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E D I T O R ' S N O T E
V A R I A T I O N S
W E B E X C L U S I V E
7 October 2004
Editor's Note
Thirty-one years ago,
researchers Jack Wennberg and Alan Gittelsohn began what has become a long
odyssey to better understand the distinctive variations in clinical practice
patterns that characterize medical care in the United States. By publishing
their landmark paper in Science (14 December 1973), they launched
a new chapter of health services research in relation to clinical care. In
1984 the editors of Health Affairs, struck by how resistant providers
and patients were to addressing unwarranted practice variation, devoted a
thematic issue to the subject (Summer 1984). Fast forward to today, and one
can only marvel at how little variations that are unexplained by, as Wennberg
notes (p. VAR-140), "illness, patient preference, or the dictates of
evidence-based medicine" have been reduced.
With the publication of these papers, Health Affairs is once again
lending its voice to the dialogue on variations. But for several reasons, this
time the opportunities for real change
seem more promising. First, Wennberg and his colleagues at Dartmouth Medical School
have developed methods to link the practice variations with specific hospitals
and physicians, and they plan to make provider-specific information available
as part of the Dartmouth Atlas of Health Care project. As they note,
provider-specific information can be used to identify efficient providers within
a given region and should prove useful in configuring provider networks. Second,
the opportunity to use this information to guide improvement is reinforced
by the work of Elliott Fisher and colleagues, which shows that the problem
of variation in intensity of treatment for chronic illness is primarily a problem
of overuse and waste, not underuse and health care rationing. Third, as discussed
in several papers, the puzzling problem of geographic variation in elective
surgery is better understood and the value of shared physician-patient decision
making, more firmly established. And fourth, the critical importance of creating
economic incentives to reward providers who reduce unwarranted variation and
the need for Medicare to assume greater leadership is increasingly recognized
by payers and Congress alike. In the November/December 2003 issue of Health
Affairs,
fifteen prominent health policy figures, including Wennberg, signed an open
letter to the Centers for Medicare and Medicaid Services (CMS) urging Medicare
to assume more aggressive leadership in the "pay for performance" effort.
The publication of these papers was made possible through a grant from the
WellPoint Foundation. Articulating his own perspective, Leonard Schaeffer,
chairman and chief executive officer of WellPoint Health Networks, asserts
that only a real commitment and cultural change will lead to the necessary
transformation of the health care system (p. VAR-117). We also owe thanks to
Robert Berenson of the Urban Institute, who served as our editorial adviser for
this special collection of papers.
Over the course of Wennberg's long pursuit, research on practice variations
could not have continued at its vigorous level without the support of the Robert
Wood Johnson Foundation (RWJF), which has invested almost $10 million in this
effort during the past decade. The RWJF has been particularly supportive of
the Dartmouth
Atlas, a treasure trove of data on practice variations, and of research
that examines how variations influence the racial and ethnic disparities that
plague the health care system.
The RWJF's commitment to building greater understanding of practice variations has
begun to attract support from other major stakeholders. Aetna, UnitedHealthcare,
and WellPoint have all pledged support to the Dartmouth group. Congress, in
part because of the persistence of practice variations, has begun to take greater
note of the critical need to accelerate efforts to improve the health care
delivery system. As Paul Harrington explains (p. VAR-136), Section 646 of the
Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003
directs the CMS to test new systems of care through collaborations with medical groups
that are willing to become more accountable for their clinical performance.
While these papers document more clearly the impact of unwarranted variations,
until the public firmly grasps their importance, progress on reducing them
will be limited. As Wennberg notes: "Making the practice-pattern story
real to Main Street would be a giant step forward in building the constituency for
change."
John
K. Iglehart
Founding Editor
DOI: 10.1377/hlthaff.var.3
©2004 Project HOPE–The People-to-People Health Foundation, Inc.
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