09/22/2009 04:14 pm ET Updated May 25, 2011

Doin' The Health Reform Hokey Pokey

Our ability to constrain American health spending may lie in the answer to one basic -- and increasingly contentious question -- whether patients with the same condition basically get the same care whether they are treated by doctors and hospitals in Manhattan or Minneapolis.

If they do, we've got a serious problem and will have to drastically ratchet back our anticipated savings from estimated efficiencies. If they don't -- a position embraced by President Obama and those around him -- savings exceeding 25% are very possible, albeit difficult to achieve.

This is quietly becoming the Big Issue in the health reform debate and pits reformers against respected physicians and hospitals who require a very different response than the one used on cable television yellers who fixate on death panels.

Among those pushing reform there's a belief that up to 30% of what is spent in high-cost areas like New York, Miami and Boston goes for care that's unneeded and does nothing to improve outcomes. If all patients could be treated in a way already typical in low-cost areas like Minneapolis and Santa Fe, reformers say, care would be much more affordable.

The challenge, they say, lies in transplanting the patterns already typical in the low-cost areas to the high-cost areas, which no one thinks will be easy. That's what feeds the focus on evidence-based medicine.

Unsurprisingly, those providing care in high-cost areas, who tend to be quite sophisticated from both medical and media perspectives, have begun to challenge this logic. They provide more care, they argue, because their patients are sicker to begin with. The reject the idea that they could do significantly less without jeopardizing their current outcome record.

If they are right, it is very hard to see how we can constrain exploding health spending. If they're wrong, the task is difficult, but at least definable. Fortunately, there's reason to conclude they are wrong. Unfortunately, given the stakes, there's little chance they'll quickly retreat.

The case for geographic disparities has been repeatedly and painstakingly made for more than 30 years by Dr. Jack Wennberg and this colleagues at Dartmouth. Their basic conclusion is that there are cultural "patterns of practice" that differ significantly one from one market to another and are driven largely by supply. If you have more physicians and hospital beds in a region, they conclude, you're likely to have more physician visits, tests and procedures.

Their most controversial conclusion is that this disparity influences spending, but not outcomes. Patients treated in areas where care is less extensive and aggressive tend to recover just as quickly, they just come away from the experience with significantly fewer bills.

There's also evidence that institutions that pay doctors salaries tend to do less while providing high quality care. The Cleveland Clinic and the Kaiser operations in California are often cited. But the leading poster child for efficient care is the Mayo Clinic, which not only has a reputation for providing high-quality care using salaried physicians, but also has the good fortune to be located in the Minneapolis area, where there's a generally a very conservative pattern of practice.

Over the years, there have been some efforts-- basically unsuccessful -- to challenge the Wennberg data, but the topic was largely academic, because it ultimately didn't make much difference. No one was lowering the boom on high-cost areas. Now that there's a real threat and it is a creating a powerful backlash challenging the Wennberg thesis, which argues, among other things that supply drives demand and that an area with many doctors and hospital beds will host many more expensive procedures than one with fewer medical personnel.

The difference between a high-cost area like New York or Boston and a low-cost one like Minneapolis of Santa Fe, they say, has little to do with wage disparities and a lot to do with the number of tests and procedures are done. The major difference is not that a CAT scan in Santa Fe is cheaper (it is) because of lower wages there, but rather that many more of them are done in New York.

If you could introduce Minneapolis medicine to Miami, reformers note, Medicare could save millions. That's an attractive idea, although no one quite knows how to implement it.

Some, including those who practice in high-cost areas, think the Mayo story is a bit distorted and have begun to fight back . They question not the quality of Mayo medicine but rather the composition of its patient population. To put it simply, they argue that Mayo is caring for people of at least middle-class backgrounds who have lived reasonably healthy lives and had the protection of health insurance. Given the low uninsured rate in Minnesota, there's probably at least some truth to that.

The broader argument is similar, suggesting that there's less care delivered in Minneapolis than New York, not because the doctors are more cautious, but more often because the patients are healthier. You don't have to be a conspiracy theorist to acknowledge that similar articles have appeared in recent weeks in the New York Times and Los Angeles Times The expensive big-city hospitals are fighting back now that they realize that reform efforts today are a major threat.

Basically they say that the data Dartmouth data is not adequately adjusted for health status and that the reason patients in the Bronx have longer hospital stays, more surgery and added tests is that they're sicker than patients in Minnesota, not because the doctors have different patterns of practice. This is a key point and one, alas, that most of us civilians are incapable of judging. Suffice to say that previous efforts to undermine the patterns of culture argument using this argument have failed.

From a narrow procedural perspective, this is disturbing because it seems to be yet another successful effort to move the debate out of a public, English-speaking forum into a private, credentialed one bounded by jargon. That leaves me uncomfortable, not only because it bars me from participation, but also because it gives the parties at interest control and suggests a very long time frame.

But the stakes are greater. If the one recipe we have for greater efficiency is discredited, that sets the whole quest for efficiency back by decades while sending a signal that any effort that requires any participant in medicine to make significant changes will probably provoke a similar nasty response.

In an effort to fight against the trend toward jargon, let me put this in language than anyone familiar with Hokey Pokey will readily understand -- that's what its all about.

More of my analysis of the health reform debate can be found at