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The health care debate centers around lots of things, but mostly it's about money. We've all heard that health care in this country is incredibly expensive. It takes up one out of every $6. NPR's Alix Spiegel has spent the last couple of months trying to understand why health care is so expensive by stripping the issue down to its most basic parts. Today, she has some answers, and her focus is doctors.
ALIX SPIEGEL: To understand the complex role of doctors in shaping the cost of medicine in this country, let's go back to 1974 to the small working-class river town of Lewiston, Maine, and a young woman with a sharp pain in her abdomen.
Ms. ROXANNE TREMBLAY: I was having a lot of problem, just a constant ache right here that never went away. And my boss kept saying, you should go get that checked. You should go get that checked. 'Cause I was like doubling right over. It was like a really, really deep ache all the time.
SPIEGEL: In 1974, Roxanne Tremblay was 29 years old, a frazzled single mom living in a modest, walk-up apartment. Roxanne was the only one supporting her young daughter, so she had to be able to work and the pain was getting in the way. So Roxanne went to see her gynecologist, a personable man who impressed Roxanne and made her feel at ease. The doctor did his examination then announced that Roxanne would need an operation. Three weeks later, Tremblay had her uterus and ovaries removed - a total hysterectomy, after which her doctor explained what he'd found.
Ms. TREMBLAY: It was what he called the seed of cancer. It wasn't cancer, but it had the potential of developing into it.
SPIEGEL: Now, Roxanne didn't mind having a hysterectomy. She never planned to get married or have kids again. But she was slightly surprised that her doctor had been so quick to operate, and before surgery, hadn't taken any X-rays or anything.
Ms. TREMBLAY: And no pictures. No.
SPIEGEL: He just felt your…
Ms. TREMBLAY: And based on what I told him then, it just come out.
SPIEGEL: Twenty-nine years old is pretty young for a hysterectomy, but in the mid-'70s in Lewiston, Maine, lots of women were getting them. Roxanne herself knew a bunch.
Ms. TREMBLAY: My boss that I had when I worked at Kmart, she had one shortly after I did. One of my friends that I've had since I was 6 years old, she lives right five minutes from here, she had one. Just about anybody you talked to would say, oh, I had a hysterectomy. Oh, yeah, so I did. So and so did mine. Or I just remember there was a lot of them. I do remember that.
SPIEGEL: Now, back in those days, most Lewiston women, including Roxanne, weren't suspicious about the number of hysterectomies. But there was someone, a health researcher in nearby Vermont, who was in interested - very interested in health statistics of every kind. His name was Jack Wennberg. And by the mid-'70s, he'd compiled data about health care practices in cities all over the State of Maine, including data which showed that in Lewiston, an unusually large number of women were having their uterus removed. He projected that if the rate of surgeries continued, 70 percent would have a hysterectomy by age 70.
Now, eventually Jack Wennberg expanded his research, and that led us to a clear understanding of what doctors and hospitals are doing with their patients all across America. So if you want to investigate doctor decisions, Jack Wennberg is a pretty good place to start, which is how I ended up in his living room.
This is me trying to set the levels on my recording equipment. To do this, I asked Wennberg what I ask most people: could you say a little something. Usually, people count to 10. Maybe they'd tell me what they ate at breakfast. But for Wennberg, a lank 75-year-old, breakfast wasn't the first thing that came to mind.
Dr. JACK WENNBERG (Founding Director, Dartmouth Atlas of Health Care Project): (German language spoken)
SPIEGEL: Nineteenth century German poetry. Apparently, for fun in college, Wennberg committed German verse to memory. Wennberg is that kind of guy - the kind of guy whose projects tend to be unusually rigorous. This was certainly the case with his work on health care. You see, Wennberg started out in the late '60s with his federal grant to improve Vermont's health care system. But because he's such a thorough type of fellow, he made a kind of crazy decision. He decided he'd try to collect information about every medical transaction of every person in every town in the whole state of Vermont. That way, he'd know what was going on.
Dr. WENNBERG: What was going on in home health agencies, what was going on in nursing homes, hospitals, doctors' offices, and we need to know for each patient what their diagnosis is, what their treatment was, how much money was spent, and what the outcomes were in so far as we could actually measure them.
SPIEGEL: Now, to collect these records Wennberg hired a bunch of researchers, people dubbed The Pit Crew, who year after year were sent out to medical records rooms to collect records. It was a massive undertaking: every medical transaction in the State of Vermont. It took two years of road trips just to collect the records for 1969. But once he had all the information, Wennberg began to slice it and dice it in all kinds of ways. And what immediately jumped out was that from one town to another, medicine in Vermont was practiced entirely differently.
