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When Doctors Disagree

The American public has been warned that medical care may soon have to be rationed. In an article in Newsweek (November 12, 1984), Dr. William Schwartz writes that “either we will accept the continued rise of hospital costs that result from full exploitation of technological advances, or we will start to ration hospital care. And if it’s the latter, we will then have to say to some people, ‘Yes, a new liver would be good for you, but as a society we can’t afford it.’ ” The economist Henry Aaron, in collaboration with Dr. Schwartz, has elaborated on this theme in a recent, widely publicized book, The Painful Prescription: Rationing Hospital Care,1 as well as in articles in The New York Times and elsewhere.

The truth is that medical care is already rationed and it always has been. One of the disgraces of national policy is that the poor and unemployed who cannot afford to pay for medical care or have no medical insurance must often accept inferior treatment, if they can get it at all. What is new is that the costs of care, whether it is paid for directly or through insurance, are rapidly exceeding the ability or willingness of even the middle class to pay. The main reason for this is that medical scientists are inventing more new diagnostic and therapeutic “medical technologies”2 than the economy can pay for. The artificial heart is a famous example. If a workable model were developed and made available to the estimated fifty thousand terminally ill cardiac patients each year who could benefit from it, that would cost between three and five billion dollars. Since it is unlikely that the government will pay the bill—as it has for kidney transplants and hemodialysis for patients dying from kidney failure—we face the prospect that this enormously expensive medical technology, if it succeeds, will be made available primarily to those willing to pay for it.

The case of the artificial heart is by no means unusual. The potential costs of new medical technologies are enormous. They include the exchange of blood plasma (plasmapheresis) in the treatment of rheumatoid arthritis and related diseases, and diagnosis by means of nuclear magnetic resonance imaging, and liver transplants. We can assume that new medical technologies will continually appear, and we can also assume that major controversies will arise over who will benefit from them and who will pay for them.

A number of measures could be taken short of rationing. These include preventive medicine that would decrease the need for medical care, such as encouraging people to stop smoking, improving prenatal care, and increasing programs for immunization. In addition, the large US investment in basic research, primarily at the National Institutes of Health, will continue to produce health-improving technology and all of it may not increase costs. As Lewis Thomas has pointed out, truly effective medical technology, such as immunization and antibiotics for specific diseases, will be less expensive than the complex but inefficient “halfway technologies,” including the artificial kidneys and hearts that make up such a dramatic part of current medical practice.3 Finally, substantial savings could be achieved by reorganizing the delivery of health care. As an example of how large these savings might be, Dr. John Wennberg of Dartmouth, appearing before a recent Senate Appropriations Committee hearing, estimated that 40 percent of hospital costs could be saved if hospitals gave “out-patient care” to many patients who are now required to occupy a hospital bed if they are to be treated.4

But a quite different approach to reducing the need for rationing has, I think, been insufficiently stressed. Doctors tend to believe that they should recommend whatever they think will be beneficial, and they tend to be optimistic about new medical techniques. But their optimism is often not based on sound evidence. Not every new treatment is successful—indeed, much of current medical practice may be ineffective. Discovering what works and what does not is something the medical profession is not very good at, and the amounts now invested in studies of the effectiveness of US medical technology have been inadequate. Furthermore, patients often fail to take part in decisions affecting their own health, or uncritically accept the optimism of their doctors. These factors, I believe, have led to widespread overtreatment of patients. What we would save from a successful national program to assess medical technologies might greatly help to avoid rationing medical care.

How strong is the evidence for overtreatment? Without comprehensive studies of the effectiveness of medical care, evidence for widespread overuse of medical technology is somewhat indirect but it is nonetheless convincing. In 1970, I reported that there were twice as many surgeons in the United States for each million of population as there were in Great Britain, and that they performed twice as many operations.5 That is to say, in a given year, an American was twice as likely to undergo surgery as a person in Great Britain. This disproportion in the probability of surgery has not changed since 1970. Yet the general health and life expectancy of the British population compares favorably with that of our own.6 Henry Aaron and William Schwartz argue convincingly that the British have failed to provide enough of some new medical technologies, such as hemodialysis and open-heart surgery, to meet the needs of their population. While their use of some procedures may be too low, ours are certainly too high.

Dr. Wennberg has produced the strongest evidence suggesting that medical treatment can be excessive in the US. Wennberg made surveys of the frequency of surgery and hospitalization in such states as Vermont, Iowa, and Massachusetts. He divided individual communities of a county or state into what he called “hospital markets” or “hospital service areas” in which most of the population used one local hospital or group of hospitals. He then gathered information about the rates of use of medical treatments, diagnostic tests, and surgical procedures in various hospital markets by examining health insurance records (such as Medicare and Medicaid) and hospital discharge records. He found, he says, that many “hospital markets” had “highly variable rates of use for most specific medical treatments, diagnostic tests, and surgical procedures, and by widely different resource use rates.” For example, he observed that

in Maine, by the time women reach seventy years of age in one hospital market the likelihood they have undergone a hysterectomy is 20 percent while in another market it is 70 percent.

