The health care debate in Washington has basically deteriorated into a choice between raising taxes or cutting care. But "that's wrong," says Don Berwick of the Institute for Healthcare Improvement. "There's a third way: It's redesign."
To try to prove his point, Berwick, along with health luminaries Elliott Fisher of the Dartmouth Medical School, Atul Gawande of Harvard and Mark McClellan of the Brookings Institution, brought doctors and hospital officials to Washington from 10 communities around the U.S. where health spending is lower than average and health care outcomes are better than average.
"How many of you, as you've implemented all these reforms in your own systems, have been telling your patients that you're rationing your care?" asked McClellan, a former top health official in the Bush administration. The audience laughed.
But for Dartmouth's Fisher, who has spent most of his career cataloging the differences in care between geographic regions of the country, the fact that many places provide more expensive care yet have no better medical outcomes is no laughing matter.
"Eliminating unnecessary care is not rationing," Fisher said. "Who among us wants to go see a physician when we could have stayed at work or stayed at home? Who of us wants to go to the hospital when we don't need to be there? These communities have shown us that it's possible to avoid that unnecessary care, and that's not rationing."
One of the more hopeful messages that Harvard surgeon Gawande took away from the daylong meeting was that change can happen relatively rapidly. "Half of these communities used to be high cost and transitioned to low cost over the last decade. So they made me hopeful that we could do it" as a nation, he said.
But translating the success of those communities — which ranged from Portland, Maine, to Everett, Wash., to Sacramento, Calif. — won't be easy. "Can you order a cultural change? Can you order cooperation? No, I don't think so," Berwick said.
An even larger problem is that while there is relative consensus that Medicare's current payment system encourages doctors and hospitals to provide too much of the wrong care, no one is quite sure how to revise it to encourage just the right amount of care.
"I guess the way I would put it is even if I was a benevolent dictator for a day, I wouldn't feel comfortable at this point, given the state of knowledge, completely overhauling the Medicare payment system," said White House Budget Director Peter Orszag, who has been studying the issue for several years.
That has led to a conundrum in lawmakers' efforts to try to achieve long-term savings in the health care system. They know that overhauling Medicare payments is a key means to achieving that goal. They also know that if they do it wrong, they could leave the health care system — and the patients it serves — worse off than it is now.