Dr. WENNBERG: As soon as we set out to do the analyses, we began to see these extraordinary differences.
SPIEGEL: People in one town might get their hemorrhoids removed five times more often than people in another town, only 30 miles away. Ditto with mastectomies, prostate operations, this was even the case in Jack Wennberg's own town.
Dr. WENNBERG: We live right on the boundary between Stowe and Waterbury Center, Vermont. And if my kids had been going to the school system in Stowe, they would have had a 75 percent chance of getting their tonsils out. If they'd gone to the Waterbury School — where they actually did — it was about 20 percent.
SPIEGEL: Wennberg, of course, wanted to figure out what was going on. And there was one explanation that almost everyone around him leaped to: it was the patients. People in some areas were just much sicker than people in other areas, or maybe they just wanted more services for some reason. Which takes us back to the city of Lewiston, Maine, and yet another Lewiston woman relieved of her uterus in the 1970s.
(Soundbite of barking dogs)
Ms. CAROL BRADFORD: My little dogs are freaking here.
SPIEGEL: Oh, hi there, little dogs.
Ms. BRADFORD: Come in. Come in. You found me.
SPIEGEL: I did, not very hard.
Carol Bradford is a church lady, the kind of woman who takes in strays and carries food to elderly neighbors. Carol, like Roxanne Tremblay, had a hysterectomy in the mid-'70s and is perfectly happy with the results. She had some benign growths on her uterus. But when I asked Bradford a theory about why there was such a high hysterectomy rate in Lewiston back then, Lewiston, she explained, is mostly Catholic.
Ms. BRADFORD: Some women were having too many children. You know, there are families here with 10, 12 children. It's a possibility that women came to the point where they just really couldn't deal with any more children, you know, and were begging the doctors to do something about it. You know, that's my personal opinion.
SPIEGEL: Well, it's not just her opinion. Most people assume that when you go into a doctor's office, the doctor simply responds; responds to sickness in your body, responds to the needs and concerns that you have. But in his work in Maine and Vermont, Wennberg demonstrated that it's a lot more complicated than this. The women of Lewiston, Maine, weren't having more hysterectomies because more of them were Catholic or because more of them were sick. Wennberg showed that in terms of sickness and demographics, the populations of different towns in Maine and Vermont were actually remarkably homogenous, which according to Jack Wennberg could mean just one thing: it wasn't the patients.
Dr. WENNBERG: We could easily see that it wasn't that patients were different between regions. So it wasn't the illness that was driving this. This must be coming from the provider side.
SPIEGEL: That was the first insight; that it was doctors, not patients, that drove medical consumption. Sickness and patient preference played a role, but a much smaller role than we originally thought. So here is the big question: why do doctors make the treatment choices they make? Is it training, money? Well, the answer to that question can also be found in the state of Maine. You see, almost 30 years ago, inspired by the work of Jack Wennberg, a group of Maine physicians undertook this incredible experiment. They decided that they themselves would discover the reason why there were such strange variations in medical treatment. To do this, they decided that doctors from all over the state would gather together by specialty four or five times a year. The doctors were supposed to sit down together, look at Maine city by city, then hash out why the care they were giving was so different, a kind of Talmudic dissection of doctor choice. And so the doctors did meet. And in these meetings, there was one thing above all that they agreed shaped decisions.
Gordon Smith, who worked on this project and is now head of the Maine Medical Association, told me that initially, the doctors were absolutely convinced that the most important thing was training in medical school and residency.
Dr. GORDON SMITH (Executive Director, Maine Medical Association): The way you were trained. Maybe you were at a particular training program that does things a certain way, and then you bring that back to your community.
SPIEGEL: But what was strange, says Bob Keller, another doctor who participated in the groups, was that during the meetings, the doctors mostly seemed to agree on how to approach the medical conditions that their patients presented, seemed to agree on when it was appropriate, for example, to go ahead with surgery.
Dr. BOB KELLER: In a meeting, they'd all say, oh, we all - absolutely, I agree. That's what - you need to have three months of pain, for example, or you need to have a certain physical finding. And if you didn't have it, you wouldn't do it. Well, that may be what they would agree on, but in fact, when you were able to use data later, you would find that it didn't always work that way, that the standard got tilted sometimes pretty significantly.