In Iowa, the chances that male residents who reach age eighty-five have undergone prostatectomy range from a low of 15 percent to a high of more than 60 percent in different hospital markets.

In Vermont the probability that resident children will undergo a tonsillectomy has ranged from a low of 8 percent in one hospital market to a high of nearly 70 percent in another.7

Similarly, Wennberg has shown that Americans living in some cities or towns in New England and in Iowa are twice as likely to undergo surgery or to be hospitalized for nonsurgical conditions as those living in other cities or towns of those states. Moreover, contrary to what one might expect would result from such wide variations in treatment, no sharp differences have been observed in the reported incidence of disease or in the mortality rate in the areas compared by Wennberg.

Why not? No one has convincingly explained why treatment varies so much. Wennberg’s studies failed to show any significant correlations between high rates of use of medical treatments and rates of illness, or insurance coverage, or access to medical service. The variations, he wrote, “also persist after adjustment for age, which tends to account for most illness-related differences in populations.” There are large variations among patients even in a state such as Vermont, where the population is relatively homogeneous in economic and social status. Wennberg considered the possibility that some variation might be explained by the varying supply in different hospital markets of physicians and facilities. But he concluded that “most” of the variations remained “unexplained” even if such differences were taken into account. He cited one study on rates of hysterectomy which showed that “per capita number of beds and gynecologists are virtually the same in hospital markets with low and with high per capita hysterectomy rates.”

Moreover, the variations in the use of medical treatments could not be explained by the incentives given to physicians by “fee-for-service medicine,” since the pattern of variation is similar not only in “fee-for-service” markets in the United States but also in “the health care regions in Canada, England, and Norway, even though obvious differences exist in the supply of surgeons, the organization and financing of services, and in the cultural and demographic characteristics of hospital market area residents.”

Wennberg’s own explanation of the variations is that physicians differ in what he calls “practice style”—in the “subjective factors” that help to determine whether a physician recommends that a patient receive a specific service and whether the treatment is offered in a hospital or an outpatient facility.

But this seems only a partial explanation. Why do physicians with similar “practice styles” seem to concentrate in certain geographic areas? If their “practice styles” were truly “subjective,” and were not intended to match the behavior of their colleagues, then variations in practice patterns would most likely not be observed. A student of these variations, Dr. David Eddy, has argued that “a physician who follows the practices of his or her colleagues is safe from criticism, free from having to explain his or her actions,” so that a “tendency to follow the pack is the most important single explanation of regional variations in medical practice.” According to this view,

differences between regions are observed because individual physicians tend to follow what is considered standard and accepted in the community. A community standard evolves from statements published in national journals and textbooks, from the opinions of established physicians, and from new ideas brought to the community by new physicians.8

But how could such different patterns take shape without marked effects on the health of local populations? The most convincing explanation, I believe, derives from the fact that for perhaps a third to a half of the care doctors provide, the benefits and risks are evenly balanced, and the net benefits are exceedingly small, if they exist at all.9 In this situation doctors who are in positions of authority may, without seeming to incur excessive risks, help to establish a pattern of greater or lesser surgical intervention or hospitalization. Neither they nor their patients may be aware that the pattern is quite different in another part of the state, or that the effectiveness of their treatments may be uncertain. The more closely we look at specific operations and treatments, moreover, the more likely it seems that some are being used excessively.

  1. 1

    Henry J. Aaron and William B. Schwartz, The Painful Prescription: Rationing Hospital Care (The Brookings Institution, 1984).

  2. 2

    The Congressional Office of Technology Assessment defines medical technologies as those “techniques, drugs, equipment, and procedures used by health-care professionals in delivering medical care to individuals, and the systems within which such care is delivered.”

  3. 3

    Lewis Thomas, The Lives of a Cell (Bantam, 1974).

  4. 4

    John E. Wennberg, Testimony Before Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, and Education, November 19, 1984.

  5. 5

    John P. Bunker, “Surgical Manpower: A Comparison of Operations and Surgeons in the United States and in England and Wales,” New England Journal of Medicine, vol. 282 (1970), pp. 135–144.

  6. 6

    World Health Statistics Annual, 1983 (Geneva: World Health Organization). See also Victor W. Sidel and Ruth Sidel, A Healthy State: An International Perspective on the Crisis in United States Medical Care (Pantheon, 1977).

  7. 7

    This and other quotations from Wennberg are from his essay “Dealing with Medical Practice Variations: A Proposal for Action,” Health Affairs (Summer 1984).

  8. 8

    See “Variations in Physician Practice: The Role of Uncertainty,” Health Affairs (Summer 1984).

  9. 9

    Economists describe such a relation of risks and benefits as “the flat of the cost-effectiveness curve.”

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