modern medicine. He is the pioneer who showcased that we do a lot of medical procedures that often hurt patients. He has documented and updated his findings extensively at his Dartmouth Atlas of Healthcare website.
Wennberg is a brilliant polymath, an MD with a degree in epidemiology. He also completed the course work towards a doctorate in sociology. And, he studied in depth the classic on the subject Introduction to Mathematical Sociologyby James Coleman. Thus, Wennberg is well equipped to handle related complex data analysis.
He categorizes health care in three categories:
1) Effective care. It is scientific based and necessary. There is no uncertainty in utilization here. This type of care accounts for only 15% of Medicare spending.
2) Preference-sensitive care. Here there are different treatment options (including no treatment `watchful waiting'). The science is not settled. This care accounts for 25% of Medicare spending.
3) Supply-sensitive care. The decision for care is made by a primary physician who refers patients to a specialist. The primary physician will utilize the specialist resources to their fullest capacity. Thus, utilization is very sensitive to health care supply. The more surgeons in a specific city, the more surgeries. The main issue is the geographical variation in frequency of care. Also, medical utilization is often negatively correlated with quality of outcome as confirmed by tracking Medicare patients. This care accounts for 60% of Medicare spending.
The improvement in health care efficiency entails focusing on 2) and 3) that account for an amazing 85% of Medicare spending and much of it is discretionary (wasted).
Wennberg uncovers the causes of geographical variation in utilization. One of them is health care supply (supply-sensitive care). Another cause is lack of consensus on treatment. The weaker the consensus the greater the divergence of a specific treatment utilization rate (preference-sensitive care). See fig. 4.1 on page 39 showing the wide range of utilization rates for Hysterectomy vs the narrow range fo Appendectomy for hospitals in three different states in 1975.
Wennberg uncovers that in health care less is better than more. This is true for many cancers. For curing breast cancer, Lumpectomy (just removing a breast tumor) combined with radiotherapy is better than the more invasive radical Mastectomy (removing the entire breast and underlying muscle tissues). Mastectomy rates are 8 times greater between the region with the highest rate vs. the region with the lowest rate (fig. 4.2 pg. 50). The PSA test to diagnose prostate cancer is a failure. It generates way too many false positive. The FDA approved the test to assist in monitoring prostate cancers that had already been diagnosed. When the PSA test was used as a preventive prostate cancer screening diagnostic used on a healthy population with very low incidence rate; the test in a Bayesian fashion generated a huge false positive rate. Even when a positive PSA test is accurate, a patient is often better off not treating his prostate cancer and opting for watchful waiting as this cancer typically progresses very slowly and does not affect lifespan. Wennberg states that 50% of older men have prostate cancer. But, 97% of men die of something else. Meanwhile, prostatectomy (removing the prostate) is associated with high rates of impotence and incontinence. Wennberg uncovers this operation is also ineffective in treating BPH (by triggering side effects worse than the condition). Prostatectomy rate in the highest region is 19 times greater than in the lowest region (fig. 4.2 pg. 50). Moving on to Hysterectomy, utilization rates are far higher than cancer treatment would justify. And, variation in such rates is huge (fig. 4.1 pg. 39).
Less is more for cardiovascular diseases too. To reduce heart attack risk, controlling cholesterol, blood sugar, blood pressure, and avoiding smoking are better than stents. Attacking plaque with stent is no better than treating it with drug alone. This is true in terms of lifespan, mortality rate, and heart attack recurrence. Stenting rates are 11 times greater between the region with the highest rate vs. region with the lowest rate (fig. 4.3 pg. 51).
Rates of surgeries are highly correlated over time. This entails that regions with high rates remain so. However, most surgery rates have gone up between 1996 and 2005. During this period, knee replacement surgery rates have increased by 61% and hip replacement by 37%.
Next, Wennberg leverages the seminal work of his colleague Elliot Fisher (covered in the second chapter of "Overtreated") that indicates that more care is not only wasted; it is dangerous. Fisher found that regions with higher spending on treatments were associated with mortality rates about 5% higher vs. lower spending regions. See the great variation in spending for different cities (Fig. 15.3 pg. 255) that seem almost perfectly correlated to mortality rates (Fig. 15.4 pg. 256) as the two graphs look almost identical. Patients’ satisfaction was also lower within those higher costs regions.