SPIEGEL: In practice, in the privacy of their own offices, they were often doing something completely different from what they said that they should do, something completely different from what they themselves thought they would do when they talked in these meetings. So why were their behaviors in practice so different? One possible explanation was fear of lawsuits. When actually face to face with a patient, some doctors got worried that if they didn't do every possible thing, they might get sued. Temperament played a role. Some doctors were just much more eager to take action. And then there was the role of local medical culture. For instance, Bob Keller says that pediatricians in some communities feel they absolutely had to send even mildly sick kids to the hospital because that's what the doctors there had always done, and families had come to expect it.
Dr. KELLER: People were very clear on that, that families in small Maine communities were used to the fact that if their kid had a temperature of 102 and had nausea and vomiting, they were going to go down to their primary care doctor, their pediatrician, and that kid was going to go into the hospital, and they've been doing it for years. And so they would be aghast if they took little Tommy down, and he had a temperature of 102 with nausea and vomiting, and the doctor said, well, go home and take this. Nobody did that.
SPIEGEL: Now, it's probably safer and less expensive not to put the kids in the hospital, and the doctors knew this. But doctors, like the rest of us, are people, and therefore, subject to subtle influences.
Here's another example: One of the many doctors I talked to while I was in Maine was an eye specialist named Frank Read, another doc from the study groups. He told me this story.
Dr. FRANK READ: My old partner that I joined here in 1971 was asked by a friend of his, you know, at what level of vision do you do a cataract operation? And he said, well, if there's one ophthalmologist in town, it's 20/200.
SPIEGEL: 20/200 is pretty bad vision.
Dr. REED: If there are two ophthalmologists in town, it's 20/80.
SPIEGEL: Not so bad.
Dr. REED: If there are three ophthalmologists in town, it's 20/40.
SPIEGEL: Pretty good vision, actually. In other words, when there are more doctors, surgery is being done on patients that are less sick. According to later work done by Jack Wennberg, the number of doctors in a town can influence the amount of medical services consumed across the board. If there's one doctor in a town with 100 patients, then he might schedule your heart checkups for once every six months. If another doctor comes to town, and now the first doctor has 50 patients, he'll just schedule your heart checkups for once every three months for a very simple reason, Frank Read says.
Dr. READ: I don't want to be sitting on my thumbs all the time. I want to be busy. And that may unconsciously loosen my criteria for doing a particular procedure.
SPIEGEL: Which brings us finally to the subject which incredibly was never, ever directly discussed during the nearly 20 years the doctors met: money, the way money affects medical decisions. Frank Read and Bob Keller told me that this subject was completely verboten.
Dr. KELLER: We didn't want to talk about money. That's something that we wouldn't want to acknowledge because it would have been a showstopper. I mean, it would have then gone right to the question of greed, and you're not going to keep a doc at the table if you say you're greedy.
SPIEGEL: Doctors are uncomfortable acknowledging the role of money, but every person I talked to admitted it affected medical decision-making, including Gordon Smith, head of the Maine Medical Association.
Dr. SMITH: Of course, it does. That's just common sense. That's human nature. The payment system is an important influence.
SPIEGEL: As you might know, most of the doctors in this country are not on salary but are paid basically like pieceworkers in a clothing factory. It's called fee for service. And the way this affects their behavior is clear. Gordon Smith.
Dr. SMITH: If you pay people more the more things they do, they're going to do more things.
SPIEGEL: And not all kinds of services are paid the same. See, on the most basic level, your doctor is either thinking, talking, advising you, or doing something to you, the procedure. For years, public health experts have agreed that when doctors have the time to do stuff like counsel you about your health behaviors, keep track of your medications, it's better for patients. Still, between talking and procedures, there is no question about which activity is better rewarded by our current payment system. Gordon Smith.
Dr. SMITH: Procedures. Procedures. That produces revenue.
SPIEGEL: And the more complicated the procedure, the higher the payment. Makes sense. But it has this unintended effect on care. Bob Keller points to his own specialty. He's a back doctor and says that one of the most frequently done operations among back doctors these days is this complicated and pretty expensive procedure called an instrumented spinal fusion. When a patient has degenerative disk disease, the doctor can go in and insert medal rods. Keller says in the old days, doctors used a much simpler and safer operation, but the more complicated one has a clear advantage for doctors.
Dr. KELLER: The surgeons could charge more because they were doing these complicated procedures. And so they were putting the screws in. They bill for putting the screws in. They were putting the plates in. They bill for putting the plates in - doing all these things. So you had a whole new high-tech procedure that was enormously attractive to spine surgeons, and it literally took off in this country. At the same time, as most good spine surgeons will admit, they had no research to support what they were doing.
