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Policy Shop Director Elliott Fisher Is Patient-Focused

Elliott Fisher, director of The Dartmouth Institute, listens to a question during an interview in West Lebanon. (Valley News - James M. Patterson)

Elliott Fisher, director of The Dartmouth Institute, listens to a question during an interview in West Lebanon. (Valley News - James M. Patterson) Purchase photo reprints »

West Lebanon — Finding new ways of empowering patients to make decisions about their own care will be among the top priorities for The Dartmouth Institute for Health Policy & Clinical Practice under its new director.

Elliott Fisher, a longtime researcher at the institute who was made director earlier this month, said the institution would keep building on its strengths in evaluating health care policy, educating practitioners and developing new models for care.

Part of that work would involve finding new ways to better inform patients and help them play a central role in deciding what kind of treatments they receive.

“The most important caregiver for someone with chronic illness is the patient themselves or the family members, or others who are there to support them,” Fisher said in an interview with Valley News editors Wednesday. “Engaging and empowering patients to become their own caregivers, empowered to become comfortable doing it, whether it’s managing their own blood pressure or managing much more complicated services, is really important.”

Fisher succeeds Dartmouth-Hitchcock CEO Jim Weinstein as director of The Dartmouth Institute, or “TDI.”

A Harvard Medical School graduate who also holds a masters in public health from University of Washington, Fisher is a general internist whose research has focused on regional variations in Medicare spending and practice.

Fisher and his TDI colleagues have long been exploring ways to boost the patient’s role in making decisions about care, particularly around the “shared decision making” approach, in which patients not only are educated about procedures, but also talk with doctors about their health goals as they figure out together what to do.

In 1999, Dartmouth-Hitchcock opened the first center dedicated to the concept. Although sharing a common tie to Dartmouth College, TDI and Dartmouth-Hitchcock function as separate entities. Fisher said there were opportunities to collaborate more closely on research and education as they test new ideas for creating a sustainable health care system.

“I think we have a tremendous opportunity to partner more effectively,” he said. “The motivation that I see among the board, the leadership of Dartmouth-Hitchcock is focused on trying to improve population health and lower costs.”

TDI researchers have looked at a variety of problems facing the U.S. health care, including the variations in practice and spending between health care providers. Fisher also developed the concept of accountable care organizations, or ACOs, an experimental model aimed at improving coordination and lowering the cost of care for Medicare patients.

Fisher has been a leading researcher at TDI since its founding in 1988. He coined the term “accountable care organization” and has followed its development as it has rolled out as part of the Affordable Care Act.

The central aim of ACOs is to encourage doctors and hospitals to lower costs while maintaining high quality care. In return, providers are rewarded through splitting the savings with Medicare.

Dartmouth-Hitchcock has established two Medicare ACOs — one in New Hampshire called “Pioneer” and another in partnership with Fletcher Allen Health Care called “OneCare Vermont.” It’s still too early to know whether those initiatives have succeeded in lowering costs while improving quality. But a study of an earlier pilot project that laid the groundwork for ACOs show that success is far from certain.

Maintaining quality care was not an issue, but finding enough savings was, according to a report issued in 2011 by the Centers for Medicare & Medicaid Services.

However, a follow up study last September that was led by Carrie Colla, an assistant professor at TDI, yielded a more promising conclusion — that savings were achieved for a particularly problematic group known as “dual eligibles,” or people who qualify for both Medicare, which covers the elderly, and Medicaid, the federal program insuring the poor. Dual eligibles are among the most expensive and difficult to manage patients in the U.S. health care system, in part because of their high rates of illness, low socioeconomic status and lack of social supports, the report said.

There also have been questions raised about whether ACOs will result in monopolies, leading to price fixing. That could happen, Fisher said, but he maintained there were hopeful signs.

“It looks at least promising,” he said. “The surprises so far, none of us will be surprised that there are some places that are using their newly formed, integrated practices they’ve bought to raise prices to payers. Take advantage of monopoly power and raise your prices. But there are many others that are really looking like they’re focused on trying to really improve care and lower costs for their patients.”

Fisher said he was surprised by the diversity of health care providers who were establishing ACOs. Beyond just hospitals and physician group practices, ACOs are also being formed by networks of small primary care doctors and federally qualified health centers. The latter provides care to medically underserved communities and vulnerable populations, people that TDI researchers will be studying closely.

“We should, as this health care reform work goes forward, pay serious attention to what happens to the people who have always been left out,” he said.

It’s unclear what role that insurers have to play, or the extent to which new models, such as single-payer being developed in Vermont, will move the nation closer to a sustainable health care system, Fisher said. These are questions that TDI will continue to explore.

“We have lots to do to figure out how to continually make health care more affordable. And that probably means everybody taking a little bit of a, seeing it less as a place to make profit and more about a place to meet the needs of our population for better care and lower costs,” he said.

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.