The divergence between the staffing and practices of high spending hospitals vs. low spending hospitals is huge (Table 10.1 page 168). The high spending ones have a lot more specialists, lot more beds, more patient days stay, more doctor's visits per patient, far more different doctors seeing patients. Yet, on all those extra health care resources used the high spending hospitals have a negative return for the patient in terms of higher mortality rates and lower patient satisfaction (Table 11.2 pg 178). Those findings are well controlled for income, demography, health, etc...
In chapter 12, Wennberg outlines all the reasons why we need to reform the way we manage chronic illness. "Doing everything possible" for an extra day of life does not work. It is a recipe for overuse, patient dissatisfaction, and in a counterproductive way earlier death. Reducing overuse is urgent because it is getting worse. Nationwide, the supply of health care has steadily risen (Table 12.1 data over 2001 - 2005 period. pg. 197) with more beds, more medical specialists per 1,000 chronically ill Medicare patient. This has resulted in a commensurate increase in supply sensitive care over the same period (Table 12.2. pg. 199) with a rise in the rate of patient days stay in intensive care, and in the rate of specialist’s visits. Additionally, overuse combined with geographic variation creates inequities. The efficient regions subsidize the inefficient ones from a Medicare financing standpoint. And, the inefficient regions punish their patients with higher out-of-pocket costs.
In chapter 13, Wennberg outlines his health care reform recommendations. They include:
1) Promoting organized systems of health care delivery to reduce overuse. Kaiser and the Mayo clinic deliver superior health care very efficiently. Doctors are salaried employee instead of entrepreneurs motivated by volume of surgeries and expensive treatments;
2) Establishing informed patient choice as the ethical and legal standard for decisions regarding elective surgeries and treatment and care at the end of life. Demand for surgeries would be more patient instead of doctor driven. Overuse in preference-sensitive and supply sensitive care would be lessened;
3) Improving the science of health care delivery;
4) Constraining undisciplined growth in health care capacity and spending. Medicare is to reduce reimbursement rates in high cost regions to reduce overuse of supply side care. It is also to reduce reimbursement rates for elective surgeries and treatments with little benefit (reduce preference sensitive treatment). The Government that subsidizes med schools should exert a greater influence on the regional supply of doctors and the doctor's mix. Both factors have a large impact on supply-sensitive care.
In the Epilogue written with Shannon Brownlee (author of "Overtreated"), they review Obamacare (Affordable Care Act) who had passed in March 2010, just months before the book was published. They acknowledged that on most counts, Obamacare is a step in the right direction as it addresses all of Wennberg's recommendations outlined within chapter 13. More specifically, within the Act the development of Accountable Care Organizations (ACO) would promote organized systems of health care. The Act also establishes a patient choice protocol (reduce overuse of preference-sensitive care). And, it would fund annually $500 million towards comparative effectiveness research focused on drugs and medical devices. And, a new Workforce Commission would monitor health care labor supply (reduce overuse of supply sensitive care).
We will just have to wait whether the Supreme Court passes or strikes down the Act probably within a month after I wrote this review.
Wennberg has analyzed the core problem with American Health Care, March 11, 2012
By Paul Buehrens (Seattle , WA USA
I'm a practicing family doctor, medical director of a private practice group, and student of health care economics, health reform, policy, and of the law of unintended consequences. Jack Wennberg has been constructing a model of how the health care system in America is actually working, and has brought many of his comprehensive studies together in this book. His research is extremely well done and the conclusions are rather startling, even to me! The level of unwarranted variation in health care is amazing, and is fractal: the variation is at ALL levels!
His conclusion that we MUST control the unconscionable construction mania among hospitals is unassailable: hospitals are clearly the key source of unwarranted utilization, and with no apparent positive, and a small but clear negative effect on people's outcomes, health, and pocketbooks. Yet even the most efficient parts of the system have huge unwarranted variation, with large room for improvement.
After reading his book, readers should take a look at some of the amazing reports at the Dartmouth Atlas, the core outgrowth of this research. Primary care doctors should commit to becoming part of the solution by bringing back in-house the process of informing patients with evidence about proposed procedures. Well informed patients have learned the negatives as well as the positives of proposed procedures partialists want to perform, and we generalists are the only folks who will help patients understand their choices well enough. Paul Buehrens MD
His conclusion that we MUST control the unconscionable construction mania among hospitals is unassailable: hospitals are clearly the key source of unwarranted utilization, and with no apparent positive, and a small but clear negative effect on people's outcomes, health, and pocketbooks. Yet even the most efficient parts of the system have huge unwarranted variation, with large room for improvement.
