July 2008
Why the differences?
In some areas of the country, seriously ill patients have trouble escaping futile and often painful overtreatment. Jean Callahan,
a social worker and attorney with the Vera Institute of Justice, a New York City public-interest group, became the court-appointed
guardian for a 90-year-old bedridden woman so completely unresponsive that Callahan never even found out whether she spoke
English. She had a feeding tube, but her stomach could not process the food. Both feet and lower legs had gangrene. The woman's
doctors "brought us into the case to consent to the amputation of one of her legs, but because the hospital considered the
surgery to be life sustaining, we didn't really have the legal power to say no," Callahan says. "It was obvious to everyone
around her that she was dying, but when we attempted to have her moved to hospice, the doctor said, 'No, I don't think she's
ready.' They eventually amputated both of her legs, and she continued to get aggressive treatment, including intravenous antibiotics.
In the end, she died of an infection."
So, why does the health-care system serve up so much more care in New York than in Iowa? "Doctors decide who needs health care, what kind, and how much but have surprisingly little information on what the 'right' amount actually is," says Dartmouth's Wennberg.
If a patient has heart failure, there is little valid evidence, and no clear rules, about when to ask a patient to return for a follow-up visit, when to hospitalize him, or at what point to admit him to the ICU. "When faced with the uncertainty of medicine, physicians will use available capacity up to its point of exhaustion, no matter how much capacity there is," the Atlas says.
Also, most American doctors are paid per visit, test, or procedure, rather than being on a salary. So the more they do to patients, the more money they make.
"If you live in Fort Myers, Fla., you're two or three times more likely to get your knee replaced than if you live in Miami," Wennberg says, "because there are more orthopedic surgeons in Fort Myers on the lookout for patients than there are in Miami."
The exception to this rule helps prove it. A few common conditions—fractured hips and appendicitis, for instance—have a clear-cut diagnosis, and the need for hospitalization is universally accepted. Regardless of the local supply of hospital beds, the rates of initial hospitalization for those conditions are virtually identical in all regions.
So, why does the health-care system serve up so much more care in New York than in Iowa? "Doctors decide who needs health care, what kind, and how much but have surprisingly little information on what the 'right' amount actually is," says Dartmouth's Wennberg.
If a patient has heart failure, there is little valid evidence, and no clear rules, about when to ask a patient to return for a follow-up visit, when to hospitalize him, or at what point to admit him to the ICU. "When faced with the uncertainty of medicine, physicians will use available capacity up to its point of exhaustion, no matter how much capacity there is," the Atlas says.
Also, most American doctors are paid per visit, test, or procedure, rather than being on a salary. So the more they do to patients, the more money they make.
"If you live in Fort Myers, Fla., you're two or three times more likely to get your knee replaced than if you live in Miami," Wennberg says, "because there are more orthopedic surgeons in Fort Myers on the lookout for patients than there are in Miami."
The exception to this rule helps prove it. A few common conditions—fractured hips and appendicitis, for instance—have a clear-cut diagnosis, and the need for hospitalization is universally accepted. Regardless of the local supply of hospital beds, the rates of initial hospitalization for those conditions are virtually identical in all regions.
