There is a big debate going on now about how to control health care costs. (Surprised?) Obama has been relying on the Dartmouth Atlas project by John Wennberg to support his assertion that there is enormous waste in the medical system that varies by geographical region that needs to be curtailed. Gardiner Harris, a reporter for the New York Times, has taken issue with this assertion and lobbed criticism at some of the underlying assumptions in the Dartmouth Atlas project. Congress has started looking to control costs by enforcing reductions in higher costs areas like New York. Not so fast says the NY Times. Increased cost may also reflect higher quality care and before we act on data, we need to make sure we have it right. Merrill Goozner, has a good post on Gooznews dissecting the debate. I have followed Wennburg’s work for years and offered my 2 cents on his work and its implications for patients who need to have treatment options available. This debate is at the core of quality healthcare and individualized patient needs. My comments posted on the Goozner site as well as links for all follow the jump.

Merrill Goozner, Doing Their Homework: Times Reporters Respond in Dartmouth Atlas Spat.

Gardiner Harris, Report Cited by Obama on Hospitals Is Criticized, NY Times 2/18/2010

My comment

 My understanding of Wennberg’s work is that he says there are three reasons for geographic variation.  One is over-utilization of services (aka waste).  The second is under-utilization of services (aka the poor or rural communities that lack certain medical equipment) and the third is preference-based care.  This last is very important.  He says that when medicine is uncertain and more than one viable treatment approach exists (think breast cancer and prostate cancer), the treatment option belongs to the patient in consultation with the treating physician and that variation because of this is acceptable variation.  This is because risk/benefit decisions need to be made at the individual level taking into account how ill this patient is, whether they have responded to certain treatments in the past, what allergies or other side effect issues they may have, and their values. 

Much of medicine is unknown; treatment studies cannot be done to resolve every question; science shifts and changes–variation based on individualized care is important.  Another point he made was that patients, given the choice, commonly choose less invasive and, therefore less expensive care.  This year my mom died and the entire family was against invasive measures that might prolong a life that lacked quality and had suffering.  I see this shift in thinking more and more–patients don’t want to bankroll services that don’t restore health or improve quality of life.

A recent article by Dr. Stricker and me in Philosophy, Ethics, Humanities and Medicine focuses on medical guidelines when there is scientific uncertainty and when treatment options should be preserved for the patient.  This is a critical question in medicine today.

 You can follow additional comments on Lyme policy at www.lymepolicywonk.org.  You can contact Lorraine Johnson at lbjohnson@lymedisease.org.