This month I received a letter from a physician who was dismayed to learn that a colleague was leaving medical practice. He wrote in his letter, “One of my dear friends was nudged into retirement because he didn’t order enough tests on the equipment which his practice had purchased…. His loss [to the field] is immeasurable; he was able to substitute good clinical judgment for a bevy of tests.”
The mantra in health care today is volume, volume, volume. In this highly caffeinated system, many doctors are required to meet productivity targets for diagnostic tests, surgeries, and office visits. As payers ratchet down payment per unit of service, the incentive exists to increase volume, and the cycle perpetuates itself.
Since the 1970s, Dartmouth researchers have brought to light unwarranted variation in health care services. Devotees of the research will remember the compelling finding in the early work of John Wennberg, which revealed that 60 percent of men in some communities in Maine had prostate surgery by the time they were age eighty, while in other communities, 20 percent of men had had the surgery.
Foundations have made major contributions to the Dartmouth research. The early findings from small-area analysis in New England were extended to the whole United States, and the Dartmouth Atlas became a web-based resource for researchers, health care providers, journalists, and policy makers. Over the years the foundations that have supported its research include the John A. Hartford Foundation, Commonwealth Fund, Robert Wood Johnson Foundation (RWJF), and the California HealthCare Foundation, as well as philanthropic arms of some health plans including WellPoint, Aetna, and United Healthcare.
Like a lighthouse warning of rocky shoals, the Dartmouth Atlas shined a light on Redding Hospital in California, which had the highest rate of heart bypass surgery in the country in 2001. After the Federal Bureau of Investigation (FBI) raided the hospital at the instigation of a patient who was concerned about a recommendation for unnecessary heart bypass surgery for nonexistent heart disease, enormous fines and penalties were paid, and the volume of heart bypass surgeries plummeted to a level consistent with the statewide average.
The Dartmouth research shined a light on McAllen, Texas, which has become a household word in the corridors of the White House and among policy wonks. Its enormously high health care costs occur because of across-the-board overuse of medicine, according to Atul Gawande’s account in the New Yorker.
Recently, I read “The Perfect Storm of Overutilization” by Ezekiel (“Zeke”) Emanuel and Victor Fuchs, which was published in 2008 in the Journal of the American Medical Association. The authors identify the factors that contribute to overutilization including physician culture, fee-for-service payment, and direct-to-consumer marketing.
While reading the article, I thought about the Dartmouth Atlas, and wondered whether health care organizations in some communities with a relatively low volume of surgeries see an opportunity to grow the number of procedures they perform to be more in line with the national average, or even higher than the average. There are no data to suggest that this occurs. But in a world where provider organizations may feel pressure to increase volume to meet revenue and productivity targets, it would be interesting to learn the reaction of providers when they realize they are practicing in low-volume communities.
In any event, what can foundations do to quell the perfect storm of overutilization? In the current climate of innovation spurred by health care reform, foundations can fund the development of new payment models as well as new delivery models that help organizations learn how to reduce waste in care delivery processes and curb overuse of tests and treatments that don’t benefit a patient.
One of the lessons from Pursuing Perfection, a national program funded by the RWJF that was conducted at seven participating health care institutions from 2001-2008 and was led by Donald Berwick, new administrator of the Centers for Medicare and Medicaid Services (CMS), is that foundation investments can help clinicians and administrators develop knowledge and skills to dramatically redesign processes of care, remove waste, and spur broader organizational transformation.
Foundations can support research that sheds light on patient experience of overtreatment. A Commonwealth Fund survey published in 2008 found that 32 percent of Americans say they have had medical care they thought was unnecessary or had little benefit. This remarkable finding merits greater understanding.
Finally, foundation funding can accelerate the adoption of shared decision making. When patients are informed of the risks and benefits of treatment options, they tend to shy away from the storm of overutilization. It’s always a good thing to stay out of the path of a storm. Foundations can fund the expansion of shared decision making and lead patients to safe harbors.