The Telltale Wombs Of Lewiston, Maine
Carol Bradford outside her house in Lewiston, Maine. - Carol Bradford outside her house in Lewiston. (John W. Poole / NPR)
In 1974, Roxanne Tremblay was 29 years old, a frazzled single mom supporting a young daughter. So when the pain came on, it presented a real problem.
The pain was sharp, a constant ache in her lower abdomen that doubled her over at work and left her breathless. Tremblay couldn't risk losing her job, so she went to see her gynecologist, one of the most popular doctors in her small working-class river city of Lewiston, Maine.
This man had always impressed Tremblay and made her feel at ease, so when he announced that she would need an operation, she didn't really question it. Tremblay never planned to get married or have kids again. She was done with all that.
Three weeks after her first appointment, Tremblay went into the hospital and had her uterus and ovaries removed — a total hysterectomy. After the operation, her doctor explained what he had found.
"It was what he called the seed of cancer," says Tremblay. "It wasn't cancer, but it had the potential of developing into it."
Twenty-nine years old is pretty young for a hysterectomy. But in the mid-'70s in Lewiston, Maine, lots of women were getting them. Tremblay says she herself knew a bunch.
(John W. Poole / NPR)
"My boss that I had when I worked at Kmart, she had one shortly after I did," Tremblay recalls. "One of my friends that I've had since I was 6 years old, she had one. Just about anyone you talked to would say 'Oh I had a hysterectomy!' 'Oh yeah I did — so and so did mine!' There was a lot of them. I do remember that."
Why So Many?
The question, of course, is, why were so many women in the city of Lewiston having hysterectomies?
(John W. Poole / NPR)
At the time, this was not a question of interest to most Lewiston women. They were busy with lives and work and families. But there was someone, a health researcher in nearby Vermont, who was very interested in the Lewiston hysterectomies. A man who was interested in operations and health statistics of every kind.
His name was Jack Wennberg, and by the mid-1970s, he had compiled data about health care practices in cities all over the state of Maine, including data showing that in the city of Lewiston, an unusually large number of women were having hysterectomies. He projected that if the rate of surgeries continued in Lewiston, 70 percent of its women would have a hysterectomy by age 70.
Wennberg discovered Lewiston's high hysterectomy rate, but he really did much more than that. Over the past 40 years, he has completely transformed our understanding of what's going on in the U.S. health care system. His research on health practices eventually expanded. He started in Vermont, then moved to Maine, until eventually he studied communities throughout America. In the process, Wennberg led us to a clearer understanding of what doctors and hospitals are doing with their patients all across the United States.
(John W. Poole / NPR)
So if you're looking for a better understanding of what drives the cost of health care in this country, health researcher Wennberg is a pretty good place to start.
Accidental Discovery
Though Wennberg is now a certified guru — a man whose insights underlie many of the arguments you currently hear about health reform — Wennberg didn't set out to revolutionize our understanding of health care. It was an accident.
(John W. Poole / NPR)
It all started in the late '60s when Wennberg, fresh out of a residency at Johns Hopkins Hospital, was given a grant from the federal government to help improve the health care system in the state of Vermont. The idea behind the federal grant was that in states all around the country, isolated rural communities weren't benefiting from many of the new, modern medical treatments that had been developed. Wennberg's job was to fix this problem in Vermont. He was supposed to help bring high-tech medicine to poor rural communities.
En route to this perfectly laudable goal, however, Wennberg made a somewhat crazy decision. He figured that if he was going to improve health care in Vermont, he should really understand what was going on in terms of medical practice on the ground. And so he decided to collect information about every medical transaction of every person in every town in the whole state.
"We needed to know what was going on in home health agencies, what was going on in nursing homes, hospitals, doctors offices," Wennberg says. "And for each patient, what their diagnosis was, what their treatment was, how much money was spent, and what the outcomes were in as far as we could measure them."
(John W. Poole / NPR)
Searching For Explanations
To collect these records, Wennberg hired researchers, people dubbed "the pit crew" who year after year were sent out to medical record rooms to collect records. It was a truly massive undertaking to gather every medical transaction in the state of Vermont. It took two years of road trips just to collect the records for 1969.
