LA TEORÍA DE LA AGENDA-SETTING

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information technology might bring to medicine. After Dr. Diamond discussed the barriers to adopting information technology in medicine, a puzzled audience member asked, “If information technology would save money, why is the health care industry so far behind every other industry?”

Dr. Diamond’s one-sentence response was “Wasted money is some-one’s bottom line.” What is waste to an insurer, a business, a taxpayer, or an individual purchaser of insurance is profit to a doctor, a hospital, a pharmaceutical company, or a medical device manufacturer. Over the past three years I have routinely asked doctors and hospital administra-tors to estimate how much of the health care services that we provide is pure waste. They usually paused to think. When I suggested, “Thirty per-cent?” they invariably responded, “Oh, at least that.”

There is evidence to support the assertion that at least one-third of what is done in medicine does not help patients. Under Dr. John Wennberg, investigators at the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, New Hampshire, have devised a technique for deter-mining usage rates of specific Medicare services in various U.S. regions.

Wennberg and his colleagues (Dr. Elliott Fisher, an internist, and Dr. Jonathan Skinner, a health economist) have had access to the Medicare database for years. For this study, they divided the United States into 306 hospital referral regions where patients live and receive their medical care. Medicare pays a uniform rate across the nation, adjusted for regional cost differences, so the investigators adjusted for price differ-ences and then examined the outcomes and care of all Medicare patients admitted with hip fractures, colorectal cancer, and heart attacks from 1993 to 1995 in all 306 regions. When Medicare spending in a region is high, the reason is increased use of services, not increased price of services.

In high-spending areas Medicare spent 60 percent more per capita on patients with these three conditions than it did in low-spending areas. For example, for the same condition, Medicare paid for 2.5 times more pro-cedures per Medicare beneficiary in Miami than it did in Minneapolis.³ Doctors in high-spending areas hospitalized patients more often, saw them in the clinic more often, ordered more tests, and performed more minor procedures. At the end of life, patients in low-spending areas spent an average of six days in the hospital, whereas patients in high-spending areas spent twenty days.⁴

The result of the increased use of medical services in high-spending areas was not improved outcomes, as might be expected. Patients cared for in those regions were at a significantly increased risk of dying over the five years after the initial hospital admission. More medical care not only worsened outcome, but it also failed to increase patients’ satisfaction with their care or to improve their functional status.

One might assume that academic medical centers, which are sup-posed to be the best health care facilities, are more uniform in their care.

But in high-spending areas, academic doctors behaved just like their peers in the same region. In the first six months after a hip fracture, patients cared for in academic medical centers in high-spending areas visited their doctors 82 percent more often, underwent 26 percent more imaging studies, 90 percent more diagnostic tests, and 46 percent more minor surgery than did patients in academic medical centers in low-spending regions.⁵

What explains this astonishing regional variation in care? The only variables that predicted high-spending versus low-spending regions were an increased concentration of specialists and hospitals. Wennberg stated,

“High-rate regions had thirty-two percent more hospital beds per capita, thirty-one percent more physicians, sixty-five percent more medical spe-cialists, seventy-five percent more general internists, and thirty-seven percent more surgeons. Low-rate regions had twenty-five percent more family practice physicians than high-rate regions.” Variations in the degree of illness among regions explained only 27 percent of the differ-ences, whereas the local supply of hospital beds and specialists accounted for 42 percent.⁶

When the study group examined the overall picture that emerged from its findings, investigators concluded that low-spending areas should be the benchmark because patient satisfaction and functional status are the same as they are in high-spending areas while mortality is improved.

If doctors in high-spending areas practiced like doctors in low-spending regions, Medicare cost could be reduced by 28.9 percent with improved quality.⁷These savings would not require any rationing of needed care;

they would not create waiting lists or delay anyone’s access to a doctor, a test, or a procedure. They are savings that would improve the quality of medical care.

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Doctors do not sit together in a room and decide to build more hos-pital beds so they can admit more patients, collude to order more diag-nostic tests, agree to perform more minor procedures so they can make more money, or keep patients in the hospital longer when they are dying.

In fact, practicing physicians are unaware of these regional differences and of their role in producing them. Rather, this wastage reflects the unrestricted application of medical services without public reporting, without uniform standards of medical practice, and without a full under-standing of which patients benefit from which tests and procedures. The differences reflect local custom. The habits and circumstances of Minnesota physicians are not the same as those of Florida physicians. For instance, there are no national standards for how often a patient should be seen after a heart attack or for heart trouble. If a town is home to many cardiologists, they naturally want to be busy. They all fully book their clin-ics, so patients with heart trouble in that community are seen more often than they might be in another community. A doctor who is liberal with patient visits is liberal with tests—and the more a doctor looks for, the more a doctor finds. Thus, excessive testing leads to unnecessary proce-dures. Half the variation among regions in the number of visits to cardi-ologists is explained by the number of cardicardi-ologists in the community.⁸