Yesterday, the Wall Street Journal attacked President Obama's plans for health care reform on the grounds that only the private sector and an environment where Americans are "exposed to the true cost of their care" can effectively regulate the cost of health care.
The White House has argued that regional variations in health care quality and cost show that health care reform can improve efficiency and quality in the health care system while cutting waste. Attempting to cast doubt on this claim, the WSJ suggests that variations in cost among regions are due to needed experimentation, not waste or greed:
Think about comparative effectiveness. Why is low-cost, high-quality Minnesota, say, already making more rational decisions than high-cost, lower-quality Texas? It's ridiculous to suggest that doctors in Rochester have access to clinical information that isn't available in Houston. If it's because the former are simply better physicians, well, medicine isn't Lake Wobegon, where everyone is the Mayo Clinic.
The reality is that after three decades of economic research, the reasons that spending varies are still highly uncertain. As in politics, everything is local in health care. Most of the variation is due to the use of services and mix of care that patients receive, while some relates to labor costs and local prices. The abiding mystery is why practice patterns oscillate so widely, even among hospitals in the same city.
Not surprisingly, variation is greatest when doctors don't agree on the best treatments — as with back injuries, for example. Another part is technology. New therapies are developed at an astonishing pace. Consider the stent, which props open arteries after a heart attack and was barely used in 1994. By 1998 stents were used in a majority of coronary surgeries. Constant innovation means that there must be trial and error, and thus regional spending variation.
Such technological change is the most important driver of health spending. Modern medicine can do so much more than it could in the past, but this costs a lot even as it has bought a lot in extending and improving lives. In a 2001 study, David Cutler (an Obama adviser) and Mark McClellan (a Bush adviser) found that the benefits of lower infant mortality and better treatment of heart attacks "have been sufficiently great that they alone are about equal to the entire cost increase for medical care over time."
No less an authority than Mr. Orszag admits that stomping out regional variation means constraining this experimentation. "Future increases in spending could be moderated if costly new medical services were adopted more selectively in the future than they have been in the past and if the diffusion of existing costly services was slowed," Mr. Orszag told Congress last year, when he was CBO director. He was careful to note that "savings are possible without a substantial loss of clinical value," but how does he know? Even if health planners in Washington could arbitrarily reduce spending in high-cost areas, low-value treatments may not be what go over the side.
The WSJ's speculations, however, are undermined by Atul Gawande's recent piece on extraordinarily high health care costs in the town of McAllen, Texas. Gawande delves into the cultural, institutional, and economic factors that drive doctors in certain areas to recommend more treatments and tests for their patients than many other doctors would consider necessary.
Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.
In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.
That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.
To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.
Far from proving the WSJ's thesis that regional variation in health costs owes to valuable experimentations in treatment, Gawande provides substantial evidence that costs rise in certain areas because of inefficiencies and perverse reward systems in the private health industry. Gawande and Dartmouth's findings strengthen the White House's case that a reformed health care system with a strong public option could improve care and reduce cost and ineffiency; the WSJ's assertions remain merely speculations. The sad case of McAllen, Texas reminds us that the current system is broken and unfair for many Americans, and that far from getting cutting-edge care, many of us are simply being overcharged, overprescribed, and underserved.