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The State of the Nation's Health

imponderably large implications for American health care," Dr. Donald Berwick, cofounder of the Institute for Healthcare Improvement (IHI), declared in 2003. "In fact, nobody wants to touch this one with a tenfoot pole."

Berwick confirms Wennberg's estimate that one out of three health-care dollars is wasted. He calls the outcomes research done at Dartmouth "the most important health-service research of this century." And Berwick faults policy-makers for not acting on the evidence: "Not a single leader of a health-care system or a single visible policy-maker has had the courage to take those findings to the next logical step, in either corporate or public-policy planning."

Berwick is not alone in recognizing that Dartmouth is talking about what almost no one else in the medical community quite dares to discuss. "By talking about unnecessary health care—and value—Dartmouth has walked into a huge vacuum," says Dr. Steven Schroeder, former president of the Robert Wood Johnson Foundation and now a Distinguished Professor of Health at UCSF. But the evidence is getting hard to ignore. "They've given power to businesspeople, who say we are not getting value for our health-care dollars," Schroeder adds.

The American public tends to be suspicious of talk by businesspeople about getting "value" for "heath-care dollars." Are they really concerned about the quality of care—or are they just trying to save money? But when prominent physicians like the IHI's Don Berwick and UCSF's Steve Schroeder, or consumer advocates like Debra Ness, speak out, people are more likely to trust the message.

"To understand that 'more is not better,' people first need to realize that 'not all health care is good,'" explains Ness. "We need to make this information easily available. And we need a credible messenger." Insurers and employers don't have the foundation of trust needed to persuade patients, says Ness. "Physicians and consumer groups need to deliver the message."

Jack Wennberg, left, and Elliott Fisher, right, have focused on doing studies that examine the relationship between per-capita medical expenditures and health outcomes, while their colleagues in the Center for the Evaluative Clinical Sciences have investigated many other aspects of health-care utilization.

Donald Berwick, cofounder of the Institute for Healthcare Improvement, confirms Wennberg's estimate that one out of three dollars spent on U.S. health-care is wasted. He calls the outcomes research being done at Dartmouth "the most important health-service research of this century."

In Minnesota, HealthPartners Medical Director George Isham agrees that physicians must take the lead. "The care system needs to be redesigned, but I'm increasingly of the view that it doesn't need to be managed from outside by private insurers or the government." Instead, believes Isham, "the incentives need to be realigned so that physicians themselves reshape care."

Yet as presidential candidates and other politicians float plans for national health-care reform, few appear to recognize that

achieving high-quality universal care requires first wringing the waste out of the system.

Most tend to look at only one part of the elephant, Schroeder observes: "Some want to cover the uninsured. Some worry about cost. Some focus on quality. They don't understand how each issue is linked to the other." Yet the Dartmouth research demonstrates that "cost-containment and quality go hand in hand."

"High-quality providers automatically contain costs by reducing errors, avoiding redundancy and unnecessary procedures," Schroeder explains. At the Mayo Clinic in low-spending Rochester, Minn., for example, patients are less likely to develop complications or infections following surgery—so they spend fewer days as inpatients and see fewer subspecialists. "Health-care organizations [in low-cost regions] are not rationing care," observed Dartmouth's

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