After reading his book, readers should take a look at some of the amazing reports at the Dartmouth Atlas, the core outgrowth of this research. Primary care doctors should commit to becoming part of the solution by bringing back in-house the process of informing patients with evidence about proposed procedures. Well informed patients have learned the negatives as well as the positives of proposed procedures partialists want to perform, and we generalists are the only folks who will help patients understand their choices well enough. Paul Buehrens MD
HELP!!! Healthcare Reform Desperately Needed!!!, May 7, 2011
Read this book too (along with Overtreated) if you want to understand what has gone wrong with American Medicine.
It always a pleasure to hear a brilliant scientist explain his work. But it is also a revelation to hear such a figure explain how he worked his way through the data with a good deal of self observation, willingness to acknowledge mis-steps and point-by-point response to those who try to provide alternative explanations to his results. Wennberg explains the studies done by the Dartmouth Health Atlas Project, how they altered his original beliefs and gradually caused him to recognize the omnipresence of self-delusion in much of the
medical-industrial complex.
Wennberg's original mission was to examine practices across the state ofVermont to make sure that rural areas were receiving the same "excellent" care as those living near academic medical centers. Looking for underserved populations, he developed a map of regions served by various medical centers and began looking at the frequency of various procedures corrected for population size. In one town, 60% of the children had had their tonsils removed by age 15, while in the next town over only 20% of the kids were tonsils free. The odds that a women had had a hysterectomy varied fourfold from region to region. Hospitalization for digestive diseases varied two fold, and for respiratory ailments, threefold. Given the relative homogeneity of the population, these differences in practice patterns made no sense. And death rates, and average age at death, were indistinquishable across regions. Rather than justifying his original concern over undertreatment, Wennberg's data made a strong case for overutilization of dubiously effective procedures favored in the local community. Furthermore, it was not the case that one region had higher utilization rates for all procedures or hospitalizations. A region with high rates for one procedure might have the lowest rate for another. Thus was born his insight that, in healthcare, "geography is destiny". What kind of medical care a patient received seems to be largely a result of local medical culture and beliefs rather than some uniform (i.e., scientifically validated) standard. A series of larger and larger projects let Wennberg and his colleagues examine different states and eventually the entire U.S. But the original patterns held - wide practice variability that followed no coherent pattern and without demonstrable benefit for outcomes.
Because he's a physician, Wennberg was able to sit down with surgeons and try to get them to explain how they decided surgery was necessary in a given case. What he found was that the decision rules used by one surgeon were totally different from, and sometimes contradictory to, another surgeon's rules. In the course of trying to understand all of this, he stumbled across a forgotten study looking at referrals for tonsillectomy inNew York City schools. When 400 children were examined, half were felt to need a tonsillectomy. When those not referred were blindly re-examined, another 40% were referred for the procedure. For the kids rejected twice, and again blindly re-examined, another 44% were recommended. In short, referral seemed to driven not by any objective reason but a belief that half of all children seen should be referred!! This is what passes for medical science? ....
How can a system be devised which protects patients from these kind of irrational variations in care? How can we hold Medicine's feet to the fire of scientific validation? "Evidence-Based Care" is hard work, time-consuming and must consume a much larger proportion of our healthcare research dollars. When patient outcomes are more important in medical research than biomechanisms, we will be on the right path.
It always a pleasure to hear a brilliant scientist explain his work. But it is also a revelation to hear such a figure explain how he worked his way through the data with a good deal of self observation, willingness to acknowledge mis-steps and point-by-point response to those who try to provide alternative explanations to his results. Wennberg explains the studies done by the Dartmouth Health Atlas Project, how they altered his original beliefs and gradually caused him to recognize the omnipresence of self-delusion in much of the
medical-industrial complex.
Wennberg's original mission was to examine practices across the state of
Because he's a physician, Wennberg was able to sit down with surgeons and try to get them to explain how they decided surgery was necessary in a given case. What he found was that the decision rules used by one surgeon were totally different from, and sometimes contradictory to, another surgeon's rules. In the course of trying to understand all of this, he stumbled across a forgotten study looking at referrals for tonsillectomy in
How can a system be devised which protects patients from these kind of irrational variations in care? How can we hold Medicine's feet to the fire of scientific validation? "Evidence-Based Care" is hard work, time-consuming and must consume a much larger proportion of our healthcare research dollars. When patient outcomes are more important in medical research than biomechanisms, we will be on the right path.