But once he had the information, Wennberg began to slice it and dice it in all kinds of ways. And what became clear almost immediately was that something was terribly off. "As soon as we set out to do the analyses we began to see these extraordinary differences," Wennberg says.
(John W. Poole / NPR)
Sitting at a table with most of the medical transactions in the state of Vermont listed before him, Wennberg was able to see just how bizarre the distribution of care was. People in one town would get their hemorrhoids removed five times more often than people in another town only 30 miles away. Ditto with mastectomies, prostate operations, back surgery.
This was even the case in Wennberg's own town.
"We lived right on the boundary between Stowe and Waterbury Center, Vt.," Wennberg says. "And if my kids had been going to the school system in Stowe, they would have had a 75 percent chance of having their tonsils out. If they had gone to the Waterbury School — where they actually did — it was about 20 percent."
(John W. Poole / NPR)
Why the differences?
There were two possible explanations.
The first explanation was that doctor behavior was somehow to blame. The second explanation was that it was the patients; that people in some areas were just much sicker than people in other areas, or maybe just wanted more services for some reason.
(John W. Poole / NPR)
This was the next problem Wennberg needed to solve.
Patients' View
Carol Bradford lives in a small house on a tree-lined Lewiston street. She's a church lady, the kind of person who takes in strays and carries food to elderly neighbors.
(John W. Poole / NPR)
Bradford, like Roxanne Tremblay, had a hysterectomy in the mid-'70s. Fibroids prompted her doctor to remove her uterus, and, like Tremblay, Bradford is perfectly happy with the result. Also like Tremblay, Bradford was not at all surprised to learn just how many women were undergoing hysterectomy operations in the 1970s. To her it made perfect sense. Lewiston, she explained one morning over coffee, is mostly Catholic.
"Some women were having too many children," she confided. "You know, there are families here with 10, 12 children. It's a possibility that women came to the point where they just really couldn't deal with any more children and were begging the doctors to do something about it."
"You know," Bradford said with a nod, "that's my personal opinion."
(John W. Poole / NPR)
But it was not just Bradford's opinion. It was everyone's opinion when Wennberg first made his discovery.
In fact most people continue to assume that when a patient goes into a doctor's office, the doctor is simply responding to sickness in the body, or the needs and concerns a patient has.
But in his work in Maine and Vermont, Wennberg demonstrated that it's actually a lot more complicated than this. The women of Lewiston, Maine, weren't having more hysterectomies because more of them were Catholic, or because more were sick. After his initial work in Vermont and Maine, Wennberg embarked on this enormous study of patients, which showed that in terms of sickness and demographics, the populations of different communities in Maine and Vermont were actually remarkably homogenous.
(John W. Poole / NPR)
This could mean just one thing, according to Wennberg. "Because we could easily see that it wasn't that patients were different between regions, so it wasn't the illness that was driving this, this must be coming from the provider side."
His insight: It was doctors, not patients, who drove medical consumption, and all kinds of things influenced the decisions a doctor makes when a patient enters his office. Sickness and patient preference play an important role, but a much smaller role than patients and the health care community had originally thought.
The Maine Experiment
The medical community's response to Wennberg was pretty muted in the 1970s when he first began to publish his work about the underlying drivers of medical care. Some were supportive, but most in the medical community either didn't believe him or simply didn't grasp the significance of the work.
But in the state of Maine Wennberg actually found a well-placed fan. Dr. Daniel Hanley was the executive director of the Maine Medical Association and a towering figure in Maine medicine. Sometime in the mid-'70s Hanley was introduced to Wennberg, and according to Gordon Smith, current head of the MMA, Hanley was absolutely smitten.
"Jack really found a follower in Dr. Hanley," Smith told me. "Hanley was fascinated with Wennberg's work. He felt like Wennberg was making an important contribution to knowledge and that doctors needed to do something about it."
What the doctors needed to do, Hanley decided, was figure out why the strange variations in medical care were taking place. The best way to do that, he figured, was to get all the doctors in Maine to sit down together on a regular basis, look at Maine city by city, and then hash out why the care they were giving was so different. The doctors would speak directly and honestly about their decision-making.
