Lebanon
Set aside the buzzwords that occasionally get past their laudable striving for plain speaking, and the good doctors’ prescriptions for American health care include strong and repeated doses of informed consumers, robust competition by providers and pricing that reflects real costs and social impacts.
That’s of particular interest to readers in the Upper Valley, where D-H is the dominant player in the health care industry. As Weeks said in an interview, D-H is “trying to lead the nation in providing population health that is patient-centered and high-value to its service area.” Those aspirations lay at the heart of the hospital’s “imagine” theme, which is widely promoted to patients and employees through the hospital’s publications, web pages and wall postings.
Unraveled goes beyond the familiar glossy images. “The book is trying to get the word to the consumer in language they understand,” Weinstein said in an interview. “What should a doctor’s appointment be like? What should you look for? How do you get engaged in shared decision-making? Does that hospital have any information about their outcomes and their costs?”
The formula laid out in Unraveling elaborates on ideas that have emerged from research and analysis done by the authors and many others at the Dartmouth Institute of Health Policy and Clinical Practice.
The Dartmouth Institute, or TDI, occupies some of the just-opened, $105 million Williamson Translational Research Building, and was founded in 1988 by John Wennberg, the creator of the influential Dartmouth Atlas of Health Care.
That atlas used data on Medicare spending during the last years of patients’ lives to document large regional variations in health care costs. In 2007, Weinstein succeeded Wennberg as head of the institute. And, Weinstein said in an interview, it was his work and role at TDI that led then-Dartmouth College President Jim Kim to encourage him to take the D-H CEO job in 2011.
TDI has been an important source of ideas for advocates for health care reform in the United States and beyond. During the debate that preceded passage of the 2010 Affordable Care Act, TDI’s research and the Dartmouth Atlas were often cited to support the claim that about $700 billion, or one-third of annual U.S. spending on health care, could be saved by eliminating waste.
That claim has been disputed by critics, who say it didn’t account for variations in the quality of health care or for the impact of poverty and regional living costs on Medicare spending. The authors of Unraveled don’t restate the $700 billion claim, but still see waste as a critical problem in health care. “If things are futile, it doesn’t make sense to spend money on them,” Weeks said in an interview. In the book, they seek to translate into consumer-friendly language the ideas developed at TDI that are being put into practice, to varying degrees, at D-H.
The book scans an array of health care interactions, arguing that emphases on preventive and primary care make health and economic sense and that diabetes, asthma and other chronic diseases and care for the dying can be managed with greater humanity at less cost. It examines medical bills and electronic health records, and finds glasses half full with possibility where others end up perplexed and thirsting for relief from aggravation.
Their aim is to root out what Weeks describes as “perverse incentives” — prices that induce providers and patients to make wasteful and unhealthy decisions — embedded in the health care market, including those that discourage provision of preventive care. “Since interventions for acute-care needs generally are reimbursed more than those for preventive care, these acute-care services ‘squeeze out’ the availability of preventive care services,” the book says.
Weeks and Weinstein look to consumers — patients and their families — to step up to help reduce waste. They write: “If reimbursement were modified to encourage access to — and use of — preventive, non-hospital care, and if health care utilization, costs, and outcomes were transparently reported, consumers could make informed decision about whether and where to obtain particular health care services.”
In an interview, Weinstein spelled out how that would work. “You should be able to walk into any hospital system and understand how many heart surgeries do they do,” he said. “What have the outcomes been? What’s the average cost? What’s the average length of stay? What’s the complication rate? What’s the readmission rate? Those things should be available to a patient who’s having to make that decision.”
While the premise of the book is the possibility of operating health care more rationally and humanely, the authors acknowledge some challenges to developing a system that measures and rewards the health of the population served rather than the quantity of services delivered.
For one thing, even if changed incentives can squeeze waste out of the system, some individuals may also feel squeezed. As the book puts it: “While performance management systems help drive higher-value care, their mostly blind application has the potential to undermine care for individual patients.”
Also, some of the services that improve population health may be delivered outside the health care system. “Other countries spend substantially less on health care but they actually spend more on social services including health-related social services,” said Weeks. The simple solution is to shift spending to where it will do more good. “We already know the money we’re spending now,” Weeks said. “Give us that money, and we’re going to redeploy it in a way that will produce more health.”
But such resource-redirection strategies have sometimes run aground on the shoals of politics. For example, a multi-decade effort to shut down massive hospitals that warehoused mentally ill patients and shift resources into community treatment and support sputtered after community services were cut to balance budgets.
At the core of the health care system envisioned by Unraveled, according to Weeks, is “involvement of patients in an objective, shared decision-making process.” But markets don’t always reinforce the growth of such processes. “One of the challenges with the competitive market is that there’s not enough clout for individuals,” said Weeks.
In fact, decades of health care reform efforts provide many cautionary tales of the clout of vested and powerful interests — pharmaceutical and insurance companies, hospitals and even doctors’ organizations — that defend the status quo. And Unraveled provides no vision for structural change, fundamental reform or — with apologies to Bernie Sanders — political revolution to accomplish the reforms it describes.
Despite its limitations, Unraveled seeks to continue a constructive argument about health care which, in addition to touching all of our lives, now comprises about one-sixth of economic activity in the U.S. What type of system is needed? What is sustainable?
And Weeks and Weinstein have earned a hearing from the public. Weeks, 52, is a psychiatrist who is now in France on a Fulbright-Tocqueville fellowship lecturing on how the methodology of the Dartmouth Atlas can be applied there. Weinstein, 65, has been at D-H for 23 years, headed up TDI for four years and became D-H’s chief executive in 2011. “I think the credibility of the book is because I am a physician, I have lost a daughter from cancer and I now run a major health system that’s trying to change the world,” Weinstein said.
The book is an accessible and, at 129 pages, concise description of the vision for a better health care system — not to mention the thinking that seeks to shape D-H, the region’s largest employer and dominant health care system.
But the book is still seeking an audience. On Friday it ranked 69,218 among books on health, fitness and dieting, and 566,614 overall, on the website of Amazon, which provided publishing services to the authors.
That hasn’t stilled authors’ efforts to be heard. “We’re giving away a lot of books, trying to get this into medical school libraries (and) nursing schools,” said Deb Kimbell, who worked with the authors on the book’s publication.
Unraveled is “a first attempt,” Weinstein said. “This isn’t the book I will eventually write.”
Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229.
Correction
Dartmouth-Hitchcock’s board of trustees selected and hired Dr. James Weinstein as the CEO and president of the D-H system in 2011. An earlier version of this story incorrectly reported the role played in that decision by then-Dartmouth College President Jim Kim, who urged Weinstein to accept the position.