John Wennberg's book, Tracking Medicine, a researcher's quest to understand health care, challenges anyone interested in health information technology or the Affordable Health Care Act to a `must read.` Wenneberg spent 40 years applying statistical analysis to the care given in various
Patient satisfaction, outcome and longevity -- even in some teaching centers - proved inversely related to the intensity of medical, surgical and hospital services. Furthermore, Wennberg found that the greater the capacity of the facility and number of specialists per capita, the greater the intensity of care. Intriguingly, he found that providers were completely unaware of this variation. Present day Certificates of Need, required for expanding the number of hospital beds -- and in large measure many other provisions in the Affordable Health Care Act - indeed reflect much of Wennberg's research.
Wennberg together with the Dartmouth Institute of Health Policy and Clinical Practice proposed four policies to improve clinical medicine and quality. They suggested:
1. Organized local systems
2. Decreasing overtreatment by shared decision making between patient and doctor
3. Strengthening the science of health care delivery
4. Constraining undisciplined growth in health care capacity
Variation Capacity and Outcome
Striking variations in the frequency of certain surgeries occurred in adjacent communities. Tonsillectomies, prostatectomies and hysterectomies varied by large factors. The surgical rate varied in proportion to the number of beds and or surgeons per population. Wennberg called this phenomena "supply sensitive care." A consistent and validated inverse relationship existed between the oversupply of providers versus patient satisfaction and outcome. Chronic disease appeared to be the greatest problem wherein institutions provided high cost acute care -- Wennberg called it "rescue care" - while neglecting lower cost managed care by primary care physicians, patient involvement and patient education. An even greater expense associated with intensity of care, based on capacity appeared to place terminally ill patients in ICU often against their wishes but with the same terminal outcome.
Communities with a high number of specialists per capita experienced worse outcomes than populations with a constrained availability of care. This statistically validated phenomenon flew in the face of conventional wisdom and the belief that American hospitals are best and more is better. Controversial, to say the least, and argued by some of the most respected medical centers, the striking variation in treatment, the relation of excess care to capacity, and the surprising inverse relation of more care to poor outcome and poor patient satisfaction, remains a valid and highly reproducible statistic.
Reasons to reform:
1. Over reliance on rescue care
2. Acute care hospitals for chronic illness
3. Excessive capacity per population
4. The establishment of more skilled nursing facilities, outpatient, and home care has not reduced inpatient use, ICU, and a high tech death.
5. Over use will not go away - getting worse
6. Not just Medicare but private fee for service as well
7. Organized care does not reduce the over use of ICU
8. Cross market subsidy of insurance premiums; that is, low use areas of care pay equally with high use populations in effect subsidizes unnecessary care.
9. Increased co-pay in high use areas a burden on patients in these areas of overuse
10. Overuse equates to decreased life expectancy for the patient
Wennberg makes the point that organized care with shared savings may be able to "rationalize the black box of supply sensitive care." He advocated practice and hospital networks, but cautions that cost may not always decrease with decreased capacity due to cost shifting. He suggests that the major cost to Medicare and other insurance stems from ICU care for terminal patients. Wennberg believes that encouraging a patient's fully informed participation in medical decisions puts the brakes on overtreatment and is the way to reign in excessive and sometimes harmful care. Such participation, however, calls for a radical change in the culture of doctor patient interaction.
Wennberg's final list of remedies
1. Fully informed participation of patient in decision
2. Constrain spending on supply sensitive care
3. Constrain preference sensitive surgery
4. Decrease the number of doctors, specialists and hospital capacity.
5. Adjust insurance premiums by local area spending
6. Feedback of information about practice variation, tracking both the variation and outcome
Wennberg particularly likes the provision in the Patient Protection and Affordable Care Act of 3/2010 specifying an
John E. Wennberg, M.D. Peggy Y. Thomson Professor (Chair) for the Evaluative Clinical Sciences, Professor of Community and Family Medicine (Epidemiology) and of Medicine Department of Community and Family Medicine and The Dartmouth Institute for Health Policy and Clinical Practice Educated Mc Gill University, MD 1961 Johns Hopkins School of Hygiene and Public Health, MPH 1966
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This book makes a huge contribution to our understanding of the problems with US medical care. The statistics speak for themselves. They fly in the face of conventional wisdom of providers, well-meaning planners and patients' families many of whom take exception to some of the end of life research, proposed in the Affordable Care Act.
