Just returned from a presentation by Dr. Elliott Fisher, Professor of Medicine at Dartmouth Medical School, on “Spending, Quality and the Paradox of Plenty”, where he addresses the problem of rising health care costs, poor quality and declining access to healthcare. His research and association with the Dartmouth Atlas of Health Care Project focuses on examining the differences in spending and medical practice patterns across regions in the U.S..

Not surprising, but always interesting are findings that are counterintuitive to those outside of the healthcare industry. For example, that higher spending regions in the country generally suffer from worse technical quality of care, slightly higher mortality, lower patient satisfaction with hospital care, and patient perceptions of worse access to primary care. Physicians in these regions also perceive greater difficulty in ensuring both the quality and continuity of healthcare.

Fisher argues that “higher spending across regions and physician groups is largely do to overuse of supply-sensitive services — hospital and ICU stays, MD visits, specialists consults; and — at the margin — more is worse.” He also thinks that “overuse is largely a consequence of reasonable differences in clinical judgment that emerges in response to local organizational attributes (capacity, clinical culture) and a national policy and culture that promotes growth and more care.”

Underlying causes include, according to Fisher:

• A lack of accountability for key local determinants of quality, costs and health outcomes
• An assumption that more is better, thus equating less care with rationing
• A payment system that rewards more care, increased capacity, high margin treatments and entrepreneurial behavior

The challenge of “improving health and reducing suffering” requires organizational accountability for quality, costs and capacity, comprehensive performance measures and new approaches to payment, says Fisher.