A Blueprint for Healthcare Reform

On this blog, we have often debated these questions: “Why is U.S. healthcare so expensive? Why is it that states like Massachusetts and California just can’t seem to find a way to provide high quality, affordable medical care for all of their citizens?”

In the past, I have suggested that the answer can be found in the work done by Dr. Jack Wennberg and his colleagues at the Dartmouth Medical School. The story that I have posted below provides the narrative behind that assertion, tracing how, over a period of thirty years, Wennberg and his team uncovered the incredible, incontrovertible waste in our health care system.

Wennberg’s work reveals that roughly one out of three of our health care dollars is squandered on unnecessary tests, ineffective, unproven, sometimes unwanted procedures and over-priced bleeding-edge drugs and devices that are no better than the less expensive products that they have replaced.

Only a Luddite would fail to appreciate the wonders of 21st century medical technology. And Wennberg is no Luddite. He is quick to acknowledge that the most expensive, aggressive care that U.S. doctors and hospitals provide is often the most effective care.

But not always. This is what is less obvious. It would seem that by spending so much more than other countries, we would be buying the best care on earth. But the evidence shows that, often, we are not. And therein lies the conflict at the heart of our money-driven health-care system: while more health care equals more profits, it does not necessarily lead to better health.

The story below, which I wrote for the winter issue of Dartmouth Medicine, will, I think, give readers a much clearer understanding of the importance of the Dartmouth research. It begins in the early 1970s, when Wennberg realized that if his home were located just 100 yards farther north, his children would be in a school district where 70 percent of all children received tonsillectomies. Instead, they lived in a school district where there was only a 20 percent chance that they would undergo the operation.

Wennberg recalls his surprise when he saw the statistics: “The
communities were very similar. It was implausible that the need for
tonsillectomies varied by that degree.”  This was the beginning of a
long journey which would teach him that, too often, in our health care
system, treatment has very little to do with the needs of the
individual patient.

The story of Wennberg’s career also reveals how, for decades, American
medicine resisted accepting Wennberg’s work. “The problem is that all
of this stuff is so antithetical to the dominant ideology in the
medical community—so antithetical that they can’t bear to talk about
it,” Wennberg explains. The fact that he speaks in the present tense
suggests that the “dominant ideology” lingers still. But what exactly
is that ideology?

“Manifest efficacy,” Wennberg says, smiling. “Everything we do [in
medicine] is effective.” His smile isn’t smug; it’s rueful. “It’s not
just doctors,” he adds. “Patients want to believe in manifest efficacy.
It places medicine closer to a religion than a science.”

The truth is that, as Dr. Atul Gawande writes in Complications: A
Surgeon’s Notes On An Imperfect Science, “uncertainty” is “the core
predicament of medicine…With all that we know nowadays about people and
diseases and how to diagnose and treat them, it can be hard to grasp,”
Gawande adds,  “how deeply the uncertainty runs.”  Yet, he declares,
“this is what makes being a patient so wrenching, being a doctor so
difficult, and being part of the society that pays the bills so

Recent news stories serve as reminders of just how much ambiguity
haunts 21st century medicine.  Just this month, Business Week came out
with a cover story suggesting that as many as three-quarters of the
thirteen million Americans now taking cholesterol-lowering medicines
like Lipitor may derive no benefit from the drug.
Yet, as the Wall Street Journal pointed out earlier this week, these
patients do risk serious side effects.

Meanwhile, the cognoscenti of American medicine have finally come to
accept Jack Wennberg’s findings about the dangers of overtreatment.
“The fact that the work they are doing is so rigorous, and the
reputation of those doing it beyond reproach, means that [it] brings
issues to the table that we wouldn’t be talking about otherwise,” says
Dr. George Isham, medical director of HealthPartners of Minnesota–
“namely the fact that more care leads to poorer quality. We are not
just talking about wasting money,” adds Isham.

Dr. Christine Cassell, president of the American Board of Internal
Medicine, agrees: “What is so profound—and so scary—is that the data is
so powerful, and it doesn’t change,” observes. “There is a stark
correlation between reduced utilization and better outcomes.”

Today virtually no one questions that there is an enormous amount of
waste in our system in the form of unnecessary tests and
hospitalizations, questionable procedures, and over-priced drugs that
are being given to over-medicated patients.  But the question remains:
how does the Dartmouth research lay out a road map for health care

Wennberg’s work offers one clear answer to our healthcare crisis: we
cannot hope to create a sustainable, high quality health care system
for every American unless we control costs by reducing the waste. We
simply cannot afford to provide care for everyone while watching health
care spending rise by 6 percent to 8 percent a year.

But this does not mean that we need to cut back on the quality of care.
Quite the opposite. The Dartmouth research demonstrates that high
quality and lower cost go hand in hand.  Unnecessary care doesn’t just
waste dollars: it can be hazardous to your health. As Wennberg’s
colleague Dr. Elliott Fisher points out: “hospitals are dangerous
places—especially if you don’t need to be there.”

The story of Wennberg’s career points to solutions by revealing where
we are likely to find the greatest waste in our health care system.  It
also describes the work Wennberg and his team are doing now, as they
create a model for a healthcare system that puts the patient, rather
than profits, at the center of the equation. When making medical
decision—and weighing what we know about risks and benefits—patients
need to be included in the decision-making process.

Finally, doctors need to continue to lead the debate about effective
medicine: “In the basic sciences, you have discussion and debate. Why
not in medicine?” Wennberg asks.  “We need to be continually evaluating
what we are doing over time. ‘Why are we doing this? What is the
evidence that it is working?’”

Full story follows.

For half a century,” Dr. John Wennberg declared in a 1977 issue of Pediatrics, “the tonsil has been the target of a large-scale, uncontrolled surgical experiment—tonsillectomy.” Jack Wennberg had just taken the pin out of a grenade—and he knew it. With the phrase “uncontrolled surgical experiment,” he acknowledged what few doctors at that time would admit: they operated on people without knowing, with certainty, whether the procedure would do the patients any good. And in this case the patients were children.Braveheart_01

During the 1930s and 1940s, half of the nation’s children had their tonsils removed, but “since World War II,” Wennberg reported in that article, “opinion has swung away from mass use” (emphasis added). By 1973, he added, only 25% of the nation’s children were undergoing the procedure. (Nevertheless, though its popularity had ebbed, tonsillectomy remained the second most common procedure in the United States, after circumcision.)

The word “opinion” in that passage is jarring. What could Wennberg mean? After all, by 1977 medicine was firmly established as a science. Wasn’t it? Surely doctors would not subject millions of children to a painful and potentially risky operation unless they had solid evidence that the surgery was truly needed.

Not according to Wennberg. With a boldness that is surprising, even today, he went on to compare doctors to meteorologists: “Pediatricians have been the weathermen in the change of clinical climate, pressing for reduction in use of tonsillectomy in their journal articles.

“Among a sample of California physicians, the offspring of pediatricians underwent fewer tonsillectomies than the children of other types of physicians. Unless, as seems highly unlikely, the children of pediatricians are healthier than the children of other physicians, this seems to reflect specialty-related differences in opinion on the value of tonsillectomy.”