Bob Keller is a back doctor in Maine who worked on this project, and he says there was only one problem with Hanley's plan: the doctors themselves. If the data were right then at least some of the doctors in the room were doing something wrong by providing care that wasn't needed. That didn't sit well with the doctors.
"No. 1, they were insulted," says Keller. "They were angry because their judgment was being challenged, and that was not allowed. And in some cases they just didn't believe it, so they would try to find holes in the data. One of the classics, they'd say, 'Oh we have more workers compensation here, we have more heavy industry!' But we were able to work through most of those things and demonstrate that wasn't the case. Then they would say, ' Our population is older! More of them need prostatectomies!' And we'd say, 'Well, we adjust for age, so that's not an argument anymore.' And some doctors never could deal with that, and they would leave the study groups. They just said, 'This is baloney; we're not going along with this.' "
But in time, says Keller, most of the doctors in Maine did warm up to these ideas. "They began to accept the data, began to accept that indeed, different physicians were using different thought processes or decision-making processes in dealing with patients."
And so in the state of Maine began this incredible experiment. Four or five times a year each medical specialty would gather together for a kind Talmudic dissection of doctor choice conducted by the doctors themselves. They wanted to look at all the geographical differences, figure out why they existed, and then try to bring their medical decisions in line with one another. They figured that by doing this they could eliminate excess care.
Doctor Influences
Smith took part in the meetings, and he said that inevitably there was one thing above all that doctors believed shaped decisions: "The way you were trained. Maybe you were at a particular training program that does things a certain way and you bring that back to your community."
Smith says to understand how their training shaped their decisions, the doctors who gathered would list on a white board all the criteria they had learned in school for doing this or that procedure. But what they found, says Keller, the back doctor who helped put the groups together, was that most of the time the doctors all seemed to agree.
"In a meeting they'd all say, 'Absolutely I agree; you need to have a certain physical finding and if you didn't have it you wouldn't do it,' " Keller says.
"Well, that might be what they agreed on, but in fact when you were able to use data later you would find that it didn't really work that way. That's the criteria and the standard got tilted, sometimes pretty significantly."
Somehow in the privacy of their own offices the doctors still enacted the agreed-on criteria differently. Why?
One reason some doctors mentioned was fear of lawsuits; some worried that if they didn't do every possible thing they might get sued. Another reason was temperament — some doctors were clearly just more eager to take action than others.
Then there was the role of local medical culture. For example, even though it didn't make sense and wasted a lot of time and money, pediatricians in some communities felt they absolutely positively had to send even mildly sick kids to the hospital.
"Families in small Maine communities were used to the fact that if their kid had a temperature of 102 and was vomiting, that kid was going into the hospital," says Keller. "They'd been doing it for years, so they'd be aghast if they took little Tommy down and he had a temperature of 102 and the doctor said, 'Well, go home and take this.' Nobody did that!"
It was probably safer and better all around not to put the kids in the hospital, and the doctors knew this. But doctors, like the rest of us, are people, and therefore are subject to subtle influences.
For instance, it turns out that if you increase the number of doctors in an area, chances are that the use of medical services will rise. If there's one doctor in a town with 100 patients, then he'll schedule your heart checkups for once every six months, but if another doctor comes to town — and now the first doctor has 50 patients — the doctor will just schedule your heart checkups for once every three months. There's a very simple reason why, says Frank Read, an eye specialist who participated in the doctor groups.
"I don't want to be sitting on my thumbs all the time — I want to be busy. And that may unconsciously loosen my criteria for doing a procedure."
Money
Which brings us finally to the subject that incredibly was never directly discussed during the nearly 20 years the doctors met: money. Specifically, the way money affects medical decision-making.
Keller explained that this subject was completely verboten.
"It would have been a show stopper. It would have gone right to the question of greed, and you're not going to keep a doctor at the table if you say that he's greedy."
Talking to doctors about money is difficult. It's uncomfortable both for patients and for doctors to think that this most important and intimate service could be contaminated. But the truth is the decisions made by your physician when you enter his office are profoundly influenced by the way that doctors get paid in this country. "That's just common sense. That's human nature," says Smith of the Maine Medical Association. "The payment system is an important influence."
