The Good News in American Medicine

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home the United States the world richestcountry is the only industrialized democracythat doesn’t provide health care for everybody of course we’d like to cover all theuninsured but how would you pay for it but these are tough choices in fact we could we have plenty of slackin the current health care system to absolutely cover everybody without spending more and get this if we did cover everybody we keep ournation healthy and probably spend less overall here’sthe scoop healthy people cost last than sickpeople do and now get this their doctors andhospitals all over america who are working hard tocut the cost medical care we have a call to lower thecosts of care to our patients by 25 percent in thenext five years the striking thing about americanmedicine is that there are huge variations in costs from one town to the next Medicarerecords show that some US county spent seventeen thousand dollars per year onthe average senior but other towns provide care that’s justas good for about six thousand dollars theircommunities all over america that provide excellentcare at reasonable cost them sometimes cover just about everybody in town in this program will travel the countryto see if you would we’ll see diverse models of health caredelivery because America doesn’t have just one healthcare system it has lots of different systems will begin our journey and Colorado the another some skepticism why are yougonna up save money in the health care systemyou’re doing it here in Grand Junction of the the Gunnison River forms its junctionwith the mighty colorado at Grand Junction a community of about a hundred thousandan ordinary american city but the doctors here have done somethingextraordinary they found a way to provide high quality care for just about everybody at the lowest medical costs inthe United States your blood sure control seems actuallybuild it better I don’t understand why when I’m notgoing to be the point lot to people writing aboutMesa County President Obama came here and said this is a national model you’rein the new yorker courses famous economist at dartmouthstudy you did you guys know you were such a goodmodel know we really did fact when that information came out thethe interesting thing was it we were then naturally trying to figure out what why what whyis it that we’re so much better what do we do differently here that’s done in the restthe country alright so think the reason that Mesa County cangive higher quality care at lower cost andother places in the country is because we all think every minute every day what’s thebest thing for the patient has the cost get involved happily keepthose costs down and how can we make sure that as manypeople as possible are insured and that every doctor takes that ancientnow there’s a commitment to it we’re gonnaspend some time in this little town to understand that commitment to low-costcare for everybody because in terms of coverage and cost control for medical care thisplace ranks right at the top among US counties how do we know that it’s in the Atlas on a lovely newengland autumn day like this an economist here at Dartmouth Collegebegan studying Medicare billing records millions ofsounds pretty boring right but in fact they found something amazing and theypublished their results in an influential study it’s called the dartmouth atlas ofhealth care and it’s the definitive text on thesubject of variation in american medicine in in the lovely old Baker library on theDartmouth campus we met doctor Elliott Fisher who runsthe national center for population health he told us that for twenty years expertshere have been tracking the huge differences in treatment and cost in different communities around thecountry one of the first studies was done comparing Boston to New Haven tourban communities that are pretty identical both haveprominent medical schools located in those two communities and found 24 differences in spendingacross those communities and could you explain that our people inBoston sicker people they have a lot of effort was made to look sad are thepatients sicker are they pour I’m could not explain onthe basis of those differences this huge national atlas of health carebegan as a purely local project in 1973 doctor jack when bird was assigned to studydifferent towns and vermont he was supposed to spot the places thatwere getting enough medical care in fact you found something ratherdifferent when we started looking at this data my eyes just one upside down as Pitt sickly incentive under servicewe just found extraordinary variation one strikingcase was tonsillectomy is for children in sometowns doctor when bird found three out of four kids had their tonsilsout in another town down the road only one out afforded and the kids werejust as healthy once we gave the information back to thepositions in morrisville and around the rest thestate of Vermont there they’re turned out to be a radicalshift in the rates tonsillectomy moore’s film they dropdown well below the state average I mean like in one year you’re making anargument for medicine based on science or based onevidence mmm is kinda bugs me cuz I was thoughtmy doctor was using evidence when she treated me basically arm people come to health carewith the underlying assumption that the carethey receive is based on their illness based on medicalevidence and based on care that they