There is that word “opinion,” cropping up once again. In themeantime—this was the really strange part—Wennberg had discovered that tonsillectomies were much more common in some communities than in others. But why?

Geography is destiny

In the early 1970s, when Wennberg began puzzling over tonsillectomies, he was working at the University of Vermont as the director of the state’s Regional Medical Program. The role involved studying the health-care system and analyzing how resources were used in different parts of the state. What he found, as he combed through hospital discharge data, was wide variation in how doctors practiced in communities right next to each other.

Braveheart_02_2 In the case of tonsillectomies, the research struck home. Literally. Wennberg at that time lived on the line between Stowe, Vt., and Waterbury, Vt. His children went to school in Waterbury, 10 miles down the road, but had the family lived about 100 yards father north, they would have been in the Stowe school system. When he looked at the health-care data for the two towns, he realized that 70% of the Stowe children had had their tonsils out by the time they were 15 years old, as opposed to only 20% of those in Waterbury. Were his kids in danger of being undertreated? Or were the children of Stowe being overtreated?

“The communities were very similar,”Wennberg explains, recalling his surprise at the finding. “It was implausible that the need for tonsillectomies varied by that degree.”

In Pediatrics in 1977, he noted that physicians defended geographic variation as “inevitable” in cases where there is “professional uncertainty” and physicians “do not know which level of use is ‘appropriate.'” Wennberg was not satisfied with the explanation: “This defense, while explaining the past, cannot justify the future,” he declared. “For one thing, the dollar costs of uncertainty are too great.”

By then, Wennberg had branched out to study geographic variations in the delivery of care in Maine. There, he calculated that in communities where few children had their tonsils out, the cost per capita for tonsillectomy was 85c. In areas where tonsillectomies were popular, the cost per capita was $4.55. “Projected nationally, the lowrate strategy costs less than $200 million; the high-rate strategy costs nearly $1 billion,” he observed. And that was in 1975 dollars.

“But the costs, of course, are not only in dollars,”Wennberg continued. They could also be measured in lives. In Vermont from 1969 to 1973 and in Maine in 1973, “three postoperative deaths followed tonsillectomy,” he wrote. “For so costly a procedure, ambiguity concerning its value will likely become increasingly intolerable.”

For years, even medical students had recognized the dearth of scientific evidence behind the procedure. “When I was in medical school, I remember one professor—a particularly arrogant Park Avenue practitioner—asking: ‘What are the indications for a tonsillectomy?'” recalls Dr. James Strickler, who was dean of Dartmouth Medical School when Wennberg joined the Dartmouth faculty. “And one of my more provocative classmates responded: ‘A hundred dollars and a pair of tonsils.'”

Wennberg went on to show that tonsillectomies were just one of many procedures done far more often in some locales than in others. He identified geographic variation in the rate of other common operations, including appendectomies, hysterectomies, prostate surgeries, and gall bladder removals.

Moreover, Wennberg had begun to demonstrate a clear connection between a community’s supply of health-care resources—such as surgeons and hospital beds—and how much surgery the residents of that community received. More surgeons and more beds equaledmore procedures. Put simply, supply seemed to drive demand.

Four years before his article appeared in Pediatrics, Wennberg had published, in the journal Science, his first study about geographic variations in health care. There, he and his coauthor, Dr. Alan Gittelsohn, established a firm connection between the supply of health-care resources in a community and how much care its citizens received. At the same time, they acknowledged that they could not say which rate of care represented “a better allocation of resources.” For a given surgery, it was not clear whether patients in communities where surgeons were in relatively short supply received too little care, or whether those in areas with a surfeit of surgeons got too much.

Few studies had been done “comparing outcomes under controlled circumstances,”Wennberg explained at the time. Sadly, the situation hasn’t improved much. “Jack’s first paper in Science was so on target,” says Dr. James Weinstein, an orthopaedic surgeon at Dartmouth. “This is what we are working on today.”Weinstein, in fact, heads the largest randomized surgical trial ever funded by the National Institutes of Health—a comparison of surgical and nonsurgical treatments for various kinds of back pain. And it is Weinstein who has been named to succeed Wennberg as the leader of the people and projects Wennberg assembled at Dartmouth.

More harm than good

But before those people and projects existed, even before Wennberg’s arrival at Dartmouth, he began to realize just how much was at stake: “Given the magnitude of the variations,” he wrote in 1973 in Science, “the possibility of too much medical care and the attendant possibility of iatrogenic illness [illness that is caused by medical care] is presumably as strong as the possibility of not enough service and unattended morbidity and mortality.” In other words, in towns blessed with many surgeons, the extra surgeons actually might be doing more harm than good.

This is not what Wennberg’s peers in the medical profession wanted to hear. In fact, he almost didn’t get that first paper published. “We tried the New England Journal of Medicine, we tried the Journal of the American Medical Association. . . . We tried all of the medical journals,” he recalls.

What did the reviewers at those journals say?Wennberg chuckles: “They didn’t say anything. We got form rejection letters.” (“This still happens,” he noted in an interview in Health Affairs in 2004. “Generally we don’t bring good news.”)

Back in 1973, he recalls, “Science was the journal of last resort, but we were delighted to get the paper accepted.” Science wasn’t a medical ical journal, so its reviewers were less likely to be clinicians who might be stung by Wennberg’s suggestion that they could be overtreating their patients. Moreover, at Science the author of a study was able to suggest potential reviewers, and Wennberg suggested people who were both prominent and aware of his work. If Science had not given writers that opportunity, it is not clear when Wennberg’s work would have seen the light of day.

“The problem is that all of this stuff is so antithetical to the dominant ideology in the medical community—so antithetical that they can’t bear to talk about it,” Wennberg reflected a few months ago. The fact that he spoke in the present tense suggests that the “dominant ideology” lingers still. But what exactly is that ideology?

“Manifest efficacy,”Wennberg says, smiling. “Everything we do [in medicine] is effective.” His smile isn’t smug; it’s rueful. “It’s not just doctors,” he adds. “Patients want to believe in manifest efficacy. It places medicine closer to a religion than a science.”

Today, “such manifest confidence is grounded in a fervent belief in medical Braveheart_03_2
technology,”Wennberg continues. “In the past, this wasn’t so important. And it didn’t cost so much. But now it’s expensive. It’s costly not just in dollars, but in the cost for patients.” In today’s “uncontrolled experiments,” patients who undergo surgical treatments run a serious risk of life-changing side effects—in the case of early stage prostate cancer, for instance, incontinence and/or impotence. Urologists may recommend surgery for such patients reflexively, and patients may assume it is their best option. Yet the National Cancer Institute’s position is that although “screening tests are able to detect prostate cancer at an early stage, it is not clear whether this earlier detection and consequent earlier treatment leads to any change in the natural history and outcome of the disease.”

But patients need to believe, must believe, that whatever treatment they get is effective, Wennberg explains. “At one point, Jack Fowler, the president of the Foundation for Informed Medical Decision Making and a friend from my Vermont days, interviewed patients
who had been treated for prostate cancer. . . . They believed their lives had been saved,”Wennberg says. “And so they were bearing the burden of their surgery—and whatever side effects they suffered—very well. That’s part of the dynamic that prevents change. The committed patient is committed to the treatment and the ideology. That circle stands in the way of change.”

