Under the tab of “why didn’t we think of that” comes news that Dartmouth College is establishing the “Dartmouth Center for Health Care Delivery Science.”  The center’s basic mission is to show how health care can be improved without increasing costs and how costs can be lowered without impacting quality. 

Dartmouth is a natural for this sort of endeavor primarily because it is home to the Dartmouth Institute for Health Policy and the Dartmouth Atlas of Health Care, which have been studying variation in health care delivery and spending for a couple of decades.  But while the Atlas gives Dartmouth the data, the college’s home state, New Hampshire, isn’t exactly a shining example of health care value. 

At more than $7,800 per Medicare recipient per year, New Hampshire spends nearly 20 percent more than Iowa ($6,686).  Of course, that’s not nearly as bad as nearby Massachusetts ($9,568) or New York ($9,995), both of which should provide convenient laboratories for what not to do for value-based health care delivery. 

This is worth noting because of something Dartmouth’s president, Jim Yong Kim, mentioned when the center was announced over the weekend.  According to Associated Press coverage of the story, Kim and state leaders have “discussed using the center to make New Hampshire a model for innovative health care.” 

This brings one thought immediately to mind: Why not Iowa? 

Obviously, Dartmouth has every right and reason to focus on its home state.  But this deserves serious consideration in Iowa, where IHA has made “value” a health care watchword.  Certainly, the tools and the people are there. The Iowa Healthcare Collaborative has united hospital and physician interests under the value flag and, like the Dartmouth Atlas, has become a vast data collector.  

The University of Iowa (UI) and Des Moines University both offer excellent schools of health care administration and medicine with easy access to not only urban medical centers but also nearby rural referral centers and Critical Access Hospitals, many of which are on the cutting edge of innovative health care delivery models.  The schools of engineering at UI and Iowa State, along with major businesses (including hospitals) that have adopted ideas like Lean and the Toyota model of process improvement, offer expertise and laboratories for systems analysis. 

What Iowa doesn’t have is seed money, like the $35 million that was anonymously donated to fund the Dartmouth center.  Perhaps if we can broaden our state leaders’ views on what drives a healthy economy (hint: it’s more than wind turbines and gambling halls) and quality of life (more than good schools and smooth roads) to realize the impact of high-value health care, some investment capital might emerge.

It’s official: Health care reform guru Donald Berwick has been formally announced by President Obama as his nominee to head the Centers for Medicare & Medicaid Services (CMS).  The first sentence of the president’s two-sentence statement about Berwick succinctly addresses why he was chosen: “Dr. Berwick has dedicated his career to improving outcomes for patients and providing better care at lower cost.” 

Bringing real value to government-supported health care will be Dr. Berwick’s foremost challenge.  And with health care reform set to trim billions of dollars from the Medicare program while adding millions of new enrollees to Medicaid, it is a formidable challenge, indeed. 

But Dr. Berwick has two things going for him.  First, he knows what he is talking about.  His work and leadership at the Institute for Healthcare Improvement (IHI), which he cofounded nearly 20 years ago, has led to changes in the way hospitals provide health care that have saved lives, lowered costs and improved quality.  IHI’s current initiative, it’s “Improvement Map,” is perhaps its most ambitious.  

The Improvement Map is an interactive, Web-based tool designed to bring together the best knowledge available on key process improvements that lead to exceptional patient care. It offers clear guidance through the often confusing health care landscape, helping hospitals set change agendas, establish priorities, organize work and optimize resources.  The Improvement Map is also a testament to IHI’s dedication to shared learning, which it established from its beginning through collaboratives, learning networks and mentor hospitals (among these are Mercy Medical Center and St. Luke’s Hospital in Cedar Rapids, University of Iowa Hospitals and Clinics in Iowa City and Buena Vista Regional Medical Center in Storm Lake). 