actuallywalk their preferences so you’re gonna getthe treatment you need and want and want I I’d like to believethat and works yeah and is that what happened no the what happens is are mucho healthcare is unwarranted it cannot be explained by illness that medical evidence and patient up inyour preferences of the years went by and the when birdgroup at dartmouth went national studying Medicare billing recordmillions and millions of from all over the country and you knowwhat they found the same thing they found in vermonthuge variations in treatment and in spending and one rule became clear in medicine supply drive demand that to theeconomist way of saying that when a town gets more doctors you get a lot more doctor visits and ofcourse the system pays for all them whether they’re need it or not we’veknown for twenty years but if you have twice as manycardiologists per capita in your community you’re gonna have twice asmany visits to cardiologists per capita you have twice as many scanners in yourcommunity patients in those communities twice as many imaging services the some of those services will bebeneficial but the extra services provided actually don’t necessarily provide anybenefits and and and in fact because if the high radiation exposure so she was CTscanning actually could cause harm this is the lesson at the dartmouthatlas if you have more scanners or more operating rooms you get more scams and more operations and a lot of it is stuff that thepatients don’t particularly want and don’t need either course we stillpay for one reason for all this variation isthat there are no clear rules about how much medical care is the right amount let’s say for example there’s a patientwith high blood pressure and the doctor getting a prescriptionand it’s working and the pressure comes down so here’s the question when should thatpatient go in for the next checkup most of us would think there’s somescientific evidence to tell us well we started aspirations at around thecountry and positions in in organ in the northwest said well wesee those patients every six months maybe every year physicians in in Miami said we shouldsee those patients every month and there’s a bill every time there’s abill every time so in a system where supply currently candrive demand we’re not getting the value that we needfrom health care there are some communities where the physicians and the hospital leadersare really starting to ask the question how can we be responsible I’m for the health of our community not only interms have their clinical health but their fiscalhealth it’s happening now is happening all overthe country one of the first places I think I’m looking with the GrandJunction Colorado this lively county seat on the westernedge of colorado has become a model for health care delivery because the doctors here did somethingamazing it’s a community that’s just aboutaverage in family income in the number of people without health insurance but the doctors here decided to takecare everybody in town and get paid the same fee for the sametreatment whether the patient as richer poorer sounds obvious right but in americanmedicine that a radical idea unlike other richcountries in the US the various payers pay different fees to the same doctorfor the same treatment standing right here for something liketreating a sore knee the doctor get one the from privateinsurers a different fee for Medicare thegovernment insurance plan for seniors and a different fee altogether formedicaid the government plan for poor people and since medicaid is generally thelowest pay around it probably won’t surprise you to learnthat many doctors never find time on their busy schedule for the Medicaidpatients that’s a common feature of americanmedicine but the doctors in Grand Junction just didn’t like leaving poorpeople out in the cold they were good for physicians here intown that we’re dealing was state Medicaid back in very earlyseventies and it was very difficult to deal stateMedicaid the pay rate was poor the administrativehassles were many so one solution might be just don’t seethe Medicaid patients that’s not an option because that’s not the right thing to do and a whole lotta this is about doingthe right thing in the nineteen seventies as the townprospered with the oil boom and the hospital expanded local doctorsdecided to do something about the system a system that left doctors underpaid andmany patients underserved under the leadership ofdoctor and Alan what a general practitioner they create a local health plan to paythe bills at the same time the doctors formed agroup with their own and independent practice Association orIPA and they had on a simple but ingenioussolution to the basic problem they pulled the money from all thedifferent payers and agreed on one sec fee for eachprocedure whether the patient was rich or poor so under your system a doctor got paidthe same amount for the same procedure regardless of which system the patientwas in correct and by blending the funds from thedifferent sources commercial medicaid medicare we were able tobalance that out and battle out the doctors to do whatthey want to do which will see a medicaid patient theygot some reimbursement without very much hassle and that met that immediate need theMedicaid patient in this community can only see a doctor the Medicaid patient can see any doctorthat I could see as the head to the health planrequirement above being a position in our network