The birth of a skeptic

Jack Wennberg probably brought more skepticism to his career than most doctors. After earning his M. D. at Mc Gill in Montreal, he did his residency at Johns Hopkins, where he also earned a master’s of public health and began a Ph. D. in sociology. “I was interested in social systems and how societies addressed large questions,” Wennberg remembers. “At the time, the Vietnam War and the civil rights movement were important drivers in my thinking.” His interest in social change translated into a fascination with public health and epidemiology, the root causes of illness, and even the health of the health-care system itself. “I was interested in measuring process, structure, and outcomes,” he explains.

From Johns Hopkins, Wennberg headed for Vermont. Back then, “I still believed in the general paradigm that science was advancing and that it was being translated rationally into effective care,” Wennberg recalled in a 2004 interview published in the journal Health Affairs. “At that time, economists and sociologists as well as patients and doctors believed . . . that the central tendency of the market was rational. . . . I had read enough sociology and was aware [enough] of the overt and covert functions within systems that I came [to Vermont] armed with some skepticism about human behavior. Having read that literature, I was prepared for interpreting what we found. But I don’t think I went into it thinking we would find such a marked variation in medical practice.”

If Wennberg was surprised by what he found, others in the medical profession resolutely refused to believe his findings of seemingly arbitrary variations in medical practice—variations driven by little more than the number of surgeons and beds available. Both the 1973 paper in Science and a similar 1977 article published in the Journal of the Maine Medical Association drew fire from critics such as Dr. Francis Moore.

Now deceased, Moore was a professor of surgery at Harvard and the chief of surgery at Boston’s Peter Bent Brigham Hospital (now Brigham and Women’s). Moore was horrified by the possibility that Wennberg’s work might have some impact in the political arena: “Both of the articles in question have recently been quoted in Washington hearings by the Kennedy Committee and the Moss Committee,” he wrote in a 1977 letter to the editor of the Maine journal. “They have been used to prove that it is the capricious whim and fiscalmotivation of surgeons that dictates the level of surgical care in the community, rather than the needs of the populations. It is unfortunate that these studies . . . with such glaring deficiencies—were published at all, and especially unfortunate that they now provide some additional basis for medical legislation of a national character.”

Wennberg’s response was temperate, though he and his coauthor allowed themselves a trace of irony in the last sentence of their rebuttal. They began by pointing out that “the phrase ‘capricious whims of hospitals, physicians and surgeons’ is strictly Dr. Moore’s, never having been employed by either of us.” Following a point-by-point refutation of Moore’s objections to their findings, they concluded: “We have attempted to ensure that the data are correct within the limits imposed by the medical record and other data systems available to us. It has been our objective to let the data tell their own story. We feel gratified that our work has received national attention and regret that Dr. Moore finds the situation ‘especially unfortunate.'”

Thirty years later, not only is Wennberg’s work widely recognized in Washington, D. C., but it is helping to shape the national discussion about health-care reform. Political leaders such as presidential candidate Hillary Rodham Clinton and Glenn Hackbarth—the chair of the Medicare Payment Advisory Commission (MedPac), the independent commission that advises Congress on Medicare spending—frequently quote what has become known simply as “the Dartmouth research.”

The national press, too, makes regular and laudatory mention of “the Dartmouth research.” A major editorial a month ago in the New York Times on “The High Cost of Health Care,” for example, cited “pioneering studies by researchers at Dartmouth [that] have shown enormous disparities in expenditures on health care from one region to another with no discernible difference in health outcomes.” (For more on the impact Wennberg’s work has had on national health policy, see “The State of the Nation’s Health” in the Spring 2007 issue of Dartmouth Medicine.)

What is even more impressive is that in the blogosphere, where much of the cutting-edge debate about health-care reform takes place nowadays, Wennberg’s name is not just widely known but universally respected. Matthew Holt, editor of The Health Care Blog, says of Wennberg that “while it takes 17 years for medical research to become part of everyday practice, it’s taken more than double that time for the work of Jack Wennberg and his colleagues at Dartmouth to permeate the national consciousness and become a staple in the New York Times. But much like another seismic debate of our time, global warming, it’s become impossible to argue with Jack on the evidence—even though his findings are tilting at a $2-trillion* industry with good reason to ignore them. And while there may not be a Nobel Prize for economics in the offing for Jack, to paraphrase a great economist who didn’t win one either, he is the defunct health services researcher to whom all practical men setting health policy in the future will be slaves.” Holt’s comment is a reference to a famous observation by John Maynard Keynes that practical men “are usually the slaves of some defunct economist.”

Practicality, in fact, has always been Wennberg’s goal: he wanted to affect how medicine is practiced. “He wasn’t just committed to solving an intellectual puzzle,” says Dr. Albert Mulley, chief of general medicine at Massachusetts General Hospital and a 1970 graduate of Dartmouth College. “He was willing to take the risk of trying to make the solution to that puzzle practical,” Mulley goes on. “That is not generally what academics do. But he wanted to solve it so that he could make the world a better place. From the perspective of an academic medical center’s reward system, this involved some risk.”

Recruited by Dartmouth

Throughout the 1970s, Wennberg continued his labors in relative obscurity. “He is one of themost tenacious individuals I’ve ever known—almost to the point of being pig-headed,” says his longtime friend Jim Strickler. “And then it turns out that he’s right. That combination annoys people.”

In 1973, Wennberg left the University of Vermont (UVM) and joined the faculty at Harvard. “UVM had not been terribly happy with what I was doing,”Wennberg confided recently. “There was not a confrontation, but you could say there was a general lack of appreciation.” But Harvard never was home. Wennberg’s family stayed on the farm in Vermont, while he commuted to Cambridge.

At about the same time, Strickler was setting the stage for eventually bringing Wennberg to Dartmouth. Then the dean of Dartmouth Medical School, Strickler hired Michael Zubkoff in 1975 to chair DMS’s Department of Community and Family Medicine. “That was a very controversial appointment,” Strickler recalls. Zubkoff wasn’t an M.D.—he had a Ph.D. in economics from Columbia. Initially, Strickler had been opposed to the idea of naming someone not a physician to chair a clinical department. But when Strickler met Zubkoff, he was surprised: “I thought he made a lot of sense. I thought he had good ideas. I liked his values.”

Once he landed the job, Zubkoff knew he wanted to bring Jack Wennberg to Dartmouth. “When I was offered the job, that was the first call I made,” he recalls. “I had met [Wennberg] and I knew his work in Vermont and Maine. And I also knew that he had been run out of town in Vermont.” Zubkoff believed that Wennberg embodied “the best example of someone who bridged clinical medicine, economics, and an understanding of markets.”

Peeling back the onion

Even so, it took Zubkoff a couple of years to put all the pieces together to bring him to Dartmouth. Meanwhile, he says, Wennberg “did some more papers, and they were well-received. And he was just very persistent. He was able to stick with the theme: ‘There are these variations in how we care for very similar patients. Why?’ Wennberg peeled the onion back and kept going deeper and deeper.

