The Telltale Wombs Of Lewiston, Maine

http://www.npr.org/templates/story/story.php?storyId=113571111&sc=fb&cc=fp

The Telltale Wombs Of Lewiston, Maine
October 8, 2009 by Alix Spiegel

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His name was Jack Wennberg, and by the mid-1970s, he had compiled data about health care practices in cities all over the state of Maine, including data showing that in the city of Lewiston, an unusually large number of women were having hysterectomies. He projected that if the rate of surgeries continued in Lewiston, 70 percent of its women would have a hysterectomy by age 70.

Wennberg discovered Lewiston's high hysterectomy rate, but he really did much more than that. Over the past 40 years, he has completely transformed our understanding of what's going on in the U.S. health care system. His research on health practices eventually expanded. He started in Vermont, then moved to Maine, until eventually he studied communities throughout America. In the process, Wennberg led us to a clearer understanding of what doctors and hospitals are doing with their patients all across the United States.

So if you're looking for a better understanding of what drives the cost of health care in this country, health researcher Wennberg is a pretty good place to start.

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But in his work in Maine and Vermont, Wennberg demonstrated that it's actually a lot more complicated than this. The women of Lewiston, Maine, weren't having more hysterectomies because more of them were Catholic, or because more were sick. After his initial work in Vermont and Maine, Wennberg embarked on this enormous study of patients, which showed that in terms of sickness and demographics, the populations of different communities in Maine and Vermont were actually remarkably homogenous.

This could mean just one thing, according to Wennberg. "Because we could easily see that it wasn't that patients were different between regions, so it wasn't the illness that was driving this, this must be coming from the provider side."

His insight: It was doctors, not patients, who drove medical consumption, and all kinds of things influenced the decisions a doctor makes when a patient enters his office. Sickness and patient preference play an important role, but a much smaller role than patients and the health care community had originally thought.

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Then there was the role of local medical culture. For example, even though it didn't make sense and wasted a lot of time and money, pediatricians in some communities felt they absolutely positively had to send even mildly sick kids to the hospital.

"Families in small Maine communities were used to the fact that if their kid had a temperature of 102 and was vomiting, that kid was going into the hospital," says Keller. "They'd been doing it for years, so they'd be aghast if they took little Tommy down and he had a temperature of 102 and the doctor said, 'Well, go home and take this.' Nobody did that!"

It was probably safer and better all around not to put the kids in the hospital, and the doctors knew this. But doctors, like the rest of us, are people, and therefore are subject to subtle influences.

For instance, it turns out that if you increase the number of doctors in an area, chances are that the use of medical services will rise. If there's one doctor in a town with 100 patients, then he'll schedule your heart checkups for once every six months, but if another doctor comes to town — and now the first doctor has 50 patients — the doctor will just schedule your heart checkups for once every three months. There's a very simple reason why, says Frank Read, an eye specialist who participated in the doctor groups.

"I don't want to be sitting on my thumbs all the time — I want to be busy. And that may unconsciously loosen my criteria for doing a procedure."

Which brings us finally to the subject that incredibly was never directly discussed during the nearly 20 years the doctors met: money. Specifically, the way money affects medical decision-making.

Keller explained that this subject was completely verboten.

"It would have been a show stopper. It would have gone right to the question of greed, and you're not going to keep a doctor at the table if you say that he's greedy."

Talking to doctors about money is difficult. It's uncomfortable both for patients and for doctors to think that this most important and intimate service could be contaminated. But the truth is the decisions made by your physician when you enter his office are profoundly influenced by the way that doctors get paid in this country. "That's just common sense. That's human nature," says Smith of the Maine Medical Association. "The payment system is an important influence."

Most of the doctors in this country are not on a salary but are paid basically like pieceworkers in a clothing factory. This is called "fee for service," and the way it affects doctor behavior is clear.

"If you pay people more, the more things they do, they're going to do more things," says Smith.

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Doctors exist in a fee-for-service system that encourages — and really because of the threat of malpractice and having to battle insurance companies — in some ways actually forces them to do more. More surgery. More tests. More of everything.

And while most Americans just assume that more care is good, it turns out that more isn't always better for patients.

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A couple of years ago Keller and some colleagues did an elegant study of one kind of back surgery in Maine, a procedure called discectomy. Keller found communities in Maine that had high rates of this surgery, communities with low rates, and communities that were somewhere in the middle. Then he followed patients who had had surgery in those communities over a five-year period to see how they fared. Keller says the conclusion was undeniable.

"In the high rate of surgery overall, the patient outcomes were the least good of those three categories. In the middle rates, the outcomes of the patients were in the middle. And in the low-rate areas — less frequent operations per capita — the outcomes were the best."

The reason that areas with more back surgery did worse, Keller says, is that doctors in those areas were operating on people whose issues were less severe; that is, patients who might not have been good candidates for an operation. So the problems associated with the surgery probably outweighed the problems of their actual sickness. For them, more wasn't better.

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In 2003, there was an enormous landmark study published by a Jack Wennberg protege named Elliott Fisher, who works at Dartmouth College. Fisher compared Medicare recipients with similar levels of sickness in areas throughout the whole United States. Fisher looked at places where elderly people used relatively few health care services and compared them with places where elderly people used a lot of health care services.

"The patients in the high-spending regions were getting about 60 percent more care; 60 percent more days in the hospital; twice as many specialist visits," Fisher says. "And yet when we followed patients for up to five years, if you lived in one of these higher-intensity communities, your survival [rate] was certainly no better, and in many cases a little bit worse."

This is probably because of a something called fragmentation of care. In high-use areas, it's often the case that many different doctors play a role in the care of a patient; many specialists are responsible for overseeing only a small part of the person. This increases the amount of treatments, tests and hospitalizations that people get, and exposes people to more risk of harm from medical error and side effects.

For most Americans this is an incredibly difficult idea to accept: It's hard to understand that more care isn't necessarily better for you.

But study after study has borne out the truth of this completely anti-intuitive conclusion. In fact, Fisher and other researchers estimate that almost one-third of the care given in our country today is that kind of care — care that isn't really helping people.

The United States spends more than $2 trillion on health care every year. So the cost of that 30 percent unnecessary care annually? $660 billion.