is that you agree to see all of our members you know doctorsreally like the idea of providing health care for everybody so just about all the positions in MesaCounty take part in the system but that’s not the only surprising thingabout medicine here at the same time they expanded accessthe doctors created a mechanism to keep costs down as the Dartmouth Atlas shows us thiscommunity provides health care for about a third that cost them a place like say Miami Florida and yet the results arebetter here lower-cost better outcome how do you dothat from the very outset we believed the administration and the physiciansthat there has to be some oversight if it wasjust open-ended no controls frankly the the budget wouldhave been busted from the very outset the doctors use billing information fromthe health plan to compare one doctors perform it with another they were still independent medicalpractices but now they were all working together tocontrol costs to you go to doctor a and you say a doctor be has diabetic patients to has betterresults and is spending less money right or whyare your your diabetics on average why dothey have a higher blood sugar level than the next person Ican see how that would improve quality how does that lead to lower costs itleads to lower costs because you start seeing were over utilizationtakes place maybe physicians that are doing I oneprocedure that maybe doesn’t need to be done is often we take it for granted the doctor’s careabout their patient’s physical health actually Grand Junction is one of thetowns were doctors are concerned about fiscal health as well Kaufman in order to get doctors to careabout the cost of health care they have to feel the cost of healthcare and so we have a risk sharing agreement where Rocky Mountain health plans thenonprofit and we feel the losses in four patientsare not healthy how do you feel lost financially youfeel the loss financially remember how we said the doctors agreedto pull the payment from all the different pairs well then they took the next step theyagreed that the system would withhold part of each payment and then that moneythat was held back is distributed at the end of the year so we build asystem around a withhold from the physicians paymentsso for docs mostly paid 100 bucks or something we would typically give himeighty and then at the end of the year basedupon how well we did in terms of cost and quality measures the physicianswill get either all of that withhold backerportion %uh or no love it if we didn’t hit our targets so instead of getting paid his wholebill the doctor willingly put some in the money into this pool that’s right that’s that’s part of ourarrangement and in some cases doctors that didn’t do well couldn’tcontract with the IP in Rocky Mountain health plans anymore to make this year and adjustment workGrand Junction has built its own system digital record-keeping because in MesaCounty information is pure gold as in someother American communities doctors have figured out that inintegrated system be électronique health records can improve care andreduce cost health care is one of the few thingsthat humans need even before they’re born he should measure 38 centimetersmeasures 38.

5 in many american towns though prenatal care for mother and child isjust not available if the mother to be doesn’t have healthinsurance that was the situation nurse midwifeJanet grant found when she arrived in Grand Junction in 1983 me there were just too many pregnantwomen for the system to handle a lot to them had no health insurance mefeel there’s the head right there I was theonly midwife in town and Nana the positions they were herewith C patients with no medicaid and so my backup position and i got togetherand said we gotta get other people to see these patients welive down on route can you guess what kinda doctor has a stork on his frontlawn and obstetrician Steve major recallsthat the whole child for system in Grand Junction was a mass and see mean women seven or eight monthspregnant come to the emergency room never seen a doc they’ve never seen adoctor and why not our or they may have once and then beenturned down okay and although there were governmentprograms in terms of medicaid and a that sort of thing that would help getting them in rolled into that was ahassle of course that a national problem theGrand Junction is a place that does what it takes to solve health care problemslike that we decided to set up a clearinghousewhich would help the patients get all their paperwork done and get seen earlier and sooner by care provider within the heart the basic idea was provide medical careregardless if insurance before the babies were born somebodywith a taste for Pines name the program be four babies clearly what are theideas before baby sister is to get people intocare as soon as possible if you give a pregnant woman goodprenatal care does it save money no question it saves a great deal ofmoney there’s very few things that her ass costly as premature babies there are studies have shown that if wecan keep baby in mom for one day it’ll save a week inthe ICU we made a commitment if you’re pregnantin this community you’re covered period we don’t care about anything else other than the fact that you’re pregnantso they’re saving lives here and saving money in the process that’sthe basic lesson what Grand Junction has done becauseproviding medical coverage for everybody right from the first breath turns out