For many years, Dr. John Wennberg was something of a pariah. His research was derided and scorned; his articles were refused by the major medical journals. Despite this, he labored for many years amassing mountains of data, fleshing out his arguments with thorough research and reasoning. With each new publication, his thesis became harder and harder to ignore or refute.
More medicine, Dr. Wennberg and his colleagues observed, is not always necessary or better. It is upon this realization that any hope of sustainable health care reform must be based.
He began with a simple question: How well are doctors and hospitals performing? His seminal article, published in 1973, examined data on the use of health care services in Vermont. He began by dividing the state up into 13 ‘service areas’ each centered around one or two regional or local hospitals. Then he compared the rates at which people in those service areas received various types of medical care, such as surgeries, lab tests and hospital admissions. He expected to see patients in rural areas receiving services at lower rates than in large academic hospitals. Instead, he found incredible variation across the state in all aspects of health care delivery.
The most extreme example he found was in how frequently people had their tonsils taken out. Per person the operation was done eleven times more often in the service area with the highest rate than that with the lowest rate. Tonsillitis — the disease for which tonsils are usually removed — was more or less equally common throughout the state. Dr. Wennberg found similar, if less pronounced, patterns in the rates of hospital admissions, length of hospital stay, x-rays, lab tests, as well as every type of surgery he studied. People in some service areas got more health care that people in others, though the overall prevalence of disease was not much different.
Doctors in some regions, he concluded, did a lot more operating, testing and hospitalizing than others without any identifiable reason. This was a revolutionary and uncomfortable realization. It was revolutionary because he identified the existence of regional practice patterns, that is, doctors working in the same area will develop a particular local way of doing things that might differ from their colleagues in the next county. And it was uncomfortable because it undercut the assertion that physicians made decisions based on well-accepted theory and fact rather than personal preference.
Most recently, a study by his protegee Dr. Elliott Fisher found patients in higher spending areas got more tests, spent more time in the hospital and incurred higher costs than patients in lower cost cities, but they did not live longer or have better outcomes. Some patients who got more care actually did worse, because of the side effects and complications of their treatment. He also found that patients in high cost cities were less likely to get preventative medicine, or some basic therapies whose effectiveness has been consistently proven in clinical trials.
From the research begun by Dr. Wennberg we learned that overtreatment, especially with expensive procedures and imaging tests, has become an ingrained feature of the medical landscape. This is in large part because of the way physicians are paid. They make money by treating their patients, not making them better. And here is the irony of the health care debate. For all the theatrics, overblown rhetoric and scary talk of “government takeovers” and “out-of-control insurance companies,” it doesn’t matter who is paying the bills if they remain based on quantity of service rendered rather than patient outcomes and satisfaction.
It is a disgrace that so many inhabitants of our nation suffer injury and illness without access to needed care while others continue to be convinced to undergo excessive tests and procedures in the misguided belief that more medicine is better medicine. It is impossible to cover the former without dealing with the latter. For this reason the most important elements of President Obama’s proposed plan are not those that deal with payers, but payees. Tying Medicare reimbursements to outcomes rather than quantity of service and encouraging the growth of the accountable care organization model are valuable steps to ensuring responsible medical practice. Providing incentives for nursing, medical and physician assistant students who want to pursue a career in primary care, as well as increasing their pay for counseling patients and enacting low-cost, high yield preventative health strategies is another.
Geoff Jara-Almonte ([email protected]) is a third year medical student.