“Professionally, my claim to fame is that I recruited Jack. And I’m no slouch,” Zubkoff adds, laughing. “I was elected to the Institute of Medicine. But just as I define myself personally as the father of my children, professionally I’m the guy who brought Jack Wennberg to Dartmouth.”

Strickler, too, looks back on the appointment with pride: “It was the best thing I did as dean of the Medical School aside from balancing the budget.” It wasn’t easy to come up with the funding for a permanent appointment for Wennberg. And there was even some resistance to his work within Dartmouth. “There were some hard-core scientists—biochemists, physiologists—who were skeptical and viewed what Wennberg was doing as a soft science, fuzzy sociology,” Strickler recalls.

“But within four or five years of his arrival, the people who were opposed to his appointment had turned around 180 degrees,” Strickler continues. And “Jack managed to co-opt our clinical faculty by working with them collaboratively.”Wennberg proved to be not only a supportive colleague but also a charismatic mentor. Soon he was no longer a lone voice. He began to build a research empire, and that spawned an educational institute.

Wennberg’s career reached a turning point in 1984. That year, he published “Dealing With Medical Practice Variations: A Proposal for Action” in Health Affairs. The journal presented his work without apology. Indeed, the prologue to the piece underlined the importance of his till-then largely unappreciated labors: “Without much attention from the profession and virtually no public fanfare, John Wennberg has been tracking the phenomenon of variations in the use of medical care for more than a decade. Wennberg, who ranks among the leaders of the nation’s tiny cadre of medical-care epidemiologists, has been driven by the notion that practice variations were important to identify and understand because they suggest a misuse of care. . . . During his research pursuits, Wennberg has uncovered systematic and persistent differences in the standardized rates of use for common surgical procedures and other medical services in the United States.” From the very first sentence of that paper, Wennberg’s voice is as clear and bold as it had been seven years earlier when he described tonsillectomy as a “large, uncontrolled surgical experiment.”

“Most people view the medical care they receive as a necessity provided by doctors who adhere to scientific norms based on previously tested and proven treatments,”Wennberg wrote. “When the contents of the medical care ‘black box’ are examined more closely, however, the type of medical service provided is often found to be as strongly influenced by subjective factors related to the attitudes of individual physicians as by science. These subjective considerations, which I call collectively the ‘practice style factor,’ can play a decisive role in determining what specific services are provided a given patient as well as whether treatment occurs in the ambulatory or the inpatient setting. As a consequence, this style factor has profound implications for the patient and the payer of care.

“For example,” he continued, “the practice style factor affects whether patients . . . with mild angina, or with a host of other ailments, receive conservative treatments in an ambulatory setting or undergo a surgical operation in a hospital. . . . The practice style that favors inpatient treatment greatly affects the demand for hospital care and has serious implications for efforts to constrain costs.

“These implications become clear when one recognizes that, within a region or state, different opinions held by physicians . . . are the most important determinant of variations in per capita costs for the treatment of specific diseases. . . . Some of the differences in opinion arise because the necessary scientific information on outcomes ismissing. . . . To resolve the differences in opinion—and to learn whether high or low rates of admission reflect appropriate care—more scientific information must be obtained.

“For other conditions, the practice style factor appears unrelated to scientific controversies. Physicians in some hospital markets practicemedicine in ways that have extremely adverse implications for the cost of care, motivated perhaps by reasons of their own or their patients’ convenience, or because of individualistic interpretations of the requirements for ‘defensive medicine.’ Whatever the reason, it certainly is not because of adherence to medical standards based on clinical outcome criteria or even on statistical norms based on average performance.”

Wennberg went on to demonstrate, once again, that the supply of hospital beds and specialists in a particular market often determines how medicine is practiced—even at the most prestigious medical centers. Comparing the health-caremarkets in New Haven, Conn., home to Yale’s teaching hospital, and in Boston, home to Harvard, Wennberg found that per-capita health-care costs were about twice as high in Boston, “largely because” Boston had more “beds and medical personnel per capita.”

Basically, because the beds were there, physicians used them. To this day, Dartmouth studies show that in areas with more specialists, patients get seen more often—simply because the specialists have more time open in their appointment books. Yet doctors in these markets aren’t consciously aware that they are hospitalizing or seeing patients more often. In the 1984 article, Wennberg reported that when he “asked clinicians who have practiced in both Yale and Harvard teaching hospitals to estimate the per-capita expenditures in each market, their answers indicate[d] they had no awareness of the magnitude of the difference. What is more surprising, many [did] not accurately guess which of the two markets is the more expensive.”

Back in 1984, Wennberg was reluctant to assert that patients in Boston were receiving too much care. As he pointed out, “to learn whether high or low rates of admission reflect appropriate care—more scientific information must be obtained.”

Achieving recognition

But, persistent as always, Wennberg pursued the “outcomes research” that would make it clear whether patients were benefiting (or not) from more care. In 1988, he established the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth. And he soon collected around him a group of like-minded researchers—statisticians, economists, clinician-investigators, epidemiologists. They published more and more papers, reinforcing and expanding on Wennberg’s findings. And they refined and improved their research methodologies.

By 1993, the CECS cadre had attained sufficient critical mass to begin teaching those methodologies. Today, the program offers two master’s degrees (M.S. and M.P.H.) and a Ph.D.

In 1996, CECS published the first Dartmouth Atlas of Health Care—taking the concept Jack Wennberg had developed in Vermont and Maine, then used in New Haven and Boston, and applying it to the whole country. (See www.dartmouthatlas.org for more about the Atlas.) That and subsequent editions of the Atlas have revealed astounding geographical variations in how medical resources are distributed and used—for example, a 33-fold difference in the rate of lumpectomies and mastectomies from one region to another. “That’s simply staggering,” Dr. Jack Lord, then vice president of the American Hospital Association, told the New York Times.

Soon, mentions in the Times and other major media outlets were all in a day’s work for Wennberg and his CECS colleagues. One of his oft-quoted collaborators is Dr. Elliott Fisher, who became the lead researcher on studies that revealed, virtually beyond doubt, that in markets where patients receive more aggressive, intensive care, outcomes are no better. And all too often they are actually worse.

Over time, it became clear that the supply of beds and specialists was not the only factor driving “more care.” Wennberg realized that what he had called the “practice style factor” in his 1984 article was also important—especially when it came to elective surgeries. In some areas, physicians favored more aggressive medicine. In these markets, patients with heart problems, for example, would be more likely to have cardiac bypasses and less likely to be encouraged to try drug therapy or lifestyle changes. And patients diagnosed with early-stage prostate cancer would be more likely to undergo surgery or radiation therapy and less likely to opt for “watchful waiting.”

Wet Wennberg recognized that, when it comes to elective surgery, there is by definition no right answer. That’s why it’s “elective.” And that means patients should consider their own priorities regarding risks and benefits, not just accept the doctor’s presumption of them. In 1989, Wennberg had cofounded the Foundation for Informed Medical Decision Making, a nonprofit organization that has blazed the trail for what’s come to be called “shared decision-making.” (For insight into DHMC’s first-in-the-nation Center for Shared Decision Making, see “Making Choice an Option” in the Fall 2007 issue of Dartmouth Medicine.) The concept’s presumption is that when medical science is ambiguous, patients deserve a chance to participate in the treatment choice, based on a frank appraisal of what is—and is not—known.