I am not a statistician, but I was a primary care clinician and manager of an efficient primary care clinic. I managed other physicians and consultants, -- not an easy task -- and I wrestled with the contentious changes that took place in the late 80s and early 90s. As such and with considerable time to think it over, I suggest that many more problems plague our health care delivery system, problems that need validation and in some case adjudication. While I am enthusiastic about reform and much of the good in the plan, I am not at all certain that the Affordable Health Care Act solves all of these problems.
For example, let me list some of the problems that seem largely overlooked:
1. The US ranks embarrassingly low in all measure of public health statistics among industrialized nations. The
2. We pay little attention to European health care systems all of which seem to be out performing our own
3. The well-established routine of increasing usual and customary fees to an ever higher and higher level to offset the discounted reimbursements, to both hospitals and physicians
4. The uninsured receiving all of their health care in the emergency room, because the ER cannot refuse care - widely acknowledged to be the most expensive form of medical delivery.
5. Hospital charges spiraling higher and higher due to the above
6. HMOs requiring referral only to the HMO listed specialists who are much less qualified, as a rule, than specialists referred to by the primary care doctor and who due to their abilities do not need the problems of contracting with an HMO.
7. The extreme discrepancy between primary care reimbursement and specialist reimbursement, which has lead to a dearth of primary care physicians and an overabundance of specialists
8. The very high liability insurance premium paid in advance by all providers but especially by the high risk surgical specialties
9. The difficulty for treating physicians to access current medical terminology, criteria of diagnosis etc at the time of patient contact
10. The expense of journals, CME and even Internet access to current medical journal articles
11. The increased competitive capacity and less scientific medicine engendered by patients migration to alternative medicine, alternative practitioners, autonomous physician extenders etc. decisions often based on the attraction of lower cost and in some cases a desire to return to nature. (Natural childbirth at home without anti natal care might be an example)
12. The abuses of drug companies: outrageously high prices -- semi-fraudulent re-patenting of popular drugs, who's patent is expiring, in order to extend their high prices and keep these products out of the generic drug market
13. The failure of insurance companies to provide a demand side restraint on healthcare coast thus enriching their own revenue with ever higher premiums
14. The characterization of medicine as a business and a free market rather than as a profession and a critical infrastructure
15. Using the threat of antitrust action, Health and Human Services and Hospital administrators, CEOs ended the local medical societies ability to censure its members and hold accountable member's behavior both in and out of the hospital.
16. The loss of medical society input in hospital staff credentialing and privileges
17. Medical conditions, which fall outside the prevue of the specialist or between specialties leads to missed diagnosies.
18. The inaccuracy of reported medical diagnosis, thus a corruption of the data base leading to erroneous statistical analysis and attempts to draw conclusions from insurance reports
19. Misdiagnosis resulting in protracted illness or worse
20. The requirement for a qualifying diagnosis to justify a laboratory test
21. Excessive CAT scans may be in part economically motivated and driven by malpractice law suits while sadly delivering excessive radiation exposure
22. The C-section rate and a continuing high hysterectomy rate
23. The poor distribution of physicians in relation to population Physicians migrate to attractive geographic locations with per capita income and amenities
24. General lack of Clinical Pathological Conferences, CPC or Morbidity and Mortality, M&M conferences, (except in major teaching hospitals and medical schools)
25. Rare or nonexistent autopsies We once judged hospitals by their autopsy rate. The autopsy and the CPC accounted for much of our past glory of
26. Does not address the patient's unhealthy attitude towards self-care whilst demanding a pill or a procedure to bail him or her out of an unsustainable life style
27. Government takes a punitive rather than educational approach to regulation of the system
Greed dominates the healthcare economy, not so much by mainstream providers as by an opportunistic periphery, a tsunami of players entering the Health Care industry to take advantage of its commercialization. Health Care is not a Free Market! It is a profession and vital
The Patient Protection & Affordable Health Care Act strives to eliminate many of the insurance abuses. However, we continue to interdict access to the big dollars by policing access but the core issue is no different from the flow of illegal drugs from
Punitive efforts to curtail overtreatment and abuses of the system paradoxically enable and promote the greed by gaming around the regulations. Solving any of these problems requires a change in both the culture of Medicine and the culture of Regulation - in favor of graduate education, information technology and a commitment to excellence. A public option by the states, run by the state's medical schools in partnership with Public health with salaried physicians run in competition with traditional fee-for-service may be the best way to get there. A serious look at European Health Care systems may tell us what works. I suspect it will require a major reeducation of our population in healthy life styles. Infant mortality will be a useful barometer to measure progress.
"The commission -- created by President Obama to address
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