HEALTH REFORM: Fact, Not Fiction

We tend to think of the Dartmouth Atlas as a series of maps, with high spending and low spending regions marked out in their respective primary colors. Yet the Atlas also represents a collection of stories, true stories, about good medical care and not so good medical care.

Some of the chief characters walked off the pages and into Washington this week with a message to policymakers and budget analysts: "We're fact, not fiction. Pay attention."

Four of the nation's top health care cost and quality experts from Dartmouth, the Institute of Healthcare Improvement, Brookings Engelberg Center and Harvard convened these health care providers (doctors, hospital execs etc.) from 10 success story communities for a one-day conference in Washington this week.

Half the communities have provided high-quality, (relatively) low-cost care for years.The other half had redesigned care in the last five years or so, and were now moving up the ranks of the efficient. To use Atul Gawande's language (he was one of the conveners, along with Don Berwick, Elliott Fisher and Mark McClellan) these were McAllens who had become, or were on their way to becoming, Grand Junctions. To use the language of Washington, they had bent their cost curves.

They came from Asheville, NC, Cedar Rapids, IA, Everett, WA, La Crosse, WI, Portland, ME, Richmond, VA, Sacramento, CA, Sayre, PA, Tallahassee, FL. and Temple, TX. Very different communities. Different economies. Different demographics. Different health care systems. Some had a lot of competition in town, some had little. Some had highly integrated systems; some did not. They all had created a shared sense of mission in their community, a determination to stop defining good medicine as "patients getting more stuff'" and instead defining it as patients getting what they need when they need it.

Participants and the program coordinators said costs can come down in communities with a lot of competition (like Sacramento) or communities with only one or two big health care players in town (like Asheville, NC). What matters isn't the amount of competition, it's whether it's "healthy competition," as Tim Charles, CEO of Mercy Medical Center in Cedar Rapids, put it. (I wrote recently about one innovative program to reduce hospital readmissions also in Cedar Rapids, at  St. Luke's Hospital.) Healthy means competing over the quality of patient care and the value -- not the cost, the value -- of that care. It doesn't mean a medical arms race, more "stuff" that brings in money but doesn't improve health.

Participants spent part of the day brainstorming and exchanging stories, giving each other tips on initiatives that bear fruit, on mistakes not to be repeated. They thought about what it would take for other communities to emulate them -- and what Washington needs to understand as it tries to craft policy that gives all Americans access to high value care.

As Don Berwick said, too much of the talk in Washington is about whether we need to raise taxes or cut care. There's a third way, he said. Redesign care. Like these communities are. Not just health care reform. But literally health care Re-Form.

I had a chance to talk to a few participants later in the day. Dr. Alan Baumgarten, MD, is a family practitioner and chief of staff at Mission Memorial Hospital. He was frankly not sure how to export Asheville's model. Asheville has long been a relatively high quality/low cost area, because that's what the local medical culture promulgates and values -- what Fisher and the Dartmouth researchers call practice patterns or norms. "It's very home-grown," Baumgarten told me. "It's evolved over time." When new young doctors come into the community wanting to practice differently, they either adapt -- or leave."They sort of disappear," he said.

His colleague, cardiologist William Hathaway, the vice chief of staff, worried a little that it's getting a tad harder to recruit young cardiologists who want to come to Asheville and practice within these community norms "I was willing to wait for the big house," he said. The next generation, he said, seems less patient.

But Dave Brooks, CEO of Providence Medical Center in Everett, Washington, a Catholic hospital north of Seattle, has been turning around his hospital, his community, in the last five to seven years. One key has been giving physicians a voice and a leadership role. This isn't an integrated system, with salaried doctors like Mayo. These are doctors in their own practices and clinics, large and small. But they have helped create clinical protocols that have helped provide more consistent, high quality care at the hospital. They have taken on leadership roles within the hospital. They serve on the board. "They help run it," Brooks said.

Another priority for Brooks is addressing care transitions -- from one doctor to another, from one hospital to another, or from hospital to nursing home or other setting. Transitions are where lots of things go wrong in medicine, and he told his board at their retreat last year that he wanted to fix it. Providence has addressed it in both conventional and unconventional ways, even bringing in local transportation officials. For instance, a patient who lives on an island with a small community hospital had chest pains. The local EMS showed up, used telemedicine to transmit his EKG and other information to Providence. They realized it was probably a heart attack, but instead of taking him to the local hospital, where he would then have to await transfer to Providence, a different plan was activated. Transportation officials were notified; the local ferry waited for the ambulance, and that ambulance then took the patient directly to Providence. There, the patient was able to skip the emergency department and go straight to the cath lab, where the team had already been alerted and was waiting for him.

 "We skipped two or three processes of care. We minimized transitions and handoffs. We eliminated waste, costs, and delays. And we had a good clinical outcome," Brooks said. "He lived."

Not all hospitals have to deal with ferry schedules, but most of the lessons identified at Tuesday's session applied across communities:

• Physician-hospital collaboration matters. They need to trust each other and have common patient-centered goals.
• Data matters. All docs think they are doing the right thing for their patients, but they don't have the data to prove it, and when they do get the data, they often find plenty of room for improvement.
• Teamwork matters; the myth of the "superphysician" who can do it all should be laid to rest.
• Efficiency matters; philosophies like LEAN work, although you have to stick with them.
• Leadership matters. Particularly physician-leadership. (This is a favorite theme of our colleague Tom Emswiler, he writes about it here and here.)

 The most important lesson -- it's real. It's happening. We know how to do it. Let's do more.