tocut the cost of health care but in Grand Junction as in everyamerican city there are a lot of people with noinsurance at all I bet it won’t surprise you to know thatthe docs in the hospitals here found a way to treat them to they builda non-profit clinic named after the French saint louis’s toMaryland it now provides health care dental careand mental health care for about 8,000 people people likeMichael Irvin a guy who never expected to find himselfin a charity clinic II expectantly some years ago formerabout myself are without health insurance aftercareer which I have what many people would considerto be Cadillac the church plans other than I i got abusiness and got to the point where I couldn’t afford Cobra and so I was without health insurancefor the first time in my life eighty percent of our patients work areactively working and they just don’t work for an employerwho offers insurance benefit there’s also another segment of thepopulation is health insurance premiums have skyrocketed in this country that they simply cannot afford to pay theirportion love what they cost him player I’ll the patient here at merrill act paywhat they can but these only cover about a fifty thebudget the remainder comes from foundationsfrom private donors and from the local hospitals what would you have done it this theirword I wouldn’t have any choice but to social use the emergency room the twohospitals here for my primary care there’s that keymessage again providing high-quality care foreverybody even people with no insurance like Michael keep people healthy keep them out of thehospital and saves the system money if you build a system as we’ve done inthis community that focuses on the delivery ofhigh-quality care you want a building a less expensivesystem because here’s the scoop healthy peoplecost less than sick people if you prevent thecondition from reoccurring for that person is checked out at the hospital is a gooddeal for that person they’re not sick again they don’t haveto go back to the hospital and it’s less expensive for the systemis it something in the water in Grand Junction orkut another city do whatyou’ve done the key is you you’ve really got a hasstrong position leadership and someone in the community that’s that’swell-respected by the physicians and someone who theyfeel has the really their interests at heart you gotta have strong leadershipotherwise it’s not gonna happen it would take commitment not to begreedy it would take a commitment to workcollaboratively together to look at what’s in the best interestto the community as opposed to what’s in the best interest of myself that’s the story of health care at thisgrand junction of Colorado rivers just about everybody is covered costsare controlled and outcomes are excellent which makesyou wonder if this typical American town can dothat why can every town doing we went back to leave the new hampshireto ask the scholars at dartmouth we like what we saw in Grand Junctionbut it’s a tiny town in the middle of nowhere the big cities doing this to oh I think the northwest in a Seattlefor example is really a pretty remarkable community Seattle Washington where the SpaceNeedle powers over feugiat sound and you can ski either onsnow or water has a slightly higher median income thanthe national average the town response on local companiesyou’ve probably heard it has also spawned far-reaching inovations in health care delivery this region hastraditionally embraced co-ops that is businesses owned by their customa famous one is Group Health Cooperative which treatsabout 600,000 people but with the structure that’s reallydifferent from what we saw in Colorado Group Health is one big practice with nine hundred doctors who work onsalary and the insurance plan all under one roof in a neighborhoodcalled factorial Group Health has been pioneering a hotnew idea and health care that’s popping up in cities around the country it’s called the patient-centered medicalhome basically it to new way to manage the traditional doctors officetouch upon at his office Kathy speaking go ahead the docs are supposed toorganize their day around the patient scheduled and the whole medical team isresponsible for every patient that’s why they get together everymorning and as huddle to plan for the cases they’ll see thatday it supposed to make life better for the patient but doctor harry Shriver who runs theplace says the Medical Home idea is better for the doctors to one thing you won’t find here his filecabinets full of patients medical records all the records at this clinic ourelectronic saves money improves care plus any patient with the computer has thesame access to his medical records that the doctor the other thing is we increased our timewith patients to up to 30 minutes with a patient face toface them was achieved by increasing something I never thought I do wasvirtual medicine well as me that means we use the Internet in atelephone to communicate with patients they’reusing email to treat patients who woulda thunk it well every otherbusiness got there 15 years ago but an american medicine this isabsolutely avant-garde that way if I call my doctor on thephone I get some assistant to May relayed a message I suppose I couldemail the doc but witchy answer course my doctor doesn’tget paid to answer emails a group health it’s part of the job andhow do you talk to your doctor you come in your YouTube iphoner up to my email really haass and i’mconcerned.

