The paradox of appropriate care

A Bostonian is about twice as likely to undergo a carotid endarterectomy as a New Havenite; for coronary bypass operations the risk is the reverse. 1New Haven residents experience substantially higher rates for hysterectomies and back surgery, while the rates for knee and hip replacements are much greater for Bostonians. Across a wide spectrum of common acute and chronic conditions such as back pain, gastroenteritis, pneumonia, and diabetes, the incidence of hospitalization is much greater for residents of Boston than for those of New Haven, even though the populations are very similar in demographic characteristics related to the need for care. These overall differences in utilization translate into large differences in expense to third-party insurers. For example, in 1982, the Medicare program's outlays were 2647 per enrollee for Boston residents while the average expenditure in New Haven county was 1561. As recently emphasized by Secretary of the Department of