By Ceci Connolly

Washington Post Staff Writer
Thursday, June 11, 2009

When President Obama touches down today in Green Bay, Wis., he will be landing in one of the highest-value health communities in the nation, a city that by numerous measures has managed to control medical spending while steadily improving health outcomes.

"If we could make the rest of the nation practice medicine the way that Green Bay does, we would have higher quality and significantly lower costs," said Peter Orszag, the Obama administration budget chief who has emerged as a key player on health-care reform.

In his drive to rein in skyrocketing health-care costs, Obama is increasingly focused on wasteful medical care that does not extend life and may actually be harmful. Today's town-hall-style meeting, his first as president to promote health reform, is intended to spotlight one city's strategy for squeezing out waste without hurting quality.

The event, coupled with a speech to the American Medical Association on Monday, represents a fresh push by the White House to sell the public on legislation that could dramatically alter how care is given and paid for in this country.

"In the coming days and weeks as Congress moves to the issue, the president will be more active in making the public case for the urgent need to reform our health-care system," said White House spokesman Dan Pfeiffer.

What Obama is likely to hear in Green Bay is testimony to the value of digital records, physician collaboration, preventive care and transparency, say those most involved in Wisconsin's innovative approach.

"There's been a fairly steady progression of quality" in areas such as diabetes care and cancer screening, said Chris Queram, executive director of the Wisconsin Collaborative for Healthcare Quality, which publishes statewide performance measures. "Every physician believes he is doing the very best for their patients, but when they see data that their group is not practicing at the same level as across the state, it's a real positive motivator to improve."

The federal Agency for Healthcare Research and Quality gives Wisconsin high scores on 100 measures, ranging from the treatment of heart disease to childhood asthma.

But it is the findings of the Dartmouth Institute for Health Policy and Clinical Practice that have generated the most excitement in the Obama administration, all the way up to the Oval Office. For more than a decade, the New Hampshire researchers have documented and mapped wide variations in the cost and types of care given to American seniors through the Medicare program, concluding that spending more on health care has not resulted in better health.

In the final two years of a patient's life, for example, they found that Medicare spent an average of $46,412 per beneficiary nationwide, with the typical patient spending 19.6 days in the hospital, including 5.1 in the intensive-care unit. Green Bay patients cost $33,334 with 14.1 days in the hospital and just 2.1 days in the ICU, while in Miami and Los Angeles, the average cost of care exceeded $71,000, and total hospitalization was about 28 days with 12 in the ICU.

Some differences can be explained by big-city prices, acknowledged Elliott Fisher, principal investigator for the Dartmouth Atlas Project, "but the differences that are really important are due to the differences in utilization rates."

Much of the evidence suggests that the more doctors, more drugs, more tests and more therapies given to patients, the worse they fare -- and the unhappier they become, said Donald Berwick, president of the independent research group Institute of Quality Improvement.

That has been the case at Gundersen Lutheran Health System in La Crosse, Wis., which has spending patterns comparable to Green Bay's. Persuading patients to sign medical directives and using electronic medical records to alert doctors and nurses, for example, the health system has dramatically reduced the intrusive, expensive end-of-life procedures that often drive up costs but rarely stave off death for long, said chief executive Jeffrey E. Thompson.

"At the end of life, what most people want is for their wishes to be respected," not to undergo an aggressive battery of tests and treatments, he said.

Richard Cooper, professor of medicine at the University of Pennsylvania, says he thinks the variations identified by the Dartmouth researchers -- due primarily to enormous hospital expenses -- are often related to patients' socioeconomic status. States such as Wisconsin have lower medical costs because they are predominantly white and middle class, he said. The notable exception is Milwaukee, with its "poverty corridor," he said. "Nobody wants to talk about the fact that if you want to deal with health care you have to deal with poverty."

In Green Bay, health providers are partnering with employers to attack the root causes of high health-care costs, said George Kerwin, chief executive of Bellin Health System. Investments in primary care and free health assessments are beginning to pay dividends -- even for the health system's own 3,000 employees, he said. After years of double-digit insurance premium hikes, Bellin has brought the increases down to less than 3 percent a year.

In La Crosse, Thompson is using similar strategies.

"In our country we've chosen to spend a ton of money on the health-care delivery part and not much" promoting healthier lifestyles, he said. As the single largest purchaser of care, the government "could use that leverage to focus on keeping people healthy rather than lots of technology-based treatment of disease," he said.