Dr. Jack Wennberg, the father of the Dartmouth Atlas, and Shannon Brownlee, the author of  Overtreated and a New America colleague, recently posted on the Health Affairs blog, recapping four major goals for repairing  the "dysfunctional, disorganized, and wasteful delivery system."

1. Improve the science of health care delivery.

The stimulus package boosted comparative effectiveness research, and the health reform bills in Congress would build on that. But studying effectiveness of treatments, in isolation, isn't enough, they argue. We also need to develop a "science of health care delivery" which they call a "black box." Patients with similar conditions are treated in very different ways and we aren't doing the necessary research into how to best to allocate resources and deliver the most effective care.

 2. Foster the expansion of organized systems of care.

These new systems, often described as Accountable Care Organizations, would reward providers that show they can be efficient and use resources judiciously -- while delivering high quality care. Shared savings (giving providers a portion of the savings during a transition period) gives the providers an incentive to bring down costs. 

3. Informed patient choice (rather than informed consent) should become the standard of care.

Patients facing elective surgeries, tests, and procedures often don't understand exactly what they are consenting to -- or what options they may have.This can lead to higher costs when they get treatment that they may not have chosen (ie surgery instead of giving physical therapy a chance), and it may encourage malpractice suits. Shared decisionmaking could reduce unwanted care, they write, but to make this the norm providers need to be paid for the time and tools they employ. (Medical homes, the authors write, are a good payment fit for informed choice.)

4. Constraining the undisciplined growth in health care capacity and spending.

The health reform bills get most of their CBO-scored savings from cutting provider payments. But Wennberg and Brownlee content that these equal-opportunity cuts (no distinction between high quality efficient hospitals and the most wasteful ones) is a lost opportunity. They would like to see Medicare's payment clout employed to  "encourage slower spending growth and greater accountability." Those who demonstrate high quality and cost accountability should be eligible for bonuses, and those that fail to restrain excess spending should face penalties (nick the payment "updates"). That would save some money in the near term but "but more importantly, it would serve as a signal that Medicare is serious about reducing future spending growth." Alternatively, payment updates could be reduced in a high-cost growth region, discouraging the "local medical arms races" that add to excess utilization and skyrocketing costs.They write:

Either way, reducing updates to high-growth regions or specific providers should discourage the easy flow of money from bond and equity markets for hospital expansion, and could spur the most inefficient providers to participate in ACOs and other shared savings programs. The key here is encouraging local providers to consider how to slow -- or even reduce -- local spending on unnecessary care. Some communities that have successfully held down costs did so by merging hospitals and eliminating unneeded capacity.

Wennberg et al also weighed in on the controversy (some emanating from University of Pennsylvania's Richard Cooper) over whether the vast Dartmouth Atlas research into geographic variation in Medicare spending adequately took health status into account, ie did the "high spending" hospitals spend more because their patients were poorer and sicker, or because they were less efficient. Wennberg and Brownlee post data showing that even in apples-to-apples comparisons (ie looking at academic medical centers in poor, urban, black communities, or even at two academic medical centers in the same community) the variations persist. Kaiser Health News recently wrote about Cooper, the controversy he engenders, and other health policy experts' assessment.