But leaders succeed only when they energize followers, and that is Dr. Berwick’s other strength.  Throughout the medical world, Dr. Berwick is highly respected not only for his ideas but for his ability to bring key players to the table and keep them there.  Time and again, Dr. Berwick has been described as “a visionary.”  Hospital leaders in Iowa continue to be pleased about his nomination: 

“I was very excited to hear of the nomination of Dr. Don Berwick as the administrator for CMS,” said Jim FitzPatrick, CEO at Mercy Medical Center-North Iowa in Mason City.  “Dr. Berwick has spent his career on a quest for improving quality in the nation’s health care system.  His passion for improving processes for our patients and keeping focus on the ‘big dot’ issues to eliminate defects in care makes him the perfect leader for CMS. 

“Dr. Berwick’s appointment to CMS would be very positive for the health care industry,” said Eric Lothe, administrator at Iowa Lutheran Hospital in Des Moines.  “He has a long history of setting transformational goals for health care quality and then achieving great results.  Dr. Berwick would continue the focused work of IHI to help physicians and hospitals improve quality, reduce errors and eliminate adverse events.” 

The real question is, can Dr. Berwick’s ability to unite diverse interests come through in a U.S. Senate that remains bitterly divided over health care reform?  Can he show that not only can Medicare and Medicaid lead the way in improving care, but they can do it at less cost?  And can he hold his ground should talk of “rationing” and perhaps even “death panels” rear its ugly head? 

Answers should come fairly quickly, as Dr. Berwick’s first stop will be in front of the Senate Finance Committee and its ranking Republican, Iowa’s own Chuck Grassley.

The editorial page of the Boston Globe provides a brief item on the importance of evidence-based medicine with regard to reducing costs and improving health care.  The editorial points to two examples: A 2007 study that showed that drugs work just as well as stents in treating chest pain and a 2002 study that showed generic drugs work just as well as name brands. 

The central point of the editorial is that neither of these cost-saving approaches has been as widely adopted as one might expect.  Why?  Because the insurance companies – both public and private – have provided few, if any, incentives to adopt them. 

This is yet another illustration of how health care spending is being driven by something other than value.  Instead, it is driven by a system that rewards quantity – a physician who does more testing and procedures will be paid, even if those tests were not the best or possibly even unnecessary. 

The Globe emphasizes evidence-based best practices and notes that “Medicare should have the authority to weigh both comparative effectiveness and cost in steering doctors to the best practices.”  In other words, Effectiveness + Cost = Value. 

In Iowa, we are fortunate to have a health care system that, particularly in the community hospital setting, is dominated by a culture of patient-centered primary care.  This means care tends to be provided in a coordinated fashion with the primary care physician at its foundation.  Patient-centered primary care works when best practices are emphasized.  And when that happens, real value in health care is the result.  

This is why Medicare would save billions of dollars every year if it demanded, as the Globe editorial suggests, the same value from others that Iowa already provides.

Big-city hospitals are once again trying to defend their big-spending ways.  The CEO of New York-Presbyterian Hospital authored a column that appears in this week’s issue of Modern Healthcare.  Facing a federal health care reform package that, at its foundation, recognizes and rewards value in health care, the CEO once again tries to cloud the picture of just what makes up quality, efficiency and value. 

He immediately trots out the tired old arguments about how the high cost of living and large number of impoverished patients drive up health care costs in certain places.  He doesn’t say exactly where those places are, so I’ll assume he means very large cities, like Manhattan, where his hospital is located. 

The problem with this argument is that there are other, similarly high-cost and high-poverty urban areas where health care costs are notably lower.  For example, according to the Dartmouth Atlas of Health Care, which has studied geographic variation in health care costs – specifically in the Medicare program – for decades, hospitals in Manhattan spend an average of $81,143 on each Medicare patient during the last two years of life (at Presbyterian, it’s $91,113).  In Los Angeles, the cost is $77,411.  In Chicago, it’s $62,565.  In Boston, it’s $57,057.  (In Iowa, it’s $33,864.) 

