'We know more about what's in a cereal box than we do about what's in the healthcare system'

Dr. James Weinstein, CEO of Dartmouth-Hitchcock health system in Lebanon, N.H., and a spine surgeon, was deeply involved in the deliberations leading up to the Affordable Care Act. He continues to press for delivery-system change. He recently sat down with Modern Healthcare editor Merrill Goozner to discuss the book he recently co-authored, Unraveled: Prescriptions to Repair a Broken Healthcare System, and what he sees as the next arenas ripe for reform. This is an edited transcript.

Modern Healthcare: Why do you think there's something fundamentally broken about our healthcare system?

Dr. James Weinstein: There are serious issues with the health system that warrant serious solutions. At Dartmouth, for decades, we've looked at the variation in care across the country. It's our turn now to come up with solutions. We're working with colleagues across the country on projects related to what I like to call informed choice to help patients have better decisionmaking. To make informed choices, they need to be well-informed. We're working on the transparency around pricing and outcomes. It's not good enough to just say this is how much is being charged or this is how much something cost. What kind of value do you get from that charge or cost or from a procedure you might have? For value-based payments, it's critically important to have transparency about what it cost. We spent a great deal of time building an infrastructure to provide those kind of answers for our patients at Dartmouth-Hitchcock and we're working with colleagues across the nation to do the same thing.

MH: Patients tend to be more conservative if they're given a role in making the choices. How does a Dartmouth prepare for a world in which you're going to be getting less revenue?

Weinstein: We must do what's right for the patient and the consumer, not what's right for Dartmouth-Hitchcock. If you start with the premise of what the patient needs and what the population needs, you might actually build your health system in a very different way. You might actually do better work and make more revenue than you do today by trying to prevent things. Today, we're paid for doing things. Imagine what we could do if we could prevent things and I didn't have to have so many hospital beds with so many sick people. We have to get upstream. We have to start dealing with our nation's greatest problems in mental illness, drug abuse, childhood obesity. Smoking is still a problem.

MH: How does a healthcare system do that on a day-to-day basis?

Weinstein: First of all, we have a strategy that deals with our organization. We take part of our investment portfolio and invest it into the populations we serve in things they need most, which aren't reimbursed well, like mental illness, like end-of-life decisions, like having the ability to make your decisions before you're going to die about how you want your life to end. We build a technology infrastructure that makes care available closer to the home. We're trying to find ways to make care consumer-friendly, not hospital-friendly. We try to find ways to work with you after you leave the hospital to keep you from coming back.

MH: You also formed an insurance arm with Harvard Pilgrim as a way of changing the reimbursement incentives inside your own system.

Weinstein: We're very excited about our partnership in the insurance space. It brings us as a system into a space where we can get closer to our patients and their needs around the premium dollar. We want to lower the cost for the patient who's actually experiencing greater cost because of the change to high-deductible plans, where they have more out-of-pocket cost. We went into the market with a premium that was 15% lower than anything else in our region to lower their out-of-pocket cost upfront. Then we created networks with other partner systems so we get continuity of care where as you go from hospital to hospital, you do not have to retell the same story over and over again. We've worked to create the kind of quality of care and practices that are evidence-based across an integrated system that does the same work, has the same medical records structure, the same protocols and the same answers. But you don't have to come to Dartmouth-Hitchcock to get that. You can go to any of our partners in the health plan or in our network.

MH: Has this created conflict with physician practices or community hospitals that are excluded from your networks?

Weinstein: Networks always potentially create a problem, and therein lies another important solution: being transparent about your cost and your outcomes. There should be competition. This country was built on competition. But let's put out the information about what value one organization provides against others.

MH: The overarching theme of your book is that we really have to transform the healthcare system into being patient-centered. What is the biggest problem in achieving patient-centeredness?

Weinstein: The payment system interferes the most with transforming the healthcare system. Many healthcare systems are fearful that if they transform, they won't survive in a way that still provides meaningful healthcare. At Dartmouth-Hitchcock, we're trying to make a very measured approach in our population strategies to deal with those who are sickest in new and different ways. We're trying to change the services we offer and what kind of workforce offers that service. Maybe it's not a physician. It's a nurse or how we use technology. We have to figure out how to get out of the fee-for-service system and contract with patients where they don't have to provide more money out of pocket to get the services they need. The systems that have been built in this country have been built to sustain their revenue stream. It may not be the right thing for the patients. The transition is difficult. Each system has to determine how they're going to do it. Many fear that change will unravel the structure they have. We need to unravel some of them.

MH: Some would characterize efforts at delivery-system transformation over the past six years as experimental rather than transformational. Where do you see it going in the next five years?

Weinstein: I think it's been disruptive. Over the next five to 10 years, what we really need to do—and I don't care what the payment system is—is have transparency about cost and outcomes. Right now, it still seems like an effort to lower the spend, not to improve the outcomes of the healthcare system and for the individual patient. We haven't transformed the system so that people actually understand what the system provides. We know more about what's in a cereal box than we do about what's in the healthcare system. We have to have that kind of cereal box explanation for every system in this country so patients can make an informed choice about their care. We can then rationally decide what we're going to spend in this country as part of our GDP—not to ration healthcare, but to rationally decide based on good information what our spend should be.