In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of John E. Wennberg, MD.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"There's been a lot of progress: Not that there has been a substantial change in the variation problem, but there's been a lot better understanding of the causes of it, and the remedies we need to put into place to actually reduce variation."
While living in Vermont in the 1970s, John E. Wennberg, MD, MPH, was flabbergasted when his studies revealed that, in one area, children might have a 75% chance of their tonsils being removed, but if they lived 100 feet away, within the border of another school district, only 20% of the kids did.
Wennberg, founder of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., has repeated this seminal story about his findings many times over the past 40 years about the variation of healthcare delivery, since it shaped his view of healthcare in America—and his life's work.
For "Jack" Wennberg, that research started a journey in which he has consistently criticized the health system for ordering too many unnecessary procedures and producing too much variation of healthcare across regions. These practices manifest themselves in results like uneven care for the chronically ill, or a national healthcare system that simply spends twice as much as it should. Wennberg's mantra has become indelibly stamped in healthcare: "More care doesn't mean better care."
For the white-haired, soft-spoken Wennberg, the data he has compiled and analyzed roars resoundingly throughout national debate on these matters.
From the outset, Wennberg saw that differences in U.S. healthcare spending were often the result of location. Among the more significant Dartmouth findings over the years has been the surprising discovery that, in some areas of the country, more aggressive care was the norm, and spending was twice at much. At the same time, he found that such spending did not necessarily improve outcomes.
Those variations of care are "still a persistent problem, definitely," Wennberg says. "If you do the same measurement we did then," he says of previous reports, "you hit the same story. For most things, they vary and vary idiosyncratically. One region will be high on this end, and will be low on another, when you are talking about surgery anyway."
Wennberg has consistently been putting his footprint on the wide swath of healthcare spending since the early Vermont study. In 1988, Wennberg started the Dartmouth Institute for Health Policy and Clinical Practice, which has been the driver of the research and studies. It was then called the Center for Evaluative Clinical Sciences at Dartmouth Medical School. After stepping down several years ago from running the institute on a daily basis, Wennberg continues his passion to study the foibles of healthcare delivery. He is the Peggy Y. Thomson Professor Emeritus in the evaluative clinical sciences.
Wennberg is also founding editor of The Dartmouth Atlas of Health Care, which examines patterns of medical resource intensity and utilization in the United States. The Atlas project has reported on patterns in end-of-life care, inadequate use of preventive care, and Medicare reimbursement failings.
Wennberg and his colleagues discovered that patients in high-spending areas would see 10 or more specialists during their final six months of life. And yet, chronically ill patients who receive the most intensive, aggressive, and expensive treatment fared no better than those who receive more conservative care.
In a 2004 study of 77 of the country's top hospitals, Wennberg and his colleagues reported what he termed "huge differences" in the management of patients with chronic conditions during the last six months of life. Nationwide, Wennberg reported that hospital days per patient during the last six months of life ranged from 9.4 to 27.1, the number of physician visits from 17.6 to 76.2, and the percentage of patients who saw more than 10 physicians ranged from 15.9% to 58.5%. Even within the same city, different hospitals revealed significant differences in "patterns of patient management," Wennberg wrote.
"That's the whole nub of the issue," Wennberg says. "It's the intensity of treating chronically ill patients that is responsible for differences in spending in places, such as Los Angeles and Minneapolis, among Medicare populations."
With findings like these, Wennberg and his colleagues have generated many headlines, and continue to reach a wide audience, as an integral part of the nation's burgeoning discussion on healthcare reform. While healthcare leaders are listening about the problems of variation of care, that doesn't mean the problems are solved, he says.
"There's been a lot of progress: Not that there has been a substantial change in the variation problem," Wennberg says, "but there's been a lot better understanding of the causes of it, and the remedies we need to put into place to actually reduce variation."
Eventually hospitals and health systems, as well as doctors and other healthcare professionals, must look beyond the costly and unnecessary procedures, but also at the money spent for increasing capacity that may not be justified by the need, Wennberg says.
Such variation is important because it is wrapped around essential elements of healthcare that can be expensive and also wasteful. That waste includes frequency of visits to physicians, the number of hospitalizations, how often people are sent to ICUs or get an MRI, Wennberg says. "There are variations associated with overall capacity, how many doctors you have, how many beds," he adds.
Not only do health systems need to have "better organization," but also it is increasingly important to provide a shared program with patients themselves, Wennberg says. "Getting patients engaged has been one of our principle goals, and we are seeing some progress in reducing variations in elective surgery." Wennberg refers to findings in a study by Group Health Cooperative in Seattle that showed a 39% reduction in knee replacement spending once health systems adopted the concept of shared decision-making about what is medically necessary. Wennberg was not involved in the study.
A graduate of Stanford University, Wennberg received his MD at McGill University, and also took post-graduate training in internal medicine and nephrology at Johns Hopkins University. While there, he became increasingly interested in epidemiological principles in the healthcare system, so he pursued a master's degree in public health.
That led him to study the tonsillectomy variations in Vermont as director of a northern New England medical program. Wennberg recalls how he and his colleague tried to shop around their findings, but were roundly rejected. "They weren't ready for it, that's for sure," Wennberg has said. The journal Science published the study.
Hospitals and health systems must continually examine their spending, but it won't be easy, he says. "They have mortgages on them, have bonds to pay off. The capacity is currently adjusted through the current cash flow, and in turn it is based on utilization, and reducing it is a problem," Wennberg says. He believes that accountable care organizations may be a way out—"to the extent that shared savings is implemented in a sophisticated way ...It would mean the management and physicians at a given institution could reduce capacity without bankrupting the institution or screwing up the bond market. Ultimately, things need to be worked out."
Wennberg continues to see how healthcare can "work out." Two years ago, he wrote a book, "Tracking Medicine: A Researcher's Quest to Understanding HealthCare."
In it, he writes that: "...much of health care is of questionable value and that informed patients often prefer a form of treatment other than the one their physicians actually prescribe. More care is not necessarily better at least when it comes to managing chronic illness. Care coordination and intelligent management of patients over the course of their illness which typically lasts until death counts far more than simply providing medical services."
Wennberg says he will keep studying the intricate flaws in healthcare as a means to finding ways to improve it. Even with four decades of research behind him, the opportunities for new, promising insights are enough to keep him busy for years to come.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.