The Washington Post health section this week ran an essay by Darshak Sanghavi, a pediatric cardiologist and assistant professor of pediatrics at the University of Massachusetts Medical School. Sanghavi wrote about the work of the Dartmouth Atlas researchers who have found significant variations in what kind of care people get across the country, how much it costs, and what the outcomes are. In brief—we'll explain a bit more below—years of research by the Dartmouth team has found that more spending, more technology ,and more specialists doesn't equal better health care. They argue that Medicare could cut its costs by about a third and patients would actually fare better.

Sanghavi, pushing emotional buttons with the story of a 15-year-old boy who needed the highest of high tech medicine and machinery to save his life after a heart attack probably caused by a virus, concluded "the Dartmouth data encourage the notion that if the supply of specialists and hospital beds were suddenly cut, doctors might reserve fancy care for patients who really needed it, and thus costs would fall. But as Alex's case suggests, these cost controls will require hard choices—and, inevitably, haphazard rationing of health care."

We've paid a lot of attention to the Dartmouth work over the years and we don't see a call for rationing, let alone an exhortation to let teenagers die if saving them costs too much money. It's particularly puzzling because Sanghavi wrote an interesting article in Slate a few months ago making points that we think the team at Dartmouth would agree with—that doctors don't pay enough attention to primary care, that they make mistakes in treating common ailments, that perverse insurance rules force doctors to perform unnecessary procedures, etc.

As a brain surgeon who has spent the last few years working on health policy in Washington, I know that some physicians would like the work of Dartmouth Institute for Health Policy and Clinical Practice—better known as the Atlas—to just go away, either because they don't like its implications or because they don't understand them. The Dartmouth Institute has documented an average of a 60 percent difference in the amount of medical services used to treat patients with such conditions as hip fracture, heart attacks, and colon cancer. The range of spending varies 2.5 fold from the highest- to the lowest-spending areas. Looking at Medicare spending overall, high-cost areas are characterized by an abundance of specialists and hospital beds. In those areas, patients are admitted to the hospital more often, kept in the intensive care unit longer, and are subject to more tests and minor procedures without any evidence of benefit to them. Low spending areas have more primary care doctors who evidently use resources more judiciously because the death rates are lower. If this is rationing, then everyone should want it, except perhaps those who benefit from its oversupply. 

The oversuppliers of medical care are not bad doctors who collude for profit. They are good doctors caught in a bad system. Paying fee-for-service, by the piece of work rather than treatment outcomes, is the most basic culprit because it rewards overuse of technology. Add in poorly evaluated (often unnecessary) surgery and voila, we have the recipe for a medical arms race. The payment system has, however, also resulted in the rapid development of sophisticated technology—like the extra-corporeal membrane oxygenation that, thank goodness, saved that 15-year-old boy. The trick is how to stop overutilization of things that we really do know aren't necessary—while maintaining the technological prowess we can rightly be proud of and grateful for.

Dr. Shanghavi's story, we fear, will cause more confusion than enlightenment. His compelling story of child's life saved by good doctors applying expensive and sophisticated medical technology somehow leads to the conclusion that if we try to fix the wide variations in the quality of medical care Alex might have died because of arbitrary rationing. Dr. Sanghavi acknowledges that healthcare cost is unsustainable but leaves his readers hanging as to what in the earth to do about it—just don't correct the wide variations in the quality and quantity of unnecessary medical services provided.

We know we can reduce medical waste and improve the quality of care without rationing, without preventing a doctor from providing care that he or she believes a patient needs. We should establish clear standards for when high technology procedures are indicated and to measure and report specialists' adherence to those standards (and take this into account as we repair our malpractice system). The answer to the irrefutable data produced at Dartmouth isn't to wish it would go away. It is to promote health care built on agreed-upon standards of practice that improve the quality of care and reduce waste without unduly interfering with the practice of medicine. Without endangering boys like Alex.