But it’s not just about how much it costs to provide health care, it’s also about how much health care is provided and whether or not it’s necessary.  The first part is about intensity, and one measure of intensity is the number of days a patient spends in the hospital.  In Manhattan, the typical Medicare patient spends nearly 35 days in the hospital during the last two years of life.  In Los Angeles, it’s 28 days.  In Chicago, it’s 26 days.  In Boston, it’s 21 days. (In Iowa, it’s about 16 days.) 

But doesn’t more time in the hospital – more health care – mean healthier patients?  The studies say no. 

Rather than making excuses about high-cost health care, hospital leaders should follow Iowa’s example by learning what creates high-value health care and then implementing it.  And Medicare should recognize and reward that value.

The issue of geographic payment disparity in the Medicare program is once again in the headlines, and it’s good news for Iowa that this fight continues to be fought. 

As many Iowans know, our state’s hospitals spend far less (and receive far less) Medicare funds than most other states.  The Dartmouth Atlas of Health Care has documented that higher-spending hospitals and states are not providing any better care and, in fact, much of that extra spending is simply wasted.  The White House and much of Congress is in agreement, and this is making some high-spending hospitals nervous, the New York Times reports: 

The issue pits hospitals in more rural states like Iowa and Minnesota, where spending tends to be lower, against those in areas like New York City and Los Angeles, and revolves around a question that has bedeviled the medical establishment for decades: how much money do hospitals need to provide adequate care for patients…

Urban hospitals are countering that they serve poorer, sicker patients.  But that does not explain why similar hospitals – such as highly regarded academic medical centers in urban areas – have extraordinary differences.  Take a look at the table below (this information all pertains to Medicare patient averages during the last two years of life): 

Hospital	Physician visits	Medicare spending	Days in the hospital
Barnes-Jewish Hospital (St. Louis)	61	$63,281	27
Cleveland Clinic	63	$55,333	24
Hospital of the University of Pennsylvania	72	$80,727	31
Johns Hopkins Hospital	57	$85,729	29
Massachusetts General Hospital	75	$78,666	29
New York-Presbyterian Hospital	83	$91,113	39
UCLA Medical Center	101	$93,842	32
UCSF Medical Center	63	$78,046	22

 

These hospitals all happen to appear at the top of U.S. News & World Report’s “Best Hospitals” list and they all serve very urban populations.  Yet the differences are stark and raise many questions.  Why, for example, are patients spending 10 more days at UCLA Medical Center then its sister institution in San Francisco?  Why are 26 more physician visits needed at New York-Presbyterian than Johns Hopkins? 

Now, just for perspective, here are the numbers for Iowa’s major medical centers, along with the overall U.S. average: 

Hospital	Physician visits	Medicare spending	Days in the hospital
Alegent Health Mercy Hospital	58	$40,831	20
Allen Memorial Hospital	47	$39,386	18
Covenant Medical Center	57	$41,998	18
Finley Hospital	56	$38,696	19
Genesis Medical Center	58	$39,964	25
Iowa Methodist Medical Center	66	$44,068	25
Jennie Edmundson Memorial Hospital	65	$40,357	22
Mercy Hospital	47	$31,229	20
Mercy Medical Center-Cedar Rapids	52	$36,590	20
Mercy Medical Center-Des Moines	73	$42,091	24
Mercy Medical Center-Dubuque	47	$32,403	16
Mercy Medical Center-Mason City	43	$37,920	14
Mercy Medical Center-Sioux City	57	$42,272	22
St. Luke’s Hospital	50	$37,263	20
St. Luke’s Regional Medical Center	59	$37,581	19
University of Iowa Hospitals & Clinics	51	$48,427	24
U.S. Average	70	$52,838	25

 

One last thing:  Though it’s convenient from a media perspective, this is not necessarily an urban vs. rural issue.  There are, as the tables above show, urban hospitals that are providing value to the Medicare and there are rural facilities that are extreme outliers when it comes to Medicare spending.  The point is it is time for Medicare, as a health care consumer, to seek out and reward value – wherever it is found.