Here is a comment I posted on the NYT site in response to Gawande, Berwick, Fisher and McClellan's article "10 Steps to Better Health Care". Thought it was worth posting here because it brings together many of the arguments that I have been making piece-meal in multiple posts.
A great piece from a venerable group indeed, thanks! Clearly we are at a tipping point, since we have known about regional variations from Drs. Wennberg's and Fisher's work for nearly 30 years and have done nothing about it till now. The trajectory of growth of our national healthcare expenditures combined with the abysmal quality and worsening access have gotten us to this political nexus where inaction is not an option.
The two central problems that are driving the situation are 1). the profit motive and 2). fear of malpractice. The profit motive for all involved in the system has created an incentive to diagnose more disease to treat with therapies developed based on the market size rather than on real needs, to perform more procedures and to build a giant bureaucracy ostensibly for the sake of checks and balances, but in reality to increase the bottom line. As for malpractice fears, because our society simplistically thinks that more care is better care, doing more is the default.
In my mind, the Mayo system works well precisely because the profit motive has been removed for those on the ground. Take the market out of healthcare, and you have a model for success. Unfortunately, single payer has very little chance of passing, as it is a political third rail in the US. And tort reform? Well, we know that no one wants to tackle that either, for so many reasons. So, best we can do is to come up with a way of defining and promoting value-based healthcare (think comparative effectiveness). Within that we really have to quantify the harms inherent in overuse and misuse, so that we can start changing this culture of more is better.
For more on these issues see the following posts on this blog: http://evimedgroup.blogspot.com/2009/08/putting-sticker-price-on-healthcare.html http://evimedgroup.blogspot.com/2009/07/convenient-failure.html http://evimedgroup.blogspot.com/2009/07/is-useless-harmful.html