assuring you know in the morning and she answers get likely here the key element at the medical home isthat here the actually sit down and talk toyour physician about all the things that alien I havemy doctor’s office you wait around half an hour to get what five minutes with the doctor no I I was concerned because when we talk that your blood pressure I heard thisyeah you know and fans worst me so this is a person who has many medicalissues every time she comes to see me and sheactually came to me from another model care where on there wasn’t enough time or interestto take care each issue know you said that youworking just here I spoke to her on the phone beforeshe came in so I knew that I was going to need do acardiogram electrocardiogram before she came and she could goupstairs get the car to grant and then we can deal with it right in the visit it makes it much moreefficient so now I can look at her old party grams and I can compare them hasn’t changed inits okay her credit and okay I can look at her payout peak flow readings and I can see how many timeshe’s needed treatment were the reactive airway disease or or asthma and what she needs naps and a what we’veseen here is a doctor who really knows her patient the position isn’t just reading a soreknee or runny nose she treat a person and she keeps trackof all the care that the other specialshere provide for that person and since they’re on salary the docsdon’t need to gin up a lot of office visitor test to enhance their income another way to save money on health careis to head of disease in advance to treat people before they getseriously ill in a medical home chronic diseases tendto be spotted early where the docs can still make a difference at the clinic in Factoria there’s anurse specialist Janet nolte whose whole job is to help people getcontrol of their diabetes before the oldest takes over their lives yeah she works with the patient again takinga lotta time to create a long-term management plan that means changing diet getting theright exercise and spotting telltale signs that the patient mighthave missed on a roll the whole idea is to treat your diseasenow before it makes you really sick and make sure health care reallyexpanded I mentioned that this notion otherpatient centered medical home is the hot new thing in health care delivery but it’s actually based on an old ideayou know and I’ll to prevention to the patients are healthier thehospital stays are shorter and the bills are much lower this takestime more time than the five minutes in andout that you find in a lot a doctor’s office here but in the end it saves money andsaves lives doctor michael solomon the presidentgroup health is delighted with the result that thisexperiment we know that for every dollar we spendto create the medical home we saved a dollar fifty it wasn’t justthat we cut anything cut jobs cut services ration it wasn’t any of that we saved money by the system acting like a system and having moreappropriate utilization the way patients would we’re here that’sbecause it’s just more efficient to treat patients in the officer via email them to put him in a hospital room weretaken to emergency it works so well that group health isembraced the Medical Home idea for all its medical centers still on the shores of Puget Sound wefound another useful model just north of Seattle in Everett Washington this town isslightly higher than the national average in family income in just aboutaverage when it comes to the number of people who are uninsured the Everett clinic is owned by thedoctors but they don’t have their own insurance company or hospital this clinic treats about 250,000patients here an average the structurescompletely different 300 docks in one big practice but this place to is famous forcontrolling the costs of health care weld star at the heart of the operationwe found a cardiologists doctor harold dash use the president atthe clinic doctor the reason we’re here is thatexpert to Dartmouth say every clinic is a model for high-qualitycare reasonable cost how do you do thatsometimes are surprised at that because we’re trying to do better we think thatour our costs of care can be improvedsubstantially we have a call to lower the costs ofcare to our patients by 25 percent in thenext five years we’re hopefully accomplish that by Naleigh reducing institutional carehospitalizations emergency room visits had Nate will give health planshopefully an opportunity to lower premiums one way to cut costs is to eliminate unneeded tests high-techtools like MRI’s and cat scans are amazing innovations that save lives but the doctors here recognize that somepatients don’t need these costly tests if you come in to an office with aparticular complaint as an example you have then soreshoulder so I understand yes I do and theirposition hitters in an order for an MRI scan theshow shoulder there will be a electronic medicalrecord a pop up will appear that will he asked the position aseries of questions related to that shoulder those questions were developed byorthopedic surgeons in conjunction with the radiology crew and why literaturethat there exists related to water the the things that have to be happy in order for you to Kuala try for thatMRI scan and if you don’t meet anyone at thosenumber possibilities then the recommendationwould be probably physical therapy me a medication for aperiod of time until you know wanna one of thosecriteria now the doctor can overrule the software and ordered the scanner she sure it’sneeded but the system cuts the number of tests and that cuts costs are these kinda cost-saving something that othercommunities could get to absolutely I think it’s becoming moreand