Tuesday, March 1, 2011

Health Reform: Four Reasons Why Geographic Variation Persists.

John Wennberg, MD, founder of the Dartmouth Atlas of Health Care, which uses Medicare data to lament geographic variations of health care delivery, has been preaching the gospel of “unwarranted” variations since 1973, without noticeable impact on medical practices.

Since 1997, MedPac ( Medicare Payment Advisory Commission) has joined in the hunt to track down variation as a means of reducing spending, again without much impact on the ground.

The “unwarranted variation” argument goes like this. If 90% of hospitals and doctors at the high end of Medicare payment spectrum would act like those in the lower-paying bottom 10%, we would save 30% on Medicare costs.

Ergo, 30% of health care expenditures are “unwarranted,” “unnecessary,” and “wasteful.”

The Dartmouth Atlas people say the number of procedures done depends on where you live, for example, “Men over 65 with early stage prostate cancer who live in San Lois Obispo, California, are 12 times more likely to have surgery to remove their prostate than those in Albany, Georgia.”

So? So it logically follows that “ unwarranted waste” stems from lack of standardization, provider greed, and ignorance of the harm of rampant variation.

If only the United States would homogenize care, i.e, make it more uniform, in the 400 Medicare regions based on evidence–based medicine and outcomes data, we would not only save money but improve “quality.” I have placed “quality” in quotes because “quality” is in the mind of the beholder.

So why have these compelling , logical arguments, so prevalent in managerial and government mindsets, failed to reduce geographic practice variation?

This failure comes down to human and societal variations and to the inalienable reality that equal results for all are well-nigh impossible in a democracy.

Here are four reasons why subduing practice variation is so difficult.

1) Doctors Do What They Are Trained to Do - Two thirds of America’s doctors are specialists. They do what they are trained to do. Surgeons cut. Ophthalmologists do cataracts. Cardiologists do stents. Orthopedists do hips and knees. Colonoscopists do biopsies through scopes. Specialists do what generalists who refer them the patients expect them to do, and what patients expect to be done.

2) Hospitals Do What They Need to Do to Stay in Business – Hospitals do what brings them the margins to have to capital and to remain viable. The highest margins have to do with heart, brain, orthopedic, oncologic, radiologic , and robotic procedures - high tech, high ticket items. These items are what hospitals market. These procedures are why many patients come to hospitals - to have the latest and best things done.

3) Patients Go Where They Are Entitled to Go - They go to the doctors and those hospitals where government and their employers and their health plans pay the freight and where their own purses remain relatively untouched. Patients care not whether they meet some standard, whether they receive more or less care than their fellows, or whether the state or federal governments are going bankrupt in the process of providing them with care at government rates.

4) Poor People Go Where They Have to Go When They are Sick - They go to doctors or the ER. Richard “Buz” Cooper, MD, a professor of medicine at the University of Pennsylvania, maintains most geographic variation stems from poverty rather than from greed or lack of knowledge about outcomes. Cooper says poverty in places like the American south and inner cities causes higher Medicare expenditures because patients there are poorer, sicker, and need more care, not because of lack of standardization, ignorance , or avarice. Doctors simply treat what comes to them.


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