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how we treat patients has to do with lack of evidence," he observes. "If we knew what to do, there wouldn't be such variation.

"I came here not just to understand the maps," says Weinstein, referring to the Dartmouth Atlas maps, which make very graphic the variations in care from one part of the country to another. "What I want to know is this," he goes on. "How do we change the maps?

"When it comes to many types of surgery, technology is changing so fast—ahead of our ability to evaluate it," he points out. "It's very hard to rein in." The Food and Drug Administration, for example, approves devices without requiring either long-term research about risks or evidence that a new product is any better than products already on the market. Thus the patient becomes the guinea pig for unproven procedures—without knowing that he or she is part of an "uncontrolled experiment," to use Wennberg's 1977 phrase.

Other countries have set up registries of devices like pacemakers and artificial joints, to track how well patients function with a given company's device and how long different devices last over time. The U.S., however, has no such resources. "We've been pushing for joint registries—we've gone to Medicare and the FDA," says Weinstein. "Why wouldn't companies want to know?" He's not giving up, however. In that way, Weinstein learned well from Wennberg.

But everyone agrees Wennberg set the bar high. His combination of intelligence, tenaciousness, and courage have left a deep imprint. The partisans he has trained and inspired are now effecting change all across the country. The national debate about health policy has been forever altered. Even the enterprise he founded at Dartmouth is undergoing alteration. When

Succeeding Wennberg (left) in July 2007 at the helm of the enterprise he built at Dartmouth was orthopaedic surgeon Jim Weinstein (right). They share the same mindset about medicine and, wags have noted, the same initials—J.W.

When some doctors complained that the Spine Center's focus on outcomes research might hurt their practice, "I really didn't mind the noise about the effect on their practice," says Weinstein. "I was concerned about the effect on the patient."

Wennberg stepped down from CECS's helm, the organization acquired a new name—the Dartmouth Institute for Health Policy and Clinical Practice—as well as a new leader.

That new director, Jim Weinstein, remains grateful that fate brought him to Dartmouth. "Jack gave me a way to see things differently—and a chance to change things. I feel very fortunate."

He and many others at Dartmouth have been singing Wennberg's praises in the wake of the leadership change. But so, too, have movers and shakers well beyond Dartmouth. In the November/December 2007 issue of

Health Affairs, the journal's 25th anniversary issue, Jack Wennberg was named "the most influential health-policy researcher of the past 25 years." And he received the 2007 Ernest Amory Codman Award from the Joint Commission, the national accreditation body for health-care organizations, for his "leadership role in using outcomes measures to improve health-care quality and safety."

Blueprint for reform
The anniversary issue of Health Affairs also contains two articles by Wennberg and others at Dartmouth—articles that are, in effect, a blueprint for health-care reform. The first, subtitled "How Medicare Can Improve Patient Decision Making and Reduce Unnecessary Care," looks at elective surgery, arguing that Medicare should make shared decision-making the standard for deciding if discretionary surgery is medically necessary.

The second paper ("How Medicare Can Reduce Waste and Improve the Care of the Chronically Ill") notes that at present "the care of Americans with severe chronic disease is disorganized, unnecessarily costly, and undisciplined by sound clinical science." Wennberg and his coauthors urge the federal government to invest in a "crash research program" designed to rapidly accumulate the evidence needed to determine the best and most efficient way to manage chronic diseases like asthma and diabetes. More efficient care would better serve patients and be less costly, the authors point out. Any cost savings, they suggest, should be shared with providers who deliver the most effective, efficient care. Both articles share the same vision: the health-care payment structure needs to reward the quality, not the quantity, of care a provider offers.

The political reform that Wennberg's critics were so afraid of back in the 1970s just may happen one day.

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Mahar is currently a fellow at the Century Foundation, where she writes and blogs about health care. She is the author of the book Money-Driven Medicine: The Real Reason Health Care Costs So Much (published in 2006 by Harper Collins) and has worked for the New York Times, Barron's, and Bloomberg. This is her third feature for Dartmouth Medicine; she wrote in the Spring 2007 issue about the impact the Dartmouth Atlas of Health Care has had on the national health-policy debate and in the Fall 2007 issue about DHMC's Center for Shared Decision Making.

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