Discussion, not dogma

CECS has also aimed to give clinicians a chance to discuss what they are doing—and, more importantly, why. “Medical education tends to be dogmatic,” Wennberg says. “The chief of medicine has the last word on medical truth. In ward rounds, any debate is squashed by [saying], ‘It’s medically appropriate to do it this way.'”

By contrast, he continues, “in the basic sciences, you have discussion and debate. Why not in medicine? We need to be continually evaluating what we are doing over time. ‘Why are we doing this?What is the evidence that it is working?’We need to fund the evaluative sciences,” Wennberg declares. For a moment, he sounds angry, because he knows that those who profit from unproven, expensive, and often ineffective treatments—device manufacturers, drug companies, even some doctors—have for years opposed head-to-head comparisons of one treatment against another. He believes academic medical centers should be on the front lines of the fight. “They need to advocate for independent comparative effectiveness research,” he says. “It is the only way to make clinical medicine a more robust science.”

This is exactly what CECS aimed to do for nearly 20 years under Wennberg’s leadership. He is still, at age 73, active in its work. And he still holds DMS’s Peggy Y. Thomson Professorship in the Evaluative Clinical Sciences—the nation’s first endowed chair devoted to outcomes research. But he has, as of July 2007, stepped down as director and passed that torch to his colleague Jim Weinstein.

In the early 1990s, Weinstein was a tenured professor of orthopaedics at the University of Iowa. He had just been asked to codirect Iowa’s office of outcomes, evaluation, and management.

“I didn’t feel that qualified,”Weinstein recalls. “As it happened, I had attended a meeting on outcomes in San Antonio where Jack had been one of the speakers, and at the time, Jack said, ‘You ought to come out to Dartmouth. We have new programs you should see.'”

Weinstein took him up on the suggestion, deciding in 1994 to spend a sabbatical year getting a master’s degree at CECS. He was especially impressed with the program’s emphasis on shared decisionmaking. “As an orthopaedic surgeon, I often didn’t feel that my patients were getting the information they needed to make their decisions,” says Weinstein. “They were talking to me, but maybe that wasn’t good enough, because I was a surgeon and surgeons do what surgeons do. Maybe they weren’t getting a fair shake.

“When it came to risk,” he continues, “I knew that many of my patients were thinking, ‘I trust my doctor. He is so good that nothing bad will happen tome.’ I wanted to say, ‘Wait. Stop. This is important. You could die. You could get an infection.'”

Wennberg recognized Weinstein’s concern for patients and deep interest in the same questions he himself was drawn to. “When I was there” at Dartmouth, Weinstein remembers, “Jack said, ‘You know, you should stay here.'” But Weinstein had an endowed chair and an established practice in Iowa. So he went back.

Weinstein also had a sick daughter, who had been diagnosed with leukemia when she was one. “By this time she was eight or nine, and she was pretty sick,” he recalls. “When I returned to Iowa, I was asking myself, ‘What am I doing with my life?’ Given what was going on in my daughter’s life, I was pretty unsettled in my own life. My wife was unsettled.” And, Weinstein adds, “when we got back to Iowa I missed the intellectual discussions that Jack stimulated.”

Demonstration project

So, in 1996, Weinstein turned his back on tenure, abandoned his endowed chair, followed his instincts, and returned to Dartmouth. “CECS and Dartmouth-Hitchcock . . . made me an offer so that I could still practice,” he recalls. Before long, he was asked to start a Spine Center at DHMC, which became a demonstration project for CECS’s precepts. It offered a chance to coordinate patient care and outcomes research from the ground up, to directly compare the effectiveness of various treatments. “I said, ‘Orthopaedists and neurosurgeons should work together, with primary-care doctors, and actually collect data on how our patients are doing,’ ” Weinstein says. Even then, even at Dartmouth, he met with some resistance. “We’re too busy,” some doctors said. “This is going to interfere with my practice,” others complained.

But Weinstein was undeterred. “My daughter’s experience in [the] health-care system had been pretty chaotic,” he recalls. “There were errors; she was given the wrong drugs; there were complications from chemo and they were not well explained. So I really didn’t mind the noise about the effect on their practice. I was concerned about the effect on the patient.”

By this time his daughter was very sick once again. In 1997, a year after his return to Dartmouth, his daughter died. She was 121/2 years old. “This really tested my spirit,” Weinstein says. “Either you withdraw and go into your hole, or you draw on it for strength. She had become my hero,” he continues. “She never complained about anything. She had suffered a lot for a long time while we had pushed on from one experimental treatment to another experimental treatment. And the doctors would say, ‘This is the protocol. This is what we do next.’ I wouldn’t want my daughter to have been with us for one day less, but . . . ” His voice trails off.

One can only imagine the agony for Weinstein—who had always worried about overtreating his patients—at being forced tomake treatment decisions for his daughter. Impossible decisions, given the paucity of information about risks, benefits, and options. When doctors say “This is the protocol,” they are simply stating “This is the way we do it.” Not why. Not whether they know why.

“After my daughter’s death,”Weinstein goes on, “my wife and I felt an obligation to try to make it better for other people. . . . So I didn’t give up practicingmedicine. I didn’t want to losemy chance to change the world of medicine from within.

“And then I was asked to become the chair of the orthopaedics department—something I hadn’t expected. It gave me a chance to advocate for the changes I wanted to make.”

What did he change? “Everything,” says Weinstein, suddenly grinning with enthusiasm. He began by connecting the department’s teaching and research missions with its clinicalmission. “Part of the problemwith geographic variation in how we treat patients has to do with lack of evidence,” he observes. “If we knew what to do, there wouldn’t be such variation.

“I came here not just to understand the maps,” says Weinstein, referring to the Dartmouth Atlas maps, which make very graphic the variations in care from one part of the country to another. “What I want to know is this,” he goes on. “How do we change the maps?

“When it comes to many types of surgery, technology is changing so fast—ahead of our ability to evaluate it,” he points out. “It’s very hard to rein in.” The Food and Drug Administration, for example, approves devices without requiring either long-term research about risks or evidence that a new product is any better than products already on the market. Thus the patient becomes the guinea pig for unproven procedures—without knowing that he or she is part of an “uncontrolled experiment,” to use Wennberg’s 1977 phrase.

Other countries have set up registries of devices like pacemakers and artificial joints, to track how well patients function with a given company’s device and how long different devices last over time. The U.S., however, has no such resources. “We’ve been pushing for joint registries—we’ve gone to Medicare and the FDA,” says Weinstein. “Why wouldn’t companies want to know?” He’s not giving up, however. In that way, Weinstein learned well from Wennberg.

But everyone agrees Wennberg set the bar high. His combination of intelligence, tenaciousness, and courage have left a deep imprint. The partisans he has trained and inspired are now effecting change all across the country. The national debate about health policy has been forever altered. Even the enterprise he founded at Dartmouth is undergoing alteration. When Wennberg stepped down from CECS’s helm, the organization acquired a new name—the Dartmouth Institute for Health Policy and Clinical Practice—as well as a new leader.