more common in large organizations that have the capability that to do that with electronic medicalrecord speaking a large organizations a company down the street called boeingthe world’s biggest maker jetliners as the Everett clinic recently to testthe new model health care delivery you see giantcompanies like Boeing generally self-insure that is they pay for their employees’health care of course they pay the most for peoplewith complex chronic health problems rivers and these are patients who had multiple emergency room visits duringthe year multiple hospitalizations and boy do they spend time with thosepatients do you ever get an hour-long visit withyour doctor in this project at the Everett clinic that became the norm every time we visittoo important in time go over everything in our history detail take care process centered around a nurse care manager and the nurse caremanager work with the physician that word manager is important herebecause patients like Charles have so much goingon at the same time you need a professional manager just tokeep track of all these symptoms and treatment and prescriptions the nurse comes and she sits down withyou for while and takes everything all your medicalhistory right there impotent brown computer everything’s right there with the doctorcomes you even puts the computer screen in yourface you see he’s your medications is thisthe history these patients were given direct phoneaccess to the nurses oppose two receptionists they were required to had communicate Uzor secure patient email which isprimary electron medical record this is kinda comprehensive preventivecare in at save money for everybody yes itdoes yeah I’m no longer in the complex carestation program and you don’t miss as much work a no sobowling games you came and I’ll bet the system spentless money cuz you never have to get really major surgery gone to the hospital and at the end theout the project belly actually saved twenty percent incost this was this was not bending the costcurve this was saving money this is what the the big buzzword forthis is medical home a place where they understand you know all your problemsand give your where they get serious in that’s whatyou are that’s alright its I just know you’re I had Jolenerodgers et my daughter’s and they were very helpful so your joint I am cash we’ve met a fan of yours today bonier patiently totally love the workyou did but you’re not a doctor I am not a doctor so what did you do forCharles well I a nurse care manager care what we didand we Courtney their care we help directlypatient to the right care at the right time and i never avoiding I’m alive PR visited allottedunnecessary hospitalizations maybe some unnecessary hospital days yeah could other communities andother medical practices use this to save money I think absolutely take a look at themedicine cabinet in any american home and you’ll see thatour country spends hugely on prescription drugs the doctors at the Everett clinic didsomething about that too the most expensive pills at the brandname drugs you know like Prozac and by Agra which are protected by a patent up but for most medications there’s acheaper version as well it’s called the generic drug and thosebargain-basement pills are chemically the same as the big-ticket brand names the USA spent a quarter of a trilliondollars each year on prescription drugs so thedocs it ever realize that this could be a ripe targetfor cost-cutting has so we look at what we were doing andat that time we were no different from any other organizations across the country pharmaceuticalrepresentatives were here frequently he went into the drawers in our officesthey were filled with samples in there was no control over prescribing and the positions that even know whatthe prescribing practices were but somebody didn’t know what the doctorprescribing the local insurance company which pay the bills so ever asked Romero Blue Cross for help we have a lot of data and so we began providing them with data and comparativedata on what their generic are prescribing patterns look like manyyears ago the great thinking with the ever clinictook that and absolutely ran with it and we also in at that time eliminated the pharmaceuticalrepresentatives from the organization and we also took out all the samples there was a lot controversy about that both on the part of physicians and onthe part of patients and then we also hired to clinical pharmacist we decided thatwe were gonna have are I’ll myself in a central point ofcontact for all the pharmaceutical companies and that I the team that I work with wasgonna provide the knowledge to our providers on how topass prescribe medications knows pharmacist had a responsibility toreview the literature for on medications to determine whatmedications really where new medicines wereimportant medicines and what we’re me to medications that were therebasically is a brand name to be provided at high cost but notprovide any better quality than visionary medication if the twenty cent pill worksas well as the one dollar pill why would a doctor prescribed expensive that’s a hard question to answer I thinksometimes am I’ve been amazed at how part of oureducation needs to include with the cost of drug therapy is the docs don’t know this coming out amed school no they don’t so but we can teach them we also look at medication airs between the time that a physician prescribes the Madison and it is fieldin the pharmacy and in fact errors were reduced by oversixty percent I don’t see what the areas you mean thedoctor prescribes the wrong pill no a the care could relate to penmanship up the position it could have related to the pharmacist in the