Variation in Health Care—Good, Bad, or Inevitable?
Sean Evans, a professor of political science at Union University, published a great article in The Jackson Sun on March 11th. He notes the current political argument between the two major parties about health care produces four central questions. First, should we provide universal coverage or universal access? Second, how much is America willing to pay for universal health care? Third, who should pay for expanded health care? Fourth, who should control health care decisions? Prof. Evans compares and contrasts the Republican and Democratic answers to these questions, but like a good professor, he also does not try to judge which answer is “better.”
I certainly don’t pretend to have the answer, but it is obvious that money, and how it is to be spent, are central to the first three questions, and certainly it is concern over money which drives much of the pressure being applied to physicians and health care systems every day. Which leads me to a consideration of the problem of variation in health care.
An economic analysis of Medicare data suggest a range of price-adjusted per member expenditures from $7,000 to $14,000 per year that patient acuity and poverty NOT explaining much of the variation. So what does account for the variation? The authors set out to see if they could define, by survey methodology, how much variation was based on physician belief and how much was based on patient preferences. They concluded:
“Ultimately, the largest degree of regional variation appears to be due to differences in physician beliefs about the efficacy of particular therapies. Physicians in our data have starkly different views about how to treat the same patients, and those views are not highly correlated with demographics, background, and practice characteristics, and are often not consistent with professional guidelines for appropriate care. As much as 36% of end-of-life Medicare expenditures, and 17% of overall Medicare expenditures are explained by physician beliefs that cannot be justified either by patient preferences or by clinical effectiveness.”
The authors go on to divide physicians into “cowboys” and “comforters.” The cowboys usually recommend care that is more aggressive than guidelines would suggest, while the comforters tend to recommend more palliative care. Of course, the differences are more at the extremes, as most physicians fall somewhere in the middle. However, the difference from a cost perspective were important: a 10% increase in the percentage of cowboys in a given area increased expenditures by 7.5%, while a 10% increase in comforters decreased expenditures by 4.1%. They conclude by noting the differences in percentages of cowboys and comforters is NOT explained solely by economic incentives—it is beliefs about efficacy that seem more dominant.
On the other hand, Hartzband and Groopman note in a New York Times opinion piece that:
“Contracts for medical care that incorporate ‘pay for performance’ direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice…
When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.
We fear this approach can dangerously lead to “moral licensing” — the physician is able to rationalize forcing or withholding treatment, regardless of clinical judgment or patient preference, as acceptable for the good of the population.”
A similar notion was expressed by Jauhar a month later in the same forum.
“In American medicine today, ‘variation’ has become a dirty word. Variation in the treatment of a medical condition is associated with wastefulness, lack of evidence and even capricious care. To minimize variation, insurers and medical specialty societies have banded together to produce a dizzying array of treatment guidelines for everything from asthma to diabetes, from urinary incontinence to gout.
At some level, this makes sense. Some types of variation are unwarranted, even deadly…But the effort to homogenize health care presumes that we always know which treatments are best and should be applied uniformly. Unfortunately, this is not the case. The evidence for most treatments in medicine remains weak. In the absence of good evidence recommending one treatment over another, trying to stamp out variation in care is irrational.
Even in my field, cardiology, a paragon of evidence-based medicine, most treatment recommendations are based on expert opinions, not randomized controlled trials. Rarely is there one best option. This is a basic conflict in modern medicine: treatment uniformity, which aims to optimize population health, versus treatment variation, which aims to respect individual choice. There is no obvious solution to this conflict, but the resolution will determine what medical care is going to look like in 10 or 20 years.”
More than a decade ago, Gabbay and May published a paper in the British Medical Journal that has not received much attention in the mainstream medical literature regarding guideline versus patient-centered care. They noted there was a knowledge-management literature from non-medical sources suggesting tacit, rather than explicit research-based knowledge underpins much professional work. From their study, they concluded this was true in this medical practice as well.
“Primary care clinicians work in “communities of practice,” combining information from a wide range of sources into “mindlines” (internalised, collectively reinforced tacit guidelines), which they use to inform their practice.”
So is variation good, bad, or inevitable? I think it is the latter—we are never going to know “all there is to know” about a given condition and its “proper” treatment, much less the problem of individual patient preferences and biological idiosyncrasies. Since it is inevitable, a more productive conversation might be “How much variation is acceptable?” or “When is variation good and when is it not?” As an example of the latter, we could use vaccination of children. Some parents are withholding vaccination against contagious diseases that can become public health threats, but enrollment in public schools requires that a child be “up to date” on his/her vaccinations. As physicians, we would probably argue that this variation is unacceptable. On the other hand, deciding whether or not to pursue aggressive surgery in the setting of advanced cancer might be highly variable, and we would decide this is acceptable.
Like in the health care funding debate, when we consider the problem of variation, we find more questions, not answers. At the macro-economic level, we might decide that we would not pay for certain medical interventions in certain circumstances, but at the individual patient level, we would still want the decision made by patients, families, and physicians. Similarly, we might decide that we want lower levels of variation in healthcare spending at the level of the metropolitan statistical area, but would accept higher amounts of variation at the level of the individual physician. Just as in the health care funding debate, we risk getting into trouble if we insist too rigidly on “the one best way” to address the issue.
12 March 2017
 Evans, S. Health Care Debate Spawns Questions. The Jackson Sun, Saturday 11 March 2017, p. 11A.
 Cutler D, Skinner J, Stern AD, Wennberg D. Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spending. National Bureau of Economic Research, Cambridge, MA, August 2013. http://www.nber.org/papers/w19320.
 Hartzband P, Groopman J. How Medical Care is Being Corrupted. The New York Times, 18 Nov 2014. http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is-being-corrupted.htm
 Jauhar S. Don’t Homogenize Health Care. The New York Times, 10 Dec 2014. http://www.nytimes.com/2014/12/11/opinion/dont-homogenize-health-care.htm.
 Gabbay J, Le May A. Evidence Based Guidelines or Collectively Constructed “Mindlines?” Ethnographic Study of Knowledge Management in Primary Care. BMJ 2004 (30 Oct);329:1013. Accessed at bmj.com.
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