That new director, Jim Weinstein, remains grateful that fate brought him to Dartmouth. “Jack gave me a way to see things differently—and a chance to change things. I feel very fortunate.”

He and many others at Dartmouth have been singing Wennberg’s praises in the wake of the leadership change. But so, too, have movers and shakers well beyond Dartmouth. In the November/December 2007 issue of Health Affairs, the journal’s 25th anniversary issue, Jack Wennberg was named “the most influential health-policy researcher of the past 25 years.” And he received the 2007 Ernest Amory Codman Award fromthe Joint Commission, the national accreditation body for health-care organizations, for his “leadership role in using outcomes measures to improve health-care quality and safety.”

Blueprint for reform

The anniversary issue of Health Affairs also contains two articles by Wennberg and others at Dartmouth—articles that are, in effect, a blueprint for health-care reform. The first, subtitled “How Medicare Can Improve Patient Decision Making and Reduce Unnecessary Care,” looks at elective surgery, arguing that Medicare should make shared decision-making the standard for deciding if discretionary surgery is medically necessary.

The second paper (“How Medicare Can Reduce Waste and Improve the Care of the Chronically Ill”) notes that at present “the care of Americans with severe chronic disease is disorganized, unnecessarily costly, and undisciplined by sound clinical science.” Wennberg and his coauthors urge the federal government to invest in a “crash research program” designed to rapidly accumulate the evidence needed to determine the best and most efficient way to manage chronic diseases like asthma and diabetes. More efficient care would better serve patients and be less costly, the authors point out. Any cost savings, they suggest, should be shared with providers who deliver the most effective, efficient care. Both articles share the same vision: the health-care payment structure needs to reward the quality, not the quantity, of care a provider offers.

The political reform that Wennberg’s critics were so afraid of back in the 1970s just may happen one day.

19 thoughts on “A Blueprint for Healthcare Reform

  1. Maggie,
    Great article and story.
    I have no doubt that widespread use of shared decision making in cases like prostate surgery, back surgery, hip and knee replacement, etc. would be both the right thing to do and would probably reduce healthcare costs. A redefinition of just what constitutes good sound medical practice in end of life situations would also probably reduce costs by eliminating a lot of surgical and other interventions that are done today but are not done in other countries because they don’t make sense when resources are finite.
    I think it’s a lot trickier, though, when we get into areas like who should get a statin drug or a cardiac stent. If statin drugs are not helpful most of the time but we cannot determine that at the individual patient level before the fact, what is a doctor to do? If we know that some patients will benefit from the drugs but we don’t know whether a specific patient will or not, even the most cost-effective, conservative practitioner is left flying blind. The same is true for stents vs medication. Could a random sample of cardiologists tell if a given patient should get a stent or a medication adjustment? Once an angiogram is performed and a blockage of some significance is found, the path of least resistance is to insert the stent both because the team is there and it can be done quickly plus it pays well. Moreover, even if patients who get the stents don’t live longer but live more comfortably because they suffer fewer incidents of angina, the patient will (rightly) perceive himself as net better off even though his increased comfort will not show up in the life expectancy statistics that we all pay such close attention to.
    There is also a lot to be said for automatically enrolling cancer patients, heart patients, recipients of assorted medical devices, etc. in registries so we can see how they all fare with various products and treatment protocols.
    The biggest question I have about the Dartmouth data, though, is where the heck has CMS been for the last 30 years? They are the big payer in the room and, until very recently, all they seem to know how to do is to write checks promptly, including to fraudsters. They have known about these huge regional variations in practice patterns for years, but they’ve done nothing to bring about convergence. It took 41 years to add a prescription drug benefit while private plans offered one for decades. With a record like that, forgive me if I have a hard time trusting them with an even larger role in our healthcare and health insurance system.

  2. Very good article and on a topic that seems to be a hot topic. Some people say we are now reaping the side affects of all the advances in technology and I hope our medical research can counter act for all the free radials that out there.

  3. Suppose you had a society where there were more people than needed to produce all the “stuff” that was consumed. What would you do with all the excess workers?
    One approach is to create make-work jobs for them. These jobs can generate useful output or not, but from an economic point of view it doesn’t matter. During the great depression the government had programs like the CCC and the WPA which attempted to produce useful results.
    Expanding the army has been a popular mechanism in some cases. Keeping men marching to and fro is better than idleness.
    The US is in this position and we have adopted a number of techniques to keep employment up. I claim that an inefficient health system is just another one of these programs. It may not have been set up deliberately as was the WPA, but the result is the same, a million people are employed.
    The inefficiencies in the system cost everyone an estimated 30% more than necessary. Rather than looking at this as a waste consider it a type of hidden tax which helps maintain full employment. If we streamlined the system and eliminated all the make-work middle men what would these people do for employment?
    The forces that keep this system inefficient aren’t likely to be overcome in the near future, all reform plans address funding primarily and have little to say about efficiency.
    Just consider every unneeded test as a Keynesian economic stimulus and be happy that the money isn’t going into some other area where there isn’t even the remote chance of something good coming out of the work. We all overpay to keep people employed. If we can, we recoup part of this expense by charging more for the services we provide.
    The problem is not that the system costs too much, but that there are too many who are left out of it altogether. This is a distributional issue, not an efficiency one.
    When looked at this way then the focus should shift towards eliminating harmful products from the market. To do this only (only!) requires reimposition of functional regulations by agencies like the FDA.
    Waste is bad, but allowing dangerous items on the market is evil.

