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Elliott Fisher: Even in 'Dark Times' for Overhaul, Health Care Can Be Fixed

By Jane Norman, CQ HealthBeat Associate Editor

Physician Elliott Fisher gained fame—and some critics—when he and his colleagues at the Dartmouth Atlas of Health Care shined a spotlight on the high-spending outliers in the health care world.

More health care does not necessarily mean better health care, the researchers at the Institute for Health Policy and Clinical Practice at Dartmouth College have argued repeatedly as they compare communities and find vast geographic differences in Medicare spending. What's more, they contend, spending continues to spiral upward with no connection to better outcomes for patients.

On Friday, as the future of the health care overhaul and attempts to rein in spending teetered, Fisher told a Washington conference of health care advocates that he still holds out hope that higher quality and lower costs in health care can be achieved over time. At least the problem has begun to be identified and a groundwork laid, he said.

"These are dark times for those of us who expected health care reform to have been passed months ago, let alone two weeks ago," he said at the Families USA meeting. "I will leave you with what I think is a very hopeful message—I think we really have the opportunity, especially working in communities in partnership with health systems and supported by the kinds of national reforms I am confident are going to pass, to really fix our health care system."

Clearly there's too much money in the system, added Fisher, professor of medicine and community and family medicine at Dartmouth Medical School. "I'm increasingly worried about the integrity of the healing professions, the integrity of the leaders of our health care systems, that are threatened under our increasingly entrepreneurial health care system," he said.

The Dartmouth Atlas divides up 306 regional markets in the nation and data for Medicare claims so that variations in spending can be compared. "This map has now made everybody in the country angry," joked Fisher as he displayed it on a screen.

The Dartmouth work was cited at length in a June 1 article in New Yorker magazine by surgeon Atul Gawande that was published just as congressional work on the overhaul was launched. Its emphasis on McAllen, Texas, as a medical profit center provoked an uproar over health care spending. Even President Obama referred to the article and Dartmouth, in remarks to the American Medical Association as he campaigned last summer for his overhaul plan and innovations such as bundled payments.

Fisher said Dartmouth studied about a million Medicare beneficiaries and details about their particular diagnoses, and compared quality of care and outcomes in low-spending regions with those with high spending.

"Where does the money go?" he asked. "We consistently found that higher spending regions are less able to provide high quality care." Physicians in high-spending areas said they had more problems coordinating care, it was harder to get patients admitted even though more beds were available, and it was more difficult to obtain a specialist, said Fisher.

Patients are not driving the variations—it's volume at least in part, he said. "Supply and payment are a very powerful influence on the way health care payment happens in the United States but they don't explain all the variation," he said. Some is due to differences in judgment, but case studies are under way to pinpoint other pressures at work.

There needs to be clarity that the aim of health care is better health, better care and lower costs; better data that's available to the community, consumers and providers; a model of health care that moves more toward a team approach among physicians; and a payment system other than fee-for-service, said Fisher.

He said the patient-centered medical home is a good idea though many consumers think it means a nursing home. "It's fundamentally about practice redesign to support the core functions of primary care," he said. Fisher also praised the concept of accountable care organizations, included as pilot programs in the health care overhaul bills. ACOs are groups of providers responsible for Medicare patients.

"I think some form of legislation will pass," he said. "The federal support for this kind of reform is likely to be there." But local leadership is also key, he said, and a sense of shared goals among physicians in a community. For example, getting rid of excess and unneeded hospital capacity—agreeing on just one cancer center instead of two—would slow rising costs. But that will take pressure from the community, Fisher said.

"Local solutions, with national support," he said.

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