Book Review, Tracking Medicine, John E. Wennberg, M.D. MPH

Book Review


John Wennberg’s book, Tracking Medicine, a researcher’s quest to understand health care, challenges anyone interested in health information technology or the Affordable Health Care Act to a `must read.` Wenneberg spent 40 years applying statistical analysis to the care given in various U.S. locations. Wennberg discovered an extreme variation in the manner and quantity of medical services rendered. He applied the science of epidemiology and statistics to understand these differences. What he found was a fundamental contradiction in the patterns of medical practice. These contradictions surprise and shock the medical establishment and others who believed that for healthcare more is better.

Patient satisfaction, outcome and longevity -- even in some teaching centers – proved inversely related to the intensity of medical, surgical and hospital services. Furthermore, Wennberg found that the greater the capacity of the facility and number of specialists per capita, the greater the intensity of care. Intriguingly, he found that providers were completely unaware of this variation. Present day Certificates of Need, required for expanding the number of hospital beds -- and in large measure many other provisions in the Affordable Health Care Act – indeed reflect much of Wennberg’s research.

Wennberg together with the Dartmouth Institute of Health Policy and Clinical Practice proposed four policies to improve clinical medicine and quality. They suggested:

1. Organized local systems
2. Decreasing overtreatment by shared decision making between patient and doctor
3. Strengthening the science of health care delivery
4. Constraining undisciplined growth in health care capacity
Variation Capacity and Outcome

Striking variations in the frequency of certain surgeries occurred in adjacent communities. Tonsillectomies, prostatectomies and hysterectomies varied by large factors. The surgical rate varied in proportion to the number of beds and or surgeons per population. Wennberg called this phenomena “supply sensitive care.” A consistent and validated inverse relationship existed between the oversupply of providers versus patient satisfaction and outcome. Chronic disease appeared to be the greatest problem wherein institutions provided high cost acute care -- Wennberg called it “rescue care” – while neglecting lower cost managed care by primary care physicians, patient involvement and patient education. An even greater expense associated with intensity of care, based on capacity appeared to place terminally ill patients in ICU often against their wishes but with the same terminal outcome.

Communities with a high number of specialists per capita experienced worse outcomes than populations with a constrained availability of care. This statistically validated phenomenon flew in the face of conventional wisdom and the belief that American hospitals are best and more is better. Controversial, to say the least, and argued by some of the most respected medical centers, the striking variation in treatment, the relation of excess care to capacity, and the surprising inverse relation of more care to poor outcome and poor patient satisfaction, remains a valid and highly reproducible statistic.

Reasons to reform:

1. Over reliance on rescue care
2. Acute care hospitals for chronic illness
3. Excessive capacity per population
4. The establishment of more skilled nursing facilities, outpatient, and home care has not reduced inpatient use, ICU, and a high tech death.
5. Over use will not go away – getting worse
6. Not just Medicare but private fee for service as well
7. Organized care does not reduce the over use of ICU
8. Cross market subsidy of insurance premiums; that is, low use areas of care pay equally with high use populations in effect subsidizes unnecessary care.
9. Increased co-pay in high use areas a burden on patients in these areas of overuse
10. Overuse equates to decreased life expectancy for the patient

Wennberg makes the point that organized care with shared savings may be able to “rationalize the black box of supply sensitive care.” He advocated practice and hospital networks, but cautions that cost may not always decrease with decreased capacity due to cost shifting. He suggests that the major cost to Medicare and other insurance stems from ICU care for terminal patients. Wennberg believes that encouraging a patient’s fully informed participation in medical decisions puts the brakes on overtreatment and is the way to reign in excessive and sometimes harmful care. Such participation, however, calls for a radical change in the culture of doctor patient interaction.

Wennberg’s final list of remedies

1. Fully informed participation of patient in decision
2. Constrain spending on supply sensitive care
3. Constrain preference sensitive surgery
4. Decrease the number of doctors, specialists and hospital capacity.
5. Adjust insurance premiums by local area spending
6. Feedback of information about practice variation, tracking both the variation and outcome

Wennberg particularly likes the provision in the Patient Protection and Affordable Care Act of 3/2010 specifying an Innovation Center within Centers for Medicare and Medicaid. His final suggestion cautions not to train primary care physicians in centers failing to limit overuse and patient choice if the primary care physicians are to become skilled in coordinating care.

John E. Wennberg, M.D. Peggy Y. Thomson Professor (Chair) for the Evaluative Clinical Sciences, Professor of Community and Family Medicine (Epidemiology) and of Medicine Department of Community and Family Medicine and The Dartmouth Institute for Health Policy and Clinical Practice Educated Mc Gill University, MD 1961 Johns Hopkins School of Hygiene and Public Health, MPH 1966

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This book makes a huge contribution to our understanding of the problems with US medical care. The statistics speak for themselves. They fly in the face of conventional wisdom of providers, well-meaning planners and patients’ families many of whom take exception to some of the end of life research, proposed in the Affordable Care Act.

I am not a statistician, but I was a primary care clinician and manager of an efficient primary care clinic. I managed other physicians and consultants, -- not an easy task -- and I wrestled with the contentious changes that took place in the late 80s and early 90s. As such and with considerable time to think it over, I suggest that many more problems plague our health care delivery system, problems that need validation and in some case adjudication. While I am enthusiastic about reform and much of the good in the plan, I am not at all certain that the Affordable Health Care Act solves all of these problems.

