Challenging Assumptions
Fisher ES, Welch HG, Wennberg JE. “Prioritizing Oregon's Hospital Resources: An Example Based on Variations in Discretionary Medical Admission Rates”. JAMA 1992 April 8; 267(14): 1925-1931.
Oregon proposed rationing specific low-value treatments – even if they had some benefit. We suggested an alternative that would have achieved comparable savings – reduce avoidable, discretionary hospital utilization.
Fisher ES, Welch HG. “Avoiding the unintended consequences of growth in medical care: how might more be worse?” JAMA. 1999 February 3; 281:446-53.
Medical care can cause harm. In this article, we explained the various ways that this can happen.
Wennberg JE, Fisher ES, Stukel TA, Skinner JS, Sharp SM, Bronner KK. “Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States.” BMJ. 2004 Mar 13;328(7440):607.
The intensity with which seriously ill patients are treated varies dramatically across highly respected hospitals. Along with other studies, this paper suggested that overtreatment and failure to pay attention to patients preferences for more conservative approaches to end-of-life care is likely to be a serious problem.
Goodman, DC, Fisher ES, Little GA, Stukel TA, Chang CH, Schoendorf KS. “The Relation Between the Availability of Neonatal Intensive Care and Neonatal Mortality.” New England Journal of Medicine. 2002 May 16; 346(20):1538-44.
The supply of neonatologists and neonatal intensive care beds varies dramatically. A minority of regions appeared to have too few neonatologists, but many more appeared to have more than needed, underscoring the importance of evaluating the performance of the health care system to guide improvement.
Goodman, DC, Fisher ES. “Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription.” New England Journal of Medicine 2008 April 17; 358(16), 1658-1661.
Concerns about a physician shortage led to calls for an expansion of the number of medical schools and residency slots. In this piece, we described the magnitude of existing variations in physician supply and the likely consequences of unfettered expansion – including further harm to primary care and increased costs to everyone – without commensurate gains in health outcomes or care.
Song Y, Skinner JS, Bynum JPW, Sutherland JM, Wennberg JE, Fisher ES “Regional Variations in Diagnostic Practices.” New England Journal of Medicine 2010 July 1; 363(1), 45-53.
We compared Medicare beneficiaries who moved to high intensity regions to identical beneficiaries who moved to low intensity regions. In the years following their moves, those who moved to high spending regions received more diagnostic tests and accumulated more diagnoses. The differences underscore the problem of risk adjustment using Medicare (or other) claims systems and show that reporting “risk adjusted” outcomes or spending will be biased in ways that make high intensity hospitals or regions look “better” than they actually are.