SPIEGEL: In fact, says Keller, one of the few high-quality studies that did exist showed it wasn't so positive.
Dr. KELLER: It showed that it isn't so great, actually, as people thought it was. And they also showed that interestingly enough, that the old-fashioned, non-instrumented fusion was as successful as the instrumented fusion, which was a real blow.
SPIEGEL: So it's pretty clear that doctors exist in a fee-for-service system that encourages, and really, because of malpractice and having to battle insurance companies, in some ways, actually forces them to do more, more and more complicated surgeries, more elaborate tests, more stuff of every kind. But while most Americans just assume that more care is good, it turns out more isn't always better for patients. This is a problem health policy experts have dubbed more is not better, and it brings us back to Lewiston, Maine, again.
Ms. NATASHA SAINT AMAND: I'm Natasha Saint Amand. I'm 25.
SPIEGEL: When I met Natasha Saint Amand, her brown hair was curled into loose ringlets and her make-up was picture perfect. I wanted to talk to her because of her experience with back surgery. You see, the rate of lower back fusions in Lewiston was much higher than in the rest of the state. Between 2003 and 2007, around 107 higher. On paper at least, Natasha was a candidate for high-tech fusion. That's because she got into a car accident five years ago and after that had serious pain in her back several times a week. Her doctor strongly recommended a fusion, so she got one, and then another, and then another, and then neck surgery. Now, she's in pain every hour of every day. She can't bend at her waist or at her knees, not from the original sickness, she says, but from the cure.
Ms. SAINT AMAND: I think it really hit me after my third back surgery and after I had my neck surgery. I think it really hit me that, wow, there is really not much I can do between the two. My leg is all nerve damaged. My lower back is nerve damaged. I have nerve damage in my left arm. There's really not much left that doesn't hurt.
SPIEGEL: It's easy to dismiss what happened to Natasha as poor quality medical care, surgeries that failed because they were poorly done, but it's probably more complicated than that.
A couple of years ago, Bob Keller and some colleagues did this really elegant study of one kind of back surgery in Maine, a procedure called discectomy. He found communities in Maine that had high rates of the surgery, communities with low rates, and communities that were somewhere in the middle. Then he followed patients who had surgery in those communities over a five-year period to see how they fared. This is what he found.
Dr. KELLER: In the high rate of surgery, overall, the patient outcomes were the least good of those three categories. In the middle rates, the outcomes of the patients were in the middle. And in the low rate areas, less frequent operations per capita, the outcomes were the best.
SPIEGEL: The reason that areas with more back surgeries did worse, Keller says, is because doctors in those areas were operating on people whose issues were less severe, patients who might not have been good candidates for an operation. So the problems associated with the surgery probably outweighed the problems of their actual sickness. That's why more wasn't better for them.
But this essential dynamic, that more isn't better, applies to much more than back surgery in Maine. In 2003, there was this enormous landmark study published by a Jack Wennberg protege named Elliott Fisher, who works at Dartmouth College. Fisher compared Medicare recipients with similar levels of sickness in areas throughout the whole United States. He looked at places where elderly people got relatively few health care services and then places where elderly people got a lot of health care services. Here's Fisher.
Mr. ELLIOTT FISHER (Dartmouth College): The patients in the high-spending regions were getting about 60 percent more care, so, you know, 60 percent more days in the hospital, twice as many specialist visits. And yet, when we followed patients for up to five years, the mortality rate, whether you were poor, rich, urban or rural, you know, if you lived in one of these higher intensity communities, your survival was certainly no better and, in many cases, worse.
SPIEGEL: This is probably because of something called fragmentation of care. In high-use areas, it's often the case that many different doctors play a role in the care of a patients. Many specialists are responsible for overseeing only a small part of the person, which increases the amount of treatments and tests and hospitalizations and exposes people to more risk of harm from medical error and side effects.
Now, for most Americans, this is an incredibly difficult idea to accept, that more care isn't necessarily better for you. But a number of studies have borne out the truth of this completely anti-intuitive conclusion. In fact, based on their studies, Fisher and other researchers estimate that almost one-third of the care given in our country today is that kind of care, care that isn't really helping people, almost one-third, care delivered by a system that pushes doctors towards more when less is probably better, care that costs the U.S. $660 billion a year.
Alix Spiegel, NPR News, Washington.
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