Personally, I find that the most objectionable feature of the conservative attitude is its propensity to reject well-substantiated new knowledge because it dislikes some of the consequences which seem to follow from it – or, to put it bluntly, its obscurantism. I will not deny that scientists as much as others are given to fads and fashions and that we have much reason to be cautious in accepting the conclusions that they draw from their latest theories. But the reasons for our reluctance must themselves be rational and must be kept separate from our regret that the new theories upset our cherished beliefs.
To follow-up on my previous post, we seem to find ourselves in a position where the overwhelming evidence is that we do not live in the country with the best health care in the world, only the most expensive (with a thanks to Barbara Starfield, who passed away this week, for steadfastly pointing this out). The previous point I was trying to make was that there is a role for regulation in various aspects of our life and health care seems to be one of them. Poorly regulated health care delivery has led to excess capacity in the cities, diminished capacity in rural and underserved areas, and care that is excessive and expensive overall. It has also led to poor general health (see We’re #37 for an in-depth analysis). It was reading comments from another health care blog that reminded me of another potential cause of poor care delivery that regulation must change.
The Dartmouth Atlas Study has looked at variations in health care for over 20 years. The study began, very simply, because investigators began asking “Why are certain rates of surgery so much higher in one place than in another (geographically proximate) place even though human beings don’t vary that much?” What they have found are some dirty little secrets about our care system:
Regarding the supply of care
Simply put, in regions where there are more hospital beds per capita, patients will be more likely to be admitted to the hospital. In regions where there are more intensive care unit beds, more patients will be cared for in the ICU. More specialists will result in more visits to specialists. And the more CT scanners are available, the more CT scans patients will receive.
In regions where there are relatively fewer medical resources, patients get less care; however, there is no evidence that these patients are worse off than their counterparts in high-resourced, high-spending regions. Patients do not experience improved survival or better quality of life if they live in regions with more care. In fact, the care they receive appears to be worse.
Regarding physicians role in the demand for care
We see dramatic variations in rates of surgical treatment for other conditions where multiple treatment options are possible, such as chronic angina (coronary bypass or angioplasty), low back pain (disc surgery or spinal fusion), arthritis of the knee or hip (joint replacement), and early stage cancer of the prostate (prostatectomy). Such extreme variation arises because patients commonly delegate decision-making to physicians, under the assumption that doctors can accurately understand patients’ values and recommend the correct treatment for them. Yet studies show that when patients are fully informed about their options, they often choose very differently from their physicians.
Regarding the type pf doctor we train
Increasing the number of physicians will make our health care system worse, not better. First, unfettered growth is likely to exacerbate regional inequities in supply and spending; our research has shown that physicians generally do not choose to practice where the need is greatest. Second, expansion of graduate medical education would most likely further undermine primary care and reinforce trends toward a fragmented, specialist-oriented health care system. Current reimbursement systems strongly favor procedure-oriented specialties, and training programs would almost certainly respond to these incentives. Third, workforce expansion will be expensive. If outcomes and patients’ perception of access improved as supply increased, then we could debate whether an expansion of training offers better value than investments in preventive care, disease management, or broader insurance coverage, which have known benefits. Instead, the costs of expansion will limit the resources available for necessary reform efforts without any evidence-based promise of a benefit.
In short, the evidence is clear. The bastardization of the market has brought us not only poorly organized and distributed care, but extreme excesses of useless care. I am willing to pay for my share of necessary medical care to ensure that if I incur an illness others will pay for me. I am also willing to support a public system that rewards physicians for delivering care of proven high quality. I am increasingly unwilling to support a system that rewards excesses in the manner that ours does. If we must maintain specialists pay at current levels, let’s stop training the excess and pay the current ones not to deliver excessive care like we did for tobacco growers not so long ago. At least then we will have healthier Americans.