John E. "Jack" Wennberg is the pioneer and leading researcher of unwarranted variation in the healthcare industry. Through four decades of work, Wennberg has documented the geographic variation in the healthcare that patients in the United States receive. In 1988 he founded the Center for Evaluative Clinical Services (CECS) at Dartmouth Medical School, which works directly with Health Dialog to address this unwarranted variation in healthcare. He currently holds the Peggy Y. Thomson Chair for the Evaluative Clinical Sciences at Dartmouth and has been Professor in the Department of Community and Family Medicine since 1980 and in the Department of Medicine since 1989. Dr. Wennberg is the founding editor of the Dartmouth Atlas of Health Care, a series of reports on how health care is used and distributed in the United States. In June 2007, Wennberg stepped down as director of the CECS, now known as The Dartmouth Institute for Health Policy and Clinical Practice (TDI).
Wennberg is a member of the Institute of Medicine of the National Academy of Sciences and of the Johns Hopkins University Society of Scholars. Wennberg is a graduate of Stanford University and the McGill University Faculty of Medicine. His postgraduate training was in internal medicine and nephrology at Johns Hopkins, but he became interested in the application of epidemiological principles to the health care system while pursuing his master’s degree in Public Health at Johns Hopkins.
He cofounded the Informed Medical Decisions Foundation in Boston, Massachusetts, a nonprofit organization that provides objective scientific information to patients about their treatment choices using interactive media.
Wennberg is Principal Investigator and Series Editor of The Dartmouth Atlas of Health Care, which examines the patterns of medical resource intensity and utilization in the United States. The Atlas project also has reported on patterns of end-of-life care, inequities in the Medicare reimbursement system, and the underuse of preventive care.
"When Jack started his work, geographic variation in health care—and the resulting variation in health care costs—was largely unknown and unremarked upon," said Health Affairs founding editor John Iglehart, who presented an award from the journal to Wennberg. "But thanks to Jack’s persistence, the idea that the care you receive is largely determined by where you live—and not necessarily by what is most appropriate for you—has become part of the common parlance of health policy."
Indeed, Wennberg’s work has shown that areas that spend more and provide more services often experience worse outcomes than lower-spending areas that provide less intensive care. In a 2002 Health Affairs article, Wennberg proposed a Medicare reform plan based on reducing unwarranted regional variations in spending by the program. In the latest Dartmouth Atlas, Wennberg and colleagues state that "the Medicare system could reduce spending by at least 30 percent while improving the medical care of the most severely ill Americans."
Wennberg’s recent work has focused on documenting outcomes and communicating outcomes information to patients. This focus is reflected in his article in the Nov/Dec 2007 issue of Health Affairs. In the first part of a two-part article, Wennberg and coauthors urge the Centers for Medicare and Medicaid Services (CMS) to use its pay-for-performance program to ensure that patients are both informed and empowered to choose appropriate discretionary treatments.
Work in Unwarranted Variation
In 1967, Wennberg worked with the Regional Medical Program created with a $350,000 grant from President Lyndon B. Johnson and began analyzing Medicare data to determine how well hospitals and doctors were performing. "Our results were fascinating, because they ran completely counter to what conventional wisdom said they would be. Everyone expected that we would clearly see underservice in the rural hospital service areas remote from academic medical centers. But when we looked at the data, we found tremendous variation in every aspect of healthcare delivery, even among communities served by academic medical centers. We found the same thing when we compare healthcare in the Boston and New Haven communities served by some of the finest academic medical centers in the world. The basic premise—that medicine was driven by science and by physicians capable of making clinical decisions based on well-established fact and theory—was simply incompatible with the data we saw. It was immediately apparent that suppliers were more important in driving demand than had been previously realized," stated Wennberg.
"The solution for unwarranted variation in preference-sensitive services is shared decision-making—the active involvement of the patient in choosing. Numerous clinical trials have shown that the patient decision-support programs, such as those available from Health Dialog and the Informed Medical Decisions Foundation, result in better decision and often a reduction in utilization. But implementation isn't easy," he says. "We need to find a way to encourage and compensate physicians for the time they spend on educating and discussing things with patients."
Albert Mulley, a physician at Massachusetts General Hospital, had been conducting research with Wennberg of Dartmouth through the Informed Medical Decisions Foundation. Together, they'd built "substantial evidence that there's a huge variation in how doctors interpret their science through their own values and preferences." George Bennett, a serial entrepreneur "couldn't resist getting involved" in helping the process of enabling patients become a part of the decision-making process. As stated by Mr. Bennett, "It was one of life's strange twists, where they had something that was morally right, medically right, politically right and it saved money." By teaming with Kevin Kimberlin of Spencer Trask & Co., Health Dialog received its initial funding.
Lowering Medicare Costs
"Americans have assumed that the fact that we spend so much more on health care than any other country stands as proof that we have the best health-care system in the world. But over the past 20 years, work done by Dartmouth’s Wennberg and Elliott Fisher has forced U.S. health care leaders to acknowledge that this simply isn’t true."