retail pharmacy filling it not on the basis that the prescriptionwas written we moved from written prescriptions toelektronik order entry and we’re very proud of ourresults %uh because her when you compare thecost of prescriptions that patients and current are setting tothe average cost of prescriptions in the state of Washington the patientswe care for save about $88 million dollars a year Ithink what you tell me as we could actually spend less on medication in get just as good result we can evenget better results really yes weaker and you found that in thispractice yes we have this is a question we call upon all thetime why did the doctors want to cut costs I it’s a very good question I i believethe reason they did it is because the year stewart’s in their community becausethey believe that it is their role to pursue affordable higher quality health carefor the community I’ve ever heard this imposing edifice is the Provident Regional Medical Center it’s beenserving ever Washington for more than a century eversent a group of nuns track to your from montreal bought a run-down hotel and turned itinto a hospital the Sisters of Providence live by themotto humility simplicity and above all charity today their hospital is a $500 million dollarfacility but it still honors the sisters missionto serve the needy which is to say the uninsured usuallyhaving insurance creates access for people who don’t haveaccess that poor and vulnerable we can make sure that we’re here forthem to do that we gotta spread our resources very far to do that weed out and make sure our resources arespent as efficiently as possible did you hear that we found another placewhere they’re determined to cut the cost of health care one at the heart surgeons at ProvidenceJames Bradley found a way to control costs bycontrolling a common but costly former treatment blood transfusions duringsurgery across the United States something likeforty to fifty percent of patients get open heart surgery get a blood transfusion but it’s notclear when or wine that should happen there arewell-known ressa blood transfusion and wrists are very well documented but the benefits are not the more Ilooked into this the the less clear if he came to me whatthe typical guidelines or wants to transfuse howmuch a chance use their hospitals that used almost noblood products for open-heart surgery and their hospitals the transfused virtually 100 percent inthe patient’s they got hurt surgery and variation is concerning to me is aposition because Inc its me that there’s an opportunityfor improvement if the utilization aboard varies from 0percent to 100 percent and all the practitioners think thattheir utilization is perfect something is wrong in other words when it comes to blood there’s hugevariation in usage and costs from one town to the next when the cardiac specialists here studythe issue they founded few patients really neededthis costly procedure to Providence now uses transfusion as a last resort Dave how much is thecost to hospital for played upon not kinda but probably as a total costto the organizational one thousand dollars a pint well really over the last three to four yearswe’ve probably saved about twelve million dollars between the blood product and the Brewerrelated support services now I I don’t want you to get the wrongidea there are patients that need a blood transfusion patients who have trauma and/or or orbleeding to death they need a blood transfusion and theirlives are saved by those blood transfusions but the surprises that many patients actually do better withoutblood transfusion wanted blood is thicker than water and a lot more expensive to so in thecardiac team that Providence figured out how successful their new approach was the idea spread to other wards all overthe hospital so this is one more case study and howdoctors who understand the need for cost control can save lives and save money at thesame time can other communities do what happenedin Everton to: absolute absolutely other communitiescan do it D it’s a question our hands and some are two very extensive but its it’s a question of it’s a questionof focus it’s a question of Dom do you approachhealthcare has something that you’re doing for yourcommunity or zip only business good autumn in New England and if that fallfoliage looks familiar well it should were back in newhampshire the homework Dartmouth and the dartmouth atlas but this time we’ve come to Dartmouth tovisit the local hospital the dartmouth-hitchcock Medical Centerat dartmouth-hitchcock the business model is a common one forbig regional hospitals some other doctors are paid by thehospital some private doctors practice here thebills are paid mainly by insurance companies and Medicare but this hospital is doing somethingthat’s still pretty uncommon in american medicine they get the patient involved in makingtreatment choices it’s an idea that has been championedfor years by the founder the dartmouth atlas doctor jack weinberg who lives rightdown the street you’re saying that doctor should ask their patients whatthey want before they recommend so they should ask in a way that leads to a authentic decision but you’resaying doctors don’t do that is not in the habit of physicians to do this your delegating decision-making to docsis the standard practice in most places so my doctor knows a lotmore and i’d so I’m not inclined to tell herwhat to do positions do have a lot of the clinicalinformation about what the risks and benefits a different treatments are that patients have the information aboutwhat they value I can tell my patients so if you’rehaving oprah if you’re having open heart surgery for an Jinnah areas some benefit your chest