“We have no illusions that we will make a chronically ill patient normal again, but our default position is to treat aggressively until it is clear that no reversible pathology exists,” he said, adding, “Full discussion with the patient or family on the feasibility or likelihood of achieving the goal is also important.” Futile care plans are not undertaken just because that is what the patient or family wants.
The report authors recommended research on how treatments affect outcomes, patients' lives, and the efficiency of clinical practice.
Evidence is lacking for how often to see patients, when to refer to specialists, and when to admit. As a result, primary care physicians will refer to a specialist or admit to a hospital if those resources are available and payments for office-based care are constrained, they said.
Patients need to be followed over time and across settings by established group practices and integrated provider systems that are capable of organizing care over the span of an individual's chronic illness. Organizations that participate in this research should be rewarded through a proposed shared-savings program with the Centers for Medicare and Medicaid Services that is designed to encourage coordination and to reduce overuse of care, they proposed.
Physician groups and hospitals should be encouraged to become real or virtual integrated systems that are willing to be accountable for the coordination, overall costs, and quality of care provided to chronic disease patients.
The authors proposed a shared-savings approach in which payments are based on per-beneficiary costs relative to appropriate spending targets. Shared savings would allow physicians and hospitals to preserve their net incomes while reducing total revenues resulting from unnecessary care and overuse of acute care hospitals.
In addition to the Robert Wood Johnson Foundation, other supporters of the Dartmouth Atlas project include the WellPoint Foundation, Aetna Foundation, United Health Foundation, and California Healthcare Foundation. The full report is at www.dartmouthatlas.org