  4. Robert, Scott, Barry,
    Robert– The problem is that, unlike the WPA, excess in our health care system is creating harm.
    The WPA allowed artists to do some wonderful work: murals, carvings, sculpture . . . The WPA also was responsible for building a beautiful bridge in Chicago.
    While some might consider art “unncessary,”
    none of this was “make-work.”
    By contrast, every single unncessary or ineffective drug, device teset treatment or procedure has the potential to do great harm.
    There is no medical procedure that doesn’t carry some risk–even a seemingly simple test and lead to a false positive which leads to further unncessary treatment–and side effects.
    And when there is no benefit, then by definition, the patient is exposed only to the risk.
    Unncessary hospitalizations are especially hazardous. There, patients pick up infections which can be life-threatening, can lead to amputations, etc.
    If our goal was simply to keep everyone employed, there are many useful things we could do: set up low-cost day-care centers with a low caregiver-child ratio; send more caregivers into nursing homes to talk to and entertain patients (pet therapy is especially effective with older patients); hire more workers to keep our streets and parks clean; provide para-professionals to assist every teacher in every public school.
    But most of these projects would not generate great profits. They would simply improve the quality of life in the U.S.
    The reason we over-treat is not because we are trying to provide full
    employment: we overtreat in order to create profits for the companies and shareholders who feed at the trough of our money-driven healthcare system–, without regard for the patients who are hurt.
    Scott– the problem is that many (though far from all) of the “advances” in medical technology were not really advances. Particularly in recent years, we’ve reached a point of diminishing returns.
    Barry–Let me begin with you last question: CMS.
    The independent Medicare Payment Advisory Commission–which advises Congress on Medicare spending–has been pushing for reforms based on the Dartmouth reserach for a number of years.
    There are two major obstacles: Congress, which is beholden to lobbyists, and the current administration which cares far more about pleasing the corporate interests making money on overtreatment than it does about having an efficent health care system.
    In the past, both people inside CMS, as well as the Medicare Payment Commission, showed a real interest in Dartmouth’s work. And many Congressmen have backed it.
    Politically, it is always difficult for government to say “no”–we are not going to approve ineffective drugs and services and Medicare will not pay for them.
    But now Medicare has reached a point where the politicians are caught between a rock (the lobbyists) and a hard place (they are running out of funds.)
    Under current law, Medicare is now supposed to cut the fees it pays doctors by 25% over the next few years–beginning this summer.
    That won’t happen. Too many docotrs would simply stop taking Medicare patients.
    So Congress has to find another way to control spending. It is very likely that the next administration will encourage Medicare to use the Dartmouth reserach to reduce waste. Some Congressmen are already behind this. Others will find that, given the choice between slashing doctors’ fees and doing something rational, they won’t have much choice.
    I agree entirely about setting up registries to monitor how various products are doing. Other countries do this.
    On statins you write: “If statin drugs are not helpful most of the time but we cannot determine that at the individual patient level before the fact, what is a doctor to do?’
    The fact is that we do know, very clearly, which paitents benefit from aleady have had a heart attack.
    Statins can help guard against a second attack. There is a lot of medical reserach on this.
    See the recent Biz Week cover story as well as tne NYT.
    We also know that statins provide no benefit for women (though they risk serious side effects-see the WSJ story on Tues.), men over 70 and men under 70 who have never had a heart attack.
    The reserach showing no benefit for these three groups goes back a number of years and can be found in Lancet, JAMA, BMJ, etc.
    Why didn’t it come out earlier? The American Heart Association was paid off, as were the cardiologists on the 2004 panel who recommended, that people with “moderately high cholesterol” also should betaking statins. They distorted and suppressed the evidence that this wasn’t true and failed to disclose that 8 or the 9 on the panel were being paid by companies that made statins (to the tune of $57,000 a year, etc.)
    It’s a long story. I’m in the middle of writing a post about it.
    On stents vs. medication we need to let panels of disinterested cariologists (with no financial stake) from some of our best academic medical centers (Cleveland Clinic, Mayo, etc. )set up
    Some patients may prefer the quick fix– they’d rather not change their diet, exercise, take aspirin, etc. But in the long run they will be healthier, and less likely to suffer from angina if they take the more conservative approach.

  5. Maggie:
    I think that our differences come from what we see as the major problems with health care. It’s like the three blind men and the elephant. It depends on which part you’re touching.
    You see “unnecessary” treatment as a serious problem coupled with high-priced medical professionals.
    I see an unnecessary insurance sector as the largest issue. We both agree that it is the profit motive which distorts the types of choices that are made when selecting treatment options.
    Judging from other countries the principle difference is that they don’t have the same profit pressure from an insurance sector, so I think that any over treatment is a result of the existence of the insurance industry.
    I’m not sure exactly how this works, but if insurance firms limit payments then it becomes a temptation for doctors to order extra treatments to make up for the low imbursement rate. To what extent this is true is hard to determine, but there is, at least the comparison between the US and several other advanced societies to allow for some estimates.
    It would also be interesting to see how treatment differs with the VA which uses a more European-style system than other US plans. One would have to limit the study to before the current wars since lack of adequate funds to the VA now are distorting their usual procedures.
    So, my hunch is that excessive treatment is a symptom of the disease and that the disease is the existence of the for-profit insurance sector as the primary payment scheme for health services in the US.
    Since there seems to be little chance of this changing in the near future, trying to rein in excessive treatment seems unlikely to get to far either.
    I’m not suggesting that we give up on highlighting poor practices, just that it will only achieve modest success and the fundamental problems will continue.
    Everyone has to decide which battles they want to fight and your choice of minimizing bad practices has some chance of leading to modest change, while my more utopian efforts to get profit out of health care altogether is of a more philosophical nature.
    I don’t see any problem with addressing practical and policy issues at the same time. There are many arms on the octopus and we can all chose the one to attack.

  6. maggie,
    I look forward to your statin post.
    The influence that big money and big profits have on authoring clinical guidelines needs a lot more press.
    ENHANCE shines some light on questionable statin guidelines. The recent ACCORD results thankfully are shining light on the pitiful evidence that tight control of blood sugars makes any important difference for type II diabetics. (keep in mind, both of these studies, despite what you’ve heard, didn’t really tell us something new evidence-wise. They just confirmed what people have been ignoring)
    The money that is currently being wasted overtreating (er..following guidelines) for cholesterol and type II diabetes (among other things) is huge, just ask any practicing primary care physician. But we’re all supposed to be following these guidelines or we’re “low quality doctors,” right?
    Maybe a look at what UKPDS actually showed for treating type II diabetics for a future post? Just sayin…..

  7. The Cesarean rate approaches one in three births. There is little evidence to support this many Cesareans but there it is. Unnecessary procedures? Probably. But why is that? The one thing the economists do not address is the influence of the tort system. Despite all the Rand studies, Dartmouth studies, etc, costs of healthcare in the US will not be reined in until there is concommitant comprehensive tort reform.

  8. Correct me if I’m wrong, but I think only about 5%-7% of births in the U.S. in the 1970’s were via cesarean section. After a number of large court awards involving children with cerebral palsy who were delivered vaginally where malpractice attorneys convinced juries that the unfortunate outcome could have been avoided if the delivery were by cesarean section, the tide started to turn. This is the area of malpractice litigation that former Senator John Edwards is best known for.
    In our litigious environment and culture, it is perfectly understandable that OBGYN’s will resort to a cesarean if they detect the slightest hint that something may be amiss with the fetus. While the fivefold increase in the percentage of cesarean deliveries over the last 30 years has undoubtedly driven up healthcare costs and increased risk to patients, it has not appreciably reduced the incidence of cerebral palsy as I understand it.
    It is probably not fair to attribute all of this change to the fear of litigation and defensive medicine. At least some of it may be due to patient preference. At any rate, it would be interesting to examine the differences in cesarean delivery rates among the OECD countries and to what extent those differences are due to litigation related issues, patient preferences or other factors.

