Inaugurating Health Care Reform: Cause and Effect Techniques in Managed Care in 2010 (Part I-e)

February 12, 2009

The theory of 'small area variation analysis,' developed by Dr. Jack Wennberg of Dartmouth is fundamental for healthcare reform, but it's on the back shelf.

The theory of 'small area variation analysis,' developed by Dr. Jack Wennberg of Dartmouth is fundamental for healthcare reform, but it's on the back shelf.

"Wennberg and his colleagues at the Center for Evaluative Clinical Sciences at Dartmouth Medical School have demonstrated that physicians in many communities are providing too much care that has little, if any, impact on health, and may even be harmful. They make the case that the health care system could save a considerable amount of money without sacrificing quality if excessive and unnecessary care were [sic.] eliminated. At the same time, they have shown that many physicians do not deliver the kinds of basic care that are known to be beneficial to patients. While Wennberg’s work on variation of health care has been widely recognized by health policy experts, it has had little influence on medical practice. The same is true of the chronic care model... This lack of acceptance points up the challenge of changing behavior and systems in ways that will provide high-quality care to patients and allocate limited health care resources wisely."

"The Dartmouth Atlas of Health Care" by Carolyn Newbergh

Reference: Wennberg JE and Gittelsohn A. “Small Area Variations in Health Care Delivery.” Science, 182: 1102—1108, 1973

How far have we come since Wennberg's revelations? Not very far as you can see from the following:

David Leonhardt in "The Big Fix" did not even acknowledge Wennberg as he discussed a take on 'unwarranted variation' by Peter Orszag, current analyst for Obama and former Director of the Congressional Budget Office under Clinton.

As Leonhardt describes it, Orszag would put up a map of the United States and show Medicare spending by region with the higher-spending places, differentiated from the lesser-spending ones. He would then make it clear that the variation isn't explained by the health of the local population or the quality of care it is receiving. That is, the higher spending regions didn’t necessarily have the sicker patients; nor did those populations necessarily receive superior care. Moreover, physicians who "spent more—on extra tests or high-tech treatments, for instance—didn’t get better results than their more conservative colleagues. In many cases, patients of the aggressive doctors stay sicker longer and die sooner because of the risks that come with invasive care."

It was 'déjà vu all over again' [a Yogi-ism]) when Orszag presented points of unexplainable variation in the healthcare scene. Forgive me, but 35 years ago variation analysis was a basic managed care tool, if not the reason for managed care's very existence—Find the variation; control the quality by reducing unwarranted variation, doggedly improve the outcome and then and only then, the cost (at least in theory).

** I suppose if they let me really do it that way, I'd still be a medical director—no regrets, however, after 3 decades of hitting my head against the wall. **