Physician variation: Implications of the Bell curve

The retirement of Dr. Jack Wennberg provides good reason to reflect on the implication of his work over the last 30 years. Dr. Wennberg's Dartmouth Atlas showed that medicine is in fact as much art as science-- science could not explain the tremendous variation in healthcare usage given similar populations in neighboring towns.

After analyzing patterns of health care use in Vermont, he found that his kids, who lived with him in the Waterbury area, had roughly a 20% chance of getting their tonsils out. Kids a few miles away, in Stowe, had about a 70% chance of undergoing the same procedure. Yet there was no significant difference between the children in the two towns.

More troubling, the variation often showed no health benefit-- and exposed participants who had an unnecessary procedure to side effects ranging from temporary injury to death. Clearly, rather than being an artistic or professional preference, the decisions of a health care professional have a profound impact on the lives of their patients...and too many procedures make one wonder if "walletitis" has gained the upper hand against "first do no harm".

For example, chronically ill patients treated at New York University Medical Center spent an average of 32.1 days in the hospital during the last six months of life, compared with 12.9 days for patients at the Mayo Clinic’s main hospital. For the last two years of life, Medicare spending for both inpatient care and doctor fees averaged $79,280 per patient at NYU compared with $37,271 at the Mayo Clinic.

This means that for the extra spending, we gain little benefit-- that we are on the "flat of the curve" in medicine. One must then question why medical spending continues to increase well outside the bounds of inflation, if it has minimal impact on the quality of care. More importantly, why aren't we as a society rewarding disproportionately, those who are good stewards of societal resources, rather than giving them an almost insulting pittance in "pay for performance" programs that erodes their bottom lines? Why also do we pretend that almost all doctors and hospitals are the same or "average", despite enormous statistical and anecdotal evidence to the contrary?

I firmly believe that we should celebrate the discovery of these differences, give doctors the opportunity to show how what they're doing adds value, and create opportunities to pay them for the extra value these innovators bring to care. And where the market feels differently, in a transparent manner, we should tell them that they're approach/ product is not wanted and should be simplified to meet our real needs.

Instead, we live in a world where the medical infrastructure's capacity for care is far greater than most need...and we don't have the individual consumer acting in their own interests to reduce the excess.