For example, let me list some of the problems that seem largely overlooked:

1. The US ranks embarrassingly low in all measure of public health statistics among industrialized nations. The U.S. ranks 37th in Life Expectancy and 46th in Infant Mortality Why might that be an important issue for the CIA?
2. We pay little attention to European health care systems all of which seem to be out performing our own
3. The well-established routine of increasing usual and customary fees to an ever higher and higher level to offset the discounted reimbursements, to both hospitals and physicians
4. The uninsured receiving all of their health care in the emergency room, because the ER cannot refuse care – widely acknowledged to be the most expensive form of medical delivery.
5. Hospital charges spiraling higher and higher due to the above
6. HMOs requiring referral only to the HMO listed specialists who are much less qualified, as a rule, than specialists referred to by the primary care doctor and who due to their abilities do not need the problems of contracting with an HMO.
7. The extreme discrepancy between primary care reimbursement and specialist reimbursement, which has lead to a dearth of primary care physicians and an overabundance of specialists
8. The very high liability insurance premium paid in advance by all providers but especially by the high risk surgical specialties
9. The difficulty for treating physicians to access current medical terminology, criteria of diagnosis etc at the time of patient contact
10. The expense of journals, CME and even Internet access to current medical journal articles
11. The increased competitive capacity and less scientific medicine engendered by patients migration to alternative medicine, alternative practitioners, autonomous physician extenders etc. decisions often based on the attraction of lower cost and in some cases a desire to return to nature. (Natural childbirth at home without anti natal care might be an example)
12. The abuses of drug companies: outrageously high prices -- semi-fraudulent re-patenting of popular drugs, who’s patent is expiring, in order to extend their high prices and keep these products out of the generic drug market
13. The failure of insurance companies to provide a demand side restraint on healthcare coast thus enriching their own revenue with ever higher premiums
14. The characterization of medicine as a business and a free market rather than as a profession and a critical infrastructure
15. Using the threat of antitrust action, Health and Human Services and Hospital administrators, CEOs ended the local medical societies ability to censure its members and hold accountable member’s behavior both in and out of the hospital.
16. The loss of medical society input in hospital staff credentialing and privileges
17. Medical conditions, which fall outside the prevue of the specialist or between specialties leads to missed diagnosies.
18. The inaccuracy of reported medical diagnosis, thus a corruption of the data base leading to erroneous statistical analysis and attempts to draw conclusions from insurance reports
19. Misdiagnosis resulting in protracted illness or worse
20. The requirement for a qualifying diagnosis to justify a laboratory test
21. Excessive CAT scans may be in part economically motivated and driven by malpractice law suits while sadly delivering excessive radiation exposure
22. The C-section rate and a continuing high hysterectomy rate
23. The poor distribution of physicians in relation to population Physicians migrate to attractive geographic locations with per capita income and amenities
24. General lack of Clinical Pathological Conferences, CPC or Morbidity and Mortality, M&M conferences, (except in major teaching hospitals and medical schools)
25. Rare or nonexistent autopsies We once judged hospitals by their autopsy rate. The autopsy and the CPC accounted for much of our past glory of U.S. scientific medicine. The risk of lawsuits based on autopsy and CPCs, although protected in theory, may be a factor.
26. Does not address the patient’s unhealthy attitude towards self-care whilst demanding a pill or a procedure to bail him or her out of an unsustainable life style
27. Government takes a punitive rather than educational approach to regulation of the system

Greed dominates the healthcare economy, not so much by mainstream providers as by an opportunistic periphery, a tsunami of players entering the Health Care industry to take advantage of its commercialization. Health Care is not a Free Market! It is a profession and vital U.S. infrastructure. Opportunists view the health care industry as free money from Medicare and by much of the enabling health insurance industry, free money that comes out of the taxpayer’s pocket, as a hidden tax on employers, or persons seeking to protect themselves with individual health insurance.

The Patient Protection & Affordable Health Care Act strives to eliminate many of the insurance abuses. However, we continue to interdict access to the big dollars by policing access but the core issue is no different from the flow of illegal drugs from Mexico and South America. The drug producing countries are not the problem – America’s appetite for illegal drugs is the problem. In medicine, all of the above crises are indicative of the greed and mentality of entitlement that drives them.

Punitive efforts to curtail overtreatment and abuses of the system paradoxically enable and promote the greed by gaming around the regulations. Solving any of these problems requires a change in both the culture of Medicaine and the culture of Regulation – in favor of graduate education, information technology and a commitment to excellence. A public option by the states, run by the state’s medical schools in partnership with Public health with salaried physicians run in competition with traditional fee-for-service may be the best way to get there. A serious look at European Health Care systems may tell us what works. I suspect it will require a major reeducation of our population in healthy life styles. Infant mortality will be a useful barometer to measure progress.

“The commission — created by President Obama to address America’s fiscal challenges — predicted that, by 2035, federal outlays for Medicare, Medicaid, the Children’s Health Insurance Program, and the health insurance exchange subsidies will account for 10 percent of U.S. gross domestic product (GDP), up from 6 percent in 2010…. If historical rates of growth continue, U.S. spending on health care from all sectors… will surpass 20 percent of GDP within five years and eat up the entire GDP by 2082…something… dramatic will have to happen between now and then…” Rand, James A. Thompson