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The State of the Nation's Health

Dartmouth's Fisher offered a possible solution: create virtual multispecialty groups on paper, clustered around the hospital where doctors in the "group" admit most of their patients. Any doctors who don't treat inpatients would be assigned to the hospital that most of their patients choose when they need to be hospitalized. (Since both doctors and patients tend to be loyal to one or two hospitals, most could easily be assigned to a virtual group.)

The hospital and its "extended medical staff" could then be held accountable, together, for the care they provide. "But first, we need to learn to measure the quality and efficiency of care," says Fisher. "Then Medicare can adjust how it pays," bundling payments to the hospital and its extended medical staff.

By rewarding "accountable groups," Medicare would encourage doctors and hospitals to work together—and to think twice about how excess capacity drives overtreatment, Fisher suggests. If groups are rewarded for prudent use of resources, they might hesitate before investing in yet another MRI unit. A new payment system also could "create incentives for physicians to say, 'Hey, the way to preserve our income is not to recruit six more cardiologists next year. We've already got 20,'" says Fisher. "It's key for doctors to realize that their future depends on professional birth control. If we try to control volume at the individual physician level, that means cutting fees, whereas if you look to the future and encourage people to make wise decisions about the capacity they're putting in place," over time they could reshape the system.

Challenges to reform
But change won't be quick. Fisher sees reform playing out over the next 10 to 15 years. The IHI's Berwick agrees: "This is a massive system facing massive change." Change needs to begin as soon as possible—but it will be a long process.

Just ask Dartmouth's Jack Wennberg

The Dartmouth research points to how we might find the funds needed to cover the uninsured. There is enough money sloshing around in the system already to provide excellent care for all—if providers in Miami, Fla., could just learn to practice medicine the way they do in Minneapolis, Minn.

what UCLA did when it saw the report comparing it to UCSF: "To make the changes they would need to make [to become as efficient as UCSF], they would have to fire a lot of doctors and close a lot of beds. And so far," he adds dryly, "we haven't seen a lot of doctors on the job market in Los Angeles."

Yet Wennberg is not unsympathetic: "They know they have a problem. But they don't see a solution. They have bonds and huge indebtedness." In other words, UCLA can't afford to slash its income stream. "We won't see any real progress until Medicare changes the economic incentives," Wennberg adds.

"Medicare has the size and reach to have an impact," explains Dr. James Mongan, CEO of Partners HealthCare in Massachusetts. "But Medicare is run by a board of directors called Congress. And politicians don't want to take money out of their districts."

"The problem is not the doctors," says Berwick. "They know the present system isn't working. It's the institutional interests—the hospitals, the insurers, the drug-makers, the device-makers that profit" from the notion that more care is always better. And all those organizations have lobbyists.

Can Congress find the political will to stand up to those lobbyists? Some say that the politicians involved in the ill-fated Clinton health-care plan of the early 1990s were too badly burned to ever stick their necks out again. But Berwick does not accept this excuse: "This country has overlearned from the Clinton experience," he declares. "It's like saying I proved you can't play the cello because I tried it one time."

It's still "early days," he adds. "The steps that we are taking now—health savings accounts and consumer-driven care—will fail. The pain will remain unabated. And then maybe we'll turn to the insights the Dartmouth team offers us."

First, he says, patients need to understand what is in their own best interests. Many still view "efficiency" as an ugly word when applied to medicine. And many cling to the notion of "my doctor." Although health-care leaders are beginning to realize that the complexity of 21st-century medicine requires that it be a "team sport," patients often don't want to be treated by a group. "Where we need to go runs counter to some deeply held American traits and values," says Hackbarth, "both our deeply ingrained belief that more is better and our belief in the autonomy of the individual."

Yet the MedPAC commissioners have heard the Dartmouth message—that a fee-for-service system designed to reward quantity, not quality, is headed for the wall. Soon, Congress will be forced to act, too. "Wennberg, Berwick . . . there are always a few people ahead of their time," says Dave Durenberger. "All it takes is for someone to light a fire, and we'll all come flocking to them."

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Maggie Mahar is a Manhattan-based journalist who has worked for the New York Times, Bloomberg, and Barron's. She has also written for Money magazine and Institutional Investor and is the author of two books—Money-Driven Medicine: The Real Reason Health Care Costs So Much (published in 2006 by HarperCollins) and Bull! A History of the Boom and Bust, 1982-2004 (published in 2003 by HarperCollins and recommended by Warren Buffet in Berkshire Hathaway's annual report). Before becoming a journalist, Mahar taught English literature at Yale. This is her first article for Dartmouth Medicine.

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