The Medical Mystery Of Sun City And Other Health-Care Oddities -- WSJ

The Medical Mystery of Sun City
And Other Health-Care Oddities

Changing the U.S. health-care system is turning out to be tougher than John Wennberg anticipated.

Thirty years ago, Dr. Wennberg noticed that kids in some parts of Vermont routinely had their tonsils removed while kids in other parts of the state didn't. The most likely explanation, he wrote in Science magazine in 1973, was simply "differences in beliefs among physicians."

Since then, the Dartmouth College physician has crunched more numbers, landed a $7 million foundation grant, formed a company to counsel patients pondering elective surgery, testified before Congress several times, spawned a cadre of researchers and created a Web site (www.dartmouthatlas.org¹) comparing how medicine is practiced in different places.

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His primary point hasn't changed: There is little scientific basis for the differences in the way medicine is practiced across the U.S. and little evidence that giving more care always extends lives. We could save a lot of money if we figured out what care is valuable and what is not -- and provided more of the first and less of the second.

The American health-care system has reacted to Dr. Wennberg's arguments with the resilience of an antibiotic-resistant bacteria.

It's not that he labors in obscurity. Dr. Wennberg is quoted in some newspaper or magazine once a week on average. Nor is his analysis difficult to comprehend. He and his troops excel at what journalists lovingly call "factoids," the morsels that make complex stories easy to digest. For instance:

• A typical 65-year-old in Miami will cost Medicare $50,000 more in his or her lifetime than a 65-year-old in Minneapolis, enough to pay for a Lexus with all the trimmings.
 
• Three of every 1,000 Medicare beneficiaries undergo heart bypass surgery each year in Albuquerque, N.M., but 11 per 1,000 do in Redding, Calif.
 
• Only 14% of the terminally ill in Sun City, Ariz., enter an intensive care unit in the last six months of life, but 49% do in Sun City, Calif.
 
• Elderly men in Binghamton, N.Y., are nine times more likely to have their prostate removed than men of the same age in Baton Rouge, La.
 
Doctors and hospitals have largely stopped complaning that if Dr. Wennberg adjusted for the fact that people in their town are sicker, older or poorer, the differences would disappear. In many communities, Wennberg-inspired report cards allow doctors and hospitals and patients to compare performance. Sometimes they even force poor performers to change.

But Dr. Wennberg hasn't significantly changed the way most doctors, hospitals, governments, insurers, employers and consumers behave. "He's been slogging away at this for 30 years, mostly in the wilderness in terms of the general public," says John Iglehart, editor of the journal Health Affairs, which published its first Wennberg paper in 1984.

The spending gap between Miami and Minneapolis hasn't narrowed. "People in Miami feel their system is doing a great job. People in Minneapolis think the same," Dr. Wennberg says. "And try to take some of the care out of Miami? Everyone assumes more is better," he says.

Dr. Wennberg, 66, isn't easily discouraged. "It depends on whether you're viewing the glass as nine-tenths empty or one-tenth full," he says. "Changing the health-care system is like changing the Catholic Church. It takes a long time."

The limited impact of three decades of research reflects some shortcomings in Dr. Wennberg's work. It focuses on easy-to-measure outcomes, such as longevity, and can't yet reveal if the quality of patients' lives is better in places where bypass surgery is more frequent. And though Dr. Wennberg identifies communities in which doctors probably do unnecessary procedures -- often out of habit, not self-interest -- he can't tell which patients should undergo surgery and which should not.

But all this highlights two facts about American health care. One is ignorance. For all the obvious benefits of medical technology and all the money we spend, we still know little about, for instance, which treatment for prostate cancer is best. Even among big university medical centers, there's huge variation in success rates for treatments of various ailments. Yet these institutions make "unconscionably little effort" to understand why, he complains.

The other is the focus on cost rather than quality. Decades of tinkering with Medicare and managed care were largely aimed at saving money. For a time, it worked, but health costs are now climbing again. "We tried to use economic incentive with doctors," says Jim Knickman of the Robert Wood Johnson Foundation, which has funded Dr. Wennberg, "but the doctors are more clever than the economists."

Yet today, few insurers offer doctors incentives to, for instance, make sure hypertensives get their blood pressure checked regularly, and there is no penalty if patients don't. Traditional Medicare pays the bills whether care was appropriate or not, whether the doctor was high or low quality.

Maybe, Dr. Wennberg suggests, it's time for government, insurers and employers to move toward paying doctors and hospitals based on the quality of the care they provide, not the quantity.

-- David Wessel

Write to David Wessel at capital@wsj.com⁴

Updated March 21, 2002