The potential savings under such an ideal arrangement are immense. If every Medicare provider in the country spent at the same rate as the lowest 10% of providers in the program, overall costs would be slashed by 30%. That alone is enough to pay for the elusive Medicare drug benefit. Additional savings might well accrue if we could implement shared decision-making, reduce underuse of preventive services, and reduce medical errors.
- Most Influential Policy Maker of the Past 25 Years, Health Affairs, Nov. 1, 1997.
- Distinguished Investigator Award, Association for Health Services Research
- Foundation’s Health Services Research Prize, Baxter Foundation
- The Richard and Hinda Rosenthal Foundation Award in Clinical Medicine
- 2007 Ernest Amory Codman Award, The Joint Commission
- 2008 Gustav O. Lienhard Award, The Institute of Medicine, Oct. 12, 2008
- Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973 Dec 14;182(117):1102-8. PMID 4750608.
- Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am 1982 Apr;246(4):120-34. PMID 7079718.
- Wennberg JE, Barnes BA, Zubkoff M. Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med 1982;16(7):811-24. PMID 7100999.
- McPherson K, Wennberg JE, Hovind OB, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med 1982 Nov 18;307(21):1310-4. PMID 7133068.
- Wennberg JE. Dealing with medical practice variations: a proposal for action. Health Aff (Millwood) 1984 Summer;3(2):6-32. PMID 6432667.
- Wennberg JE, Freeman JL, Culp WJ. Are hospital services rationed in New Haven or over-utilised in Boston? Lancet 1987 May 23;1(8543):1185-9. PMID 2883497.
- Fowler FJ Jr, Wennberg JE, Timothy RP, Barry MJ, Mulley AG Jr, Hanley D. Symptom status and quality of life following prostatectomy. JAMA 1988 May 27;259(20):3018-22. PMID 2452905.
- Roos NP, Wennberg JE, Malenka DJ, Fisher ES, McPherson K, Andersen TF, Cohen MM, Ramsey E. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med 1989 Apr 27;320(17):1120-4. PMID 2469015.
- Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic variation in expenditures for physicians' services in the United States. N Engl J Med 1993 Mar 4;328(9):621-7. PMID 8429854.
- Lu-Yao GL, McLerran D, Wasson J, Wennberg JE. An assessment of radical prostatectomy. Time trends, geographic variation, and outcomes. The Prostate Patient Outcomes Research Team. JAMA 1993 May 26;269(20):2633-6. PMID 8487445.
- Fleming C, Wasson JH, Albertsen PC, Barry MJ, Wennberg JE. A decision analysis of alternative treatment strategies for clinically localized prostate cancer. Prostate Patient Outcomes Research Team. JAMA 1993 May 26;269(20):2650-8. PMID 8487449.
- Fowler FJ Jr, Barry MJ, Lu-Yao G, Roman A, Wasson J, Wennberg JE. Patient-reported complications and follow-up treatment after radical prostatectomy. The national Medicare experience: 1988-1990 (updated June 1993). Urology 1993 Dec;42(6):622-9. PMID 8256394.
- Barry MJ, Fowler FJ Jr, Mulley AG Jr, Henderson JV Jr, Wennberg JE. Patient reactions to a program designed to facilitate patient participation in treatment decisions for benign prostatic hyperplasia. Med Care 1995 Aug;33(8):771-82. PMID 7543639.
- O'Connor GT, Quinton HB, Traven ND, Ramunno LD, Dodds TA, Marciniak TA, Wennberg JE. Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project. JAMA 1999 Feb 17;281(7):627-33. PMID 10029124.
- 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. PMID 15016692.
- Wennberg JE, Fisher ES, Stukel TA, Sharp SM. Use of Medicare claims data to monitor provider-specific performance among patients with severe chronic illness. Health Aff (Millwood) 2004 Oct 7;Suppl Web Exclusives:VAR5-18. PMID 15471771.
- Wennberg JE, Fisher ES, Baker L, Sharp SM, Bronner KK. Evaluating the efficiency of California providers in caring for patients with chronic illnesses. Health Aff (Millwood) 2005 Jul-Dec;Suppl Web Exclusives:W5-526-43. PMID 16291779.
- Wennberg JE, Fisher ES, et al. The care of patients with severe chronic illness: a report on the Medicare program by the Dartmouth Atlas Project. Hanover, New Hampshire: Center for the Evaluative Clinical Sciences, Dartmouth Medical School, 2006.
- Health Affairs Press Release: Nov. 1,, 2007
- Clamping down on variation - Managed Healthcare Executive
- Mr. George Bennett on the founding of Health Dialog, By Hal Lancaster, Wall Street Journal, 03 August 1999
- Dartmouth Medicine Magazine :: The State of the Nation's Health
- The Dartmouth, Wennberg Given Health Care Award, Oct. 16, 2008