Monday, September 10, 2007

Regional Variation - Why Minimizing Practice Variation is Hard

Thirty five years ago, Dr. John Wennberg analyzed Medicare data to highlight regional and small practice variations. Seventeen years before that, Medicare was introduced. In the early 1970s, managed care began its rise to the ascendancy.

Now managed care and Medicare share a common philosophy – the best path to a systematic, organized, purposeful, and improved health system is striving for minimal variation between practices in all regions of the U.S..

Yet today we’re no closer to controlling variation across the country than ever. It isn’t lack of trying. Large regional multispecialty with salaried physicians preach and practice the minimal variation gospel. Managed care routinely excludes physician “outliers” who don’t toe the line. And CMS is now engaged in minimum variation push featuring benchmarks, clinical guidelines, value-added purchasing, and processing and outcome metrics -- all under the umbrella term of pay-for-performance.

The strategies for achieving low variation include,

1. Identifying and focusing on controlling care high risk patients
2. Giving physicians financial incentives
3. Intervening by excluding physician outliers
4. Improving care continuously
5. Implementing disease management programs
6. investing heavily in information technologies for tracking and enforcement purposes
7. Encouraging evidence-based medicine
8. Engaging patients in the care process
9. Controlling the capacity of specialists providing care

Yet variation marches on. Why do some doctors resist conformity, fail to comply with some rules and regulations, and choose not to follow some guidelines designed to reduce variation?

Let me count the ways.

• First, people become doctors because they want to exercise their own judgment, to be their own bosses, rather than to be mere technicians beholden to some higher power. That’s simply the nature of the physician culture, which believes in independent thinking and doing what they deem best based on their experiences and training. .

• Second, like it or not, ignore it or not, there’s enormous regional cultural diversity in this country. I’ve practiced in the South, Midwest, Southwest, and East, and I can tell you first-hand doctors don’t think alike, organize alike, or act alike, and patients differ in their expectations from doctors.

• Third, doctors in different sections of the country receive their training from different teachers and mentors with different philosophies. Some training programs teach and preach aggressive therapies, often based on innovations developed by the teachers themselves; others are more conservative.

• Four, every patient, every disease, and every doctor differs in their approach to diagnosis and therapy. Take back pain. Some believe back pain is largely psychological in origin, other attribute it strictly to mechanical malfunction, still others to yearning for disability or workers compensation payments.

As I list these factors, I’m thinking of computer facial-recognition technologies that can differentiate every person on earth based on their different facial structure, as unique as a fingerprint, and pick that person out of a crowd of thousands. The same goes for patients and doctors.

I’m reminded of the story of the rats of Hamelin City ( I don’t think of doctors as rats. The point isn’t the rats, it’s that we doctors come in all shapes and sizes with varying philosophies.).

And out of the houses the rats came running.
Great rats, small rats, lean rats, brawny rats,
Brown rats, black rats, gray rats, tawny rats,
Grave old plodders, gay young friskers,
Fathers, mothers, uncles, cousins,
Cocking tails and pricking whiskers,
Families by tens and dozens,
Brothers, sisters, husbands, wives.

None of this is to say we can’t manage care better, cheaper, and at a higher levels of quality. It’s also not to say health care and doctors shouldn’t be managed. We need to abide by some common rules. We’re the drivers behind a $2.2 trillion industry that requires management. But to expect this care will have no or little variation is unrealistic, given human variability. Enforcing uniformity will not work.

Minimizing individual and regional variation among physicians is hard because of the physician culture of independent thinking, regional differences in care expectations, regional differences in training and mentoring, and inevitable individual differences in patients, doctors, and diseases.

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