By ATUL GAWANDE, DONALD BERWICK, ELLIOTT FISHER and MARK McCLELLAN, WE have reached a sobering point in our national health-reform debate. Americans have recognized that our health system is bankrupting us
and that we have dealt with this by letting the system price more and more people out of health care. So we are trying to decide if we are willing to change — willing to ensure that everyone can have coverage. That means banishing the phrase “pre-existing condition.” It also means finding ways to pay for coverage for those who can’t afford it without help.
Both of these steps stir heated argument, not to mention lobbyists’ hearts. But what creates the deepest unease is considering what we will have to do about the system’s exploding costs if pushing more people out is no longer an option. We have really discussed only two options: raising taxes or rationing care. The public is understandably alarmed.
There is a far more desirable alternative: to change how care is delivered so that it is both less expensive and more effective. But there is widespread skepticism about whether that is possible.
Yes, many European health systems have done it, but we are not
Yet in studying communities all over
To find models of success, we searched among our country’s 306 Hospital Referral Regions, as defined by the Dartmouth Atlas of Health Care, for “positive outliers.” Our criteria were simple: find regions with per capita Medicare costs that are low or markedly declining in rank and where federal measures of quality are above average. In the end, 74 regions passed our test.
So we invited physicians, hospital executives and local leaders from 10 of these regions to a meeting in
If the rest of
Caveat: Because we relied on Medicare data for our selections, it is possible that some of these regions are not so low-cost from the viewpoint of non-Medicare patients. But overall data strongly suggest that most of these regions are providing excellent care for all patients while being far more successful than others at not overusing or misusing health care resources.
So how do they do that? Some have followed the Mayo model, with salaried doctors employed by a unified local system focused on quality of care: these include
The physicians and hospital leaders from
“I was embarrassed for us,” said Jim Levett, a cardiac surgeon and the head of a large physician group. More important, the area’s doctors and clinics are turning that embarrassment into change by seeking out solutions to reduce the expense and harm of unnecessary scans.
That number of scans in
The team from
In their own ways, each of these successful communities tells the same simple story: better, safer, lower-cost care is within reach. Many high-cost regions are just a few hours’ drive from a lower-cost, higher-quality region. And in the more efficient areas, neither the physicians nor the citizens reported feeling that care is “rationed.” Indeed, it’s rational.
Many in Congress and the Obama administration seem to recognize this. The various reform bills making their way through the process have included provisions to protect successful medical communities by incorporating payment approaches that reward those that slow spending growth while improving patient outcomes. This is the right direction for reform.
There is a lot of troubling rhetoric being thrown around in the health care debate. But we don’t need to be trapped between charges that reforms will ration care and doing nothing about costs and coverage. We must instead look at the communities that are already redesigning American health care for the better, and pursue ways for the nation to follow their lead.
Atul Gawande directs the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston and is a staff writer at The New Yorker; Donald Berwick is the president of the Institute for Healthcare Improvement in Cambridge, Mass.; Elliott Fisher directs policy-reform efforts at the Dartmouth Institute for Health Policy and Clinical Practice; and Mark McClellan is the director of health care reform policy at the Brookings Institution. All are physicians.