Geographic Variations in the Use of Services: Do They Have Any Clinical Significance?

Prologue: The primary role that private physicians have played in the design of government efforts to moderate the cost of medical care has been to take exception to the public intrusions into their professional world. Such railing, be it in the name of concern for patients, social equity, quality of care, professional freedom, or the vaunted reputation of American medicine is simply not enough. That, at least, is the strong message of Robert Brook and his colleagues at the Rand Corporation. Because physicians have not aggressively engaged the problem of constraining society's investment in medical care, the government's proposed solutions have been largely economically based; that is to say, they have sought to constrain rates of increase in the cost of services rather than identifying the most efficacious care and paying for it, and refusing to reimburse for treatments found ineffective. Brook and his colleagues say that physicians must undertake the close self-examination necessary to propose better allocations of medical resources, grounded in clinical insight and practice. Brook is a senior health services researcher at Rand and a professor of medicine and public health at the University of California, Los Angeles. Brook is well known for his research in the measurement of quality of care. He has served as director of the health status and quality of care components of Rand's health insurance experiment. More recently, he convened the first international meeting in March 1984 to explore with the experts of other countries the phenomenon of variations. (See UpDate in this issue, for a conference summary.) Brook is a member of the National Academy of Sciences's Institute of Medicine. All of the coauthors are affiliated with Rand. Lohr is a health policy analyst. Chassin is an internist who formerly worked for the federal Professional Standards Review Organization (PSRO) program. Kosecoffand Fink, both of whom hold Ph.Ds., are specialists in program evaluation, and Solomon, an internist, is former chairman of the Department of Medicine at UCLA.