Dealing With Medical Practice Variations: A Proposal for Action

Prologue: Without much attention from the profession and virtually no public fanfare, John Wennberg has been tracking the phenomenon of variations in the use of medical care for more than a decade. Wennberg, who ranks among the leaders of the nations tiny cadre of medical care epidemiologists, has been driven by the notion that practice variations were important to identify and understand because they suggest a misuse of care. Wennberg trained at Johns Hopkins University in internal medicine and also holds a master's degree in public health from that institution. Currently, he is a professor in the Department of Community and Family Medicine at Dartmouth Medical School From 1974 to 1979, he served on the faculty of the Harvard Medical School, attached to the Department of Preventive and Social Medicine. During his research pursuits, Wennberg has uncovered systematic and persistent differences in the standardized rates of use for common surgical procedures and other medical services in the United States. But this phenomenon is not limited to any particular health care delivery system. Such variations have been found wherever Wennberg and his colleagues have looked, be it New England, Iowa, the United Kingdom, or Norway, as well as among the political subdivisions within these areas. Wennberg believes that the principal reason for the dramatic variations in use of medical care can be found in what he characterizes as the “practice style factor.” Wennberg s conclusion has particular relevance to Medicares new hospital payment approach based on diagnosis-related groups (DRGs). Built into this approach to cost containment is an assumption that the mix of hospitalized patients is largely unaffected by physician practice styles. But, as he has found, professional discretion is a very important variable and must be taken into consideration in dealing with the health cost conundrum.