  9. Barry, Art pcb and Robert–
    Barry & Art –
    The jump in C-sections has little to do with patient preference. Very few women who have ever known anyone who had a C-section would prefer to go that route.
    Yes, labor is painful, but convalescing from a
    C-section is also painful–and takes much longer.
    And it happens when you have a new baby that you want to take care of.
    Finally, C-sections are not good for the baby for a number of reasons, beginning with the fact that the mother is in no shape to “bond” with the baby shortly after birth.
    My daughter recently sat in a hospital waiting room while a friend gave birth.
    The doctor talked the friend into a c-section.
    This had nothing to do with fear of litigation. The friend was young, very healthy, and had only been in labor for a few hours.
    The doctor just didn’t want to hang around–and made that clear.
    He wanted to either give her a drug like Pitocin to “speed things up” or–do the C-section.
    Pitocin is a hallucinogenic. I was given it when my first child was born. I began hallucinating that I was dying of cancer and that the people around me were trying to beat me to death.
    This is a horrible, horrible way to give birth– I would much rather have gone through a longer labor.
    My daughter’s friend chose the C-section. My daughter visited her in the hospital in the days that followed and after she went home. Her conclusion: “I would never let anyone do that to me.”
    I have heard numerous stories from young women about doctors trying to talk them into c-sections for the doctor’s convenien ce.
    Today, I did a little Googling and found this article (from the Washington Post)which confirms what I have heard anecdotally and read elsewhere:
    “Since 1996 the C-section rate in our country has cliimbed 46 percent; nearly one in three of the 4.1 million annual births are via Caesarean surgery, which is statistically the riskiest way to give birth.”
    The National Women’s Conference Committee also points out the dangers: “Half of all women having C-Secs suffer complications, and the maternal mortality rate for C-Sec delivery is 4 times that for vaginal delivery. . . EVen after a woman has had One Caesarean, Vaginal Birth is safer for both mother and child than repeat Caesareans.”
    Barry & Art– Note: since a C-section is the riskiest way to give birth, a doctor increases his chance of being sued if he chooses a C-section–especially if he talks the patient into it.
    The Washington Post article continues: “The United States spends twice as much per birth as other developed countries, where medical intervention in hospitals is usually reserved for high-risk situations.”
    And finally, the Post notes that in the U.S.
    ” Hospitals, insurance companies and doctors’ schedules all discourage natural labor, largely because labors without intervention such as Pitocin, Cervadil (drugs that speed up labor) or C-section are usually long, hard to predict, and thus disruptive to the way a hospital functions.”
    Women need to make sure that they have an advocate (usually the child’s father) who will stand up for them and, if absolutely necessary, threaten to sue
    a doctor who is trying to push the mother into a C-section (or a drug to “speed things up”)unless the baby is in trouble.
    (I’m generally Not a fan of threating to sue people, but if that’s what it takes . . . Hospitals can be very intimidating places. )
    According to the World Health Organization, in a developed country a 12% C-section rate would be about right. That’s about how often a C-section would be needed for health reasons. We’re doing nearly three times as many C-sections–and this has nothing to do with protecting the mother, the child, or even protecting the doc from a lawsuit.
    BTW– thanks to both of you for bringing this up. I’ve thought about doing a post about C-sections, and you’ve prodded me to start doing some research.
    pcb–yes, I should look into the type II diabetes story. And you are right–these are not new stories. What is amazing is that they were kept out of the mainstream media for so long.
    Robert– I, too, would like to get profit out of healthcare. Inevitably it
    creates a conflict of interest.
    But you should realize that many European countries have for-profit insurance companies. The difference between them and the U.S. is that their
    insurers are tightly regulated. They are not allowed to do things like
    “cherry pick” healthy customers, charge sick people more, or sell anyone insurance policies that are full of holes.
    They don’t have the overtreamtent problem that we have in part becuause these countries limit volume–sometimes by creating global budgets for each region of the coutnry and allocating a fixed amount of money to that region for healtlhcare each year. Because each region has to live within a budget, it can’t buy unncessary equipment (an MRI unit that duplicates one at a nearby hospital) or do unncessary procedures.
    In some countries, there is a cap on how many surgeries an individual surgeon can do each year.
    Generally, it is good when a surgeon does many of the same type of surgery, over and over–practice makes perfect.
    But in this country there are some surgeons who do too many–so that they wind up operating when they are very tired, or wind up “supervising” surgeries on two or three different floors of the hospital–doing one while two of their residents do the other two (without any real supervision.)
    In terms of the cost of overtreatment–it is now generally agreed that one out of every three of our health care dollars is now wasted on unncessary tests, unproven, ineffective proceudres, and over-priced cutting edge drugs and devices that are no better than the less expensive products they have replaced.
    Finally, these days insurers are not refusing to cover many procedures. They were doing that in the 1990s, under “managed care” but by the end of the 1990s, there as such a backlash against managed care–in the media, by employers, etc.–that insurers said okay, we’ll cover whatever the doctor advises, and pass the cost on in the form of higher premiums.
    That’s why premiums went up more than 70 percent between 2000 and 2005.
    Medicare is the payoer that has been cutting back–not so much on what it covers, but on what it pays per service (by keeping fees flat–and not keeping up with inflation).
    And that is the main reason many doctors are trying to do more volume.
    But private insurance is not driving overtreatment.
    That said, I would love to see private insurers regulated–see my most recent post (from Friday) and the suggestions that I link to.
    Finally, if we are going to have private sector insurers, I would really like to see them be not-for-profits rather than for-profits.

  10. Since I’m apparently not easily dissuaded, I’ll ask again. How is your proposed system of Universal/Mandated Health Insurance different from that of the UK? I ask because they appear to be having some difficulty.
    I would also like it point out that things like this call into question any and all direct comparisons between or among various countries’ health care systems. Differing (and outright manipulated) definitions must be taken into account.

  11. As always it is finding the balance between resources and cost. My belief is that wait times can be a good yardstick for access. Is it possible to measure wait times across both public and private sectors? Then allow them to either reduce or increase until the desired balance is found. We have no universal measuring stick (except wait times?) so that society (whether US, Canada or UK) can balance cost and access. I blog at http://www.waittimes.blogspot.com on wait time tools.

  12. Great Post! It should be a must-read for all health profession/public policy students – and for current practitioners in those fields (at a minimum).
    I also appreciate the distinctions posed in robert feinman’s comment to maggie, and if you’re intersted to see this point playing out real-time in the policy an politics of reform where I live in Massachusetts, click below. It’s a health reform “blog” called Commonhealth (in truth it functions more like a PR vehicle for the architects of our state “reform” law). It’s run by NPR/wbur in MA. Yesterday’s invited post was by a HMO CEO, entitled INSURANCE AGENTS OF CHANGE by Eric H. Schultz, and my comment about commercial insurance itself being the root of other system problems is the 4th comment down.

  13. BobMan, Ann, and TD
    BobMan– Thanks very much for sending the link to the Forbes story. The fact that Forbes is acknowledging the crisis in our health care system will palert people that the system really is broken
    Though I have to point out, Forbes doesn’t suggest that the uninsured are better off than the rest of us. The uninsured die earlier, are less likely to get the painkiller they need in an ER, — overall, they receive inferior care.
    Ann & TD– thank you very much.
    Ann- Thanks for sending the link. I haven’t yet looked at it, but I will. (The last 5 days have been impossible. I spent Wed. at JFKairport– without going anywhere. Though I did sit on a plane for 2 1/2 hours at the gate. They couldn’t find the part they needed to repair the plane.
    . After 7 hours at the airport, I went home, got up at 4 a.m. the next morning to take an early morning flight to Houston where I was giving a speech that afternoon.
    I really liked the people I met in Houston, but I’m still recovering–which is why I’ve been MIA on this blog.

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  15. All this talk about what’s going on, but I have not read anything explaining how to fix our problem. We all know what the problem is, but what do YOU suggest we do to correct it. The best advice I read thus far is tort reform. Better yet, I think we need to look at the Accountable Care Organization structure. This is going to be the future of healthcare in America