pain willget better if you’re having chest pain for your heart disease but there’s a small proportion ofpatients who have some cognitive impairment who have trouble with theirmemory after the procedure I can tell my patients those risks butthe patient has to tell me whether they care about their chest painor not they may not they may not think playing tennis is very important anymore they may have an upcoming wedding withtheir daughter and may want to remember their daughters name the patient’svalues have to help guide the decision-making the fancy term for thisis shared decision-making that means thepatient gets involved in major decisions doctor Jim Weinstein director at thehospital is a specialist in spine surgery which is pretty darn close to rocketscience but he wants the patient not the specialist to make the treatment decisions she’searly in the course Leslie likely to have a this problem that’s pressing on a nerve man actuallyinterested in having surgery to wants to get rid of the pain we’vetalked with our colleagues in the pain clinic and they believe that they canhelp her with some medication if your symptoms get worse and the painpersists we would go ahead and order the MRI study to investigated further no problem no no pain in this league now sotraditionally in america patient comes in and says my back hurtsshe’s gonna get steered to a spinal surgeon who then doesn’t X-ray does an MRI does test the surgery the question isdoes the patient have the signs symptoms and clinicalfindings in there they well informed about thedecision in these elective operations andempowered to make that decision because they have to live with thedecision this hospital has a whole unit the center for shared decision-makingwere each patient get an education about the Ranger treatments for herspecific health problem so is is this what you had jackie guess was the tank house generally surgeons tend to recommend an operationand the patient tend to go along I mean it’s not that easy tosecond-guess a brain surgeon her spine specialist at Dartmouth 0 this process is moreinvolved in a brief chat and the doctor’s office i watch the DVD looked at the outcome studies did my research saw that I was probably a good candidate and I probablywould have a a good outcome and pushing some patients like Jackie choose to havesurgery but some choose not to and what we found even as conservative as I him top really we had a 30 percent drop in our surgeryrates into surgery so as a doctor if you givethe patient that information and she decides not to have the surgerydozen the doctor make less money yes well as be brutally frank your thishospital is famous for good outcomes at low cost but you’rerunning fifty million dollars in the red yeah and maybe if you did more stuff you’d be a you’d be in black yeah but wedon’t ever wanna do more stuff that’s not our value system we’re gonnajust their course were 1.

3 billion dollar operation fiftymillion dollars we can we can figure out how to manage that and we will because we haveto we have an obligation to the communityhere to be here to serve them and not to make money we’re not here to do that well I’mthinkin as a taxpayer who fund medicare and medicaid I gotta like you because you’re reducing health carecosts in america I hope you like me not just because I’mreducing costs because I’m allowing the patient to be involved inthe decision process in fact they actually choose and they like it in this program we’ve seen communitiesfrom coast to coast that provide quality health care at reasonable cost the problem is a lot of places don’t dothat some county spent three times as much asMesa County Colorado with no better results so where does allthat money go the additional spending in thehigh-spending regions is largely devoted to hospital stays for patients would betreated as outpatients analyst pending regions two visits tospecialists that would be managed by primary care physicians in the lower spending regions andunnecessary tests and procedures the patients in the lower spendingregions would wouldn’t simply not receive these were unnecessary tests andprocedures so if we didn’t do them how much can wesay well you know we estimate that if everyone UnitedStates immediately could adopt the practice patterns to the lower spendingregions health care spending we go by down by 30percent and now others have confirmed this you know that probably thirty percent ofUS health care spending is devoted to unnecessary services 30 percent that 700 $800 billion dollarsa year that’s a lotta money that we could saveif we could reorganize the delivery system and help all physicians practicesefficiently and and parsimonious Lee on as they are in the slow spendingregions not everybody agrees with an estimatedthirty percent but the consensus is we would save 102billions if every town in america could be asufficient as the places we seen in this programit’s doable its you know we prove that it’s not thatcomplicated it’s doable all over the country ifdoctors hospitals and insurance plans will work together to keep track of costs and hold themdown it’s doable is medical practices are willing to usenew technology and new delivery models to give them more time with patientsit’s doable if doctors are willing to give theirpatient a real voice in making treatment decisions and it’s doable if all others insistthat our local hospitals and local doctors perform as well as the placeswe’ve seen in this program if every community would take thosesteps we could finally achieve the goal of high quality health care at reasonable cost for every Americanthe the ok ok ok good up.

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