He's got a point you know. We all have much thanks to give to variation - for if it weren't for variation, we as humans would undoubtedly not exist. Stealing a page from Darwin's On the Origin of Species, we see that evolution through natural selection depends and draws on this variation inherent to living things. The differences among individuals allow for competition, creating relative fitness; while within the individual, on a biochemical level, genes of sexually reproducing organisms are passed on to offspring, genomes are shuffled and variation is maintained within the population* (and this is important). For when, the circumstances change and the situation calls for a completely different set of traits for gaining a competitive advantage - dark features instead of light, speed as opposed to bulk - the "Greatest Show on Earth" takes center stage to showcase the utility of all of that wonderful variation - that that was on display and that that lay dormant - by mixing and matching until a more fit creature, possibly even species, emerges equipped for survival amid the new way of the land.
Of course, that's not the only possible end to this story. For the same reason that dinosaurs aren't walking alongside men today. Sometimes the genetic lottery comes out unfavorably and a species becomes extinct (and sometimes a giant asteroid collides with Earth).
Now think about this framework that I've laid out above, and instead of species let's think of health care systems. You may be privy to the tremendous amount of variation that exists in the United States' domestic system of health care today...We have patients who receive world class care and others who can't even access or afford care. We have primary care along with every kind of specialist and within each class we even have numerous different ways of practicing. We have a range of prices that we charge for essentially the same procedures. So a person going to hospital A might pay $4000 for X procedure, while a person who chooses to go to hospital B for X procedure pays only $3000...and I'm afraid that growing up dealing with its idiosyncrasies, we may have also grown deluded to believe that this is the way it has to be...
Luckily, we are beginning to see some ways out of this. First of all, with added transparency we can begin to map the variation that exists and persists in our health care system. Here, when I say we, I really mean Dr. John Wennberg and his colleagues at the Dartmouth Institute for Health Policy and Clinical Practice. For over two decades, the Dartmouth Institute has been collecting and analyzing stores of information on resource utilization via Medicare (our nation's single payer system), which insures America's 65-and-over population, and organizing their findings into freely available tools shared online at Dartmouth Atlas. Taking one quick look, it's not hard to see that things vary rather widely across the country, within regions and even within states and cities.
|Mapping the variation in health care resource utilization across the fifty nifty United States. On their site you can zoom in and out to view different regions' variability on a range of topics in health care.|
What this tells me, and Dr. Wennberg & Co. would agree, is that there is an incredible amount of waste in our health care system - waste defined as spending that doesn't result in better outcomes - by some measure almost 30% of all health care spending! Think about that. With health care spending running a total of $2.7 trillion a year, that means that over $800,000,000 is wasted per year! Think what we could do instead with all of that funding?? What a waste...
If that isn't enough, two weeks ago the Massachusetts Health Policy Commission released their Annual Cost Trends Report (full pdf), which showed that Massachusetts, the heralded gold standard of our domestic health care system, has exhibited 21-39% of spending as waste, measured at $14.7-26.9 billion in 2012. With much of our health care culture owing its roots to the values of the Hippocratic Oath, "first, do no harm", we're finding it harder to ignore the opposition to that rule apparent in these two distinct, but equally far reaching studies, and many else like them. In fact, it appears quite clearly, we do do harm, considerable harm at that (in the form of undertreatment, overtreatment and mistreatment or errors); to our patients and society at large.
Taking this all in stride, we're beginning to comprehend that, to some extent, we're all complicit.
But, there is hope. Going back to what I said earlier, in quoting Dr. Tom Lee, "variation equals opportunity"; we have our eureka moment. Our "Ah-ha I've got it!" If some are able to get by on less without adversely affecting health outcomes then how about we learn what enables them to do so and share best practices in order to bring all providers across our nation in line with a new standard of operation!? Some of you out there, with a few more years on me and your wits about you, may respond: "you mean what happened in the early 90's with HMO's (health management organizations)?" Expecting to get by on less, which equated to care rationing. For those unfamiliar to these times, care rationing is bad. And that's not what we hope to achieve with current and future reform efforts. No, instead we need to think bigger! We want to have our cake and eat it too!
I repeat. We can have high quality care and open access to it, covering everyone, improving the health of our population while cutting costs to increase affordability and reduce the financial burden of health care! Remember...Triple Aim'en!
The question then is how do we get there?