Most of the doctors in this country are not on a salary but are paid basically like pieceworkers in a clothing factory. This is called "fee for service," and the way it affects doctor behavior is clear.
"If you pay people more, the more things they do, they're going to do more things," says Smith.
The U.S. health care payment system rewards doctors for taking action and doing procedures. This reality is so powerful that it hasn't just changed the individual behavior of doctors. Keller says that the specialties themselves have changed, bending like flowers to the sun, moving toward the source of heat.
Consider dermatology. "In the old days, dermatologists just did medical visits," says Keller. "They looked at people, they looked at their skin lesions, they advised them. Now they're all doing Botox, they're doing various procedures. So dermatologists are making very high incomes now, but they are doing procedures; that's where they're getting it. The specialties changed because it's a procedural-driven world that we're in."
And the more complicated the procedure the higher the payment.
This is perfectly logical but has an unintended effect on care. Keller points to his own specialty of back doctor. He says one of the most frequent operations these days is a highly complicated procedure called an instrumented spinal fusion. When a patient has degenerative disk disease, the doctor inserts metal rods to stabilize the spine.
Keller says in the old days, doctors used a much less complicated and safer operation. But the more complicated one had a clear advantage: "The surgeons could charge more because they could do these complicated procedures. So they were putting the screws in and they billed for putting the screws in. They were putting the plates in, and they billed for putting the plates in. So you had this whole new high-tech procedure, and it was enormously attractive to spine surgeons and it literally took off in this country, at the same time as most good spine surgeons will admit that they had no research to support what they were doing."
In fact, says Keller, one high-quality study demonstrated it wasn't so positive. "It showed that it isn't so great, actually as people thought it was," he says. "And they also showed, interestingly enough, that the old-fashioned non-instrumented fusion was as successful as the instrumented fusion — which was a real blow."
More Is Not Better
And this, in miniature, is one of the big problems with the way that the current system is set up. It's a problem some call "more is not better."
Doctors exist in a fee-for-service system that encourages — and really because of the threat of malpractice and having to battle insurance companies — in some ways actually forces them to do more. More surgery. More tests. More of everything.
And while most Americans just assume that more care is good, it turns out that more isn't always better for patients.
Natasha Saint Amand is 25 and wears her brown hair curled into loose ringlets. Her makeup is picture perfect. Amand has spent her whole life in the Lewiston area, but like most people who live there, had no idea that the area had an unusually high rate of back surgery. The rate has varied over the years, but between 2003 and 2007, the rate of lower-back fusions in Lewiston was around 107 percent higher than in the rest of Maine.
Five years ago, Saint Amand was in a car accident and after that had serious pain in her back several times a week. Her doctor strongly recommended a fusion, and so she got one. And then another. And then another. And then neck surgery.
Now Saint Amand is in pain every hour of every day. She can't bend at the waist or at her knees. Not for the original sickness, she says, but from the cure. She is disabled, and she says really understanding the reality of that took a long time.
"I think it really hit me after after my third back surgery and after I had my neck surgery," Saint Amand says. "It really hit me that, wow, there's really not much I can do. My leg is all nerve-damaged. My lower back is nerve-damaged. I have nerve damage in my left arm. There's really not much left that doesn't hurt."
It would be easy to dismiss what happened to Saint Amand as poor-quality medical care; surgeries that failed because they were badly done. But it's probably more complicated than that.
A couple of years ago Keller and some colleagues did an elegant study of one kind of back surgery in Maine, a procedure called discectomy. Keller found communities in Maine that had high rates of this surgery, communities with low rates, and communities that were somewhere in the middle. Then he followed patients who had had surgery in those communities over a five-year period to see how they fared. Keller says the conclusion was undeniable.
"In the high rate of surgery overall, the patient outcomes were the least good of those three categories. In the middle rates, the outcomes of the patients were in the middle. And in the low-rate areas — less frequent operations per capita — the outcomes were the best."
The reason that areas with more back surgery did worse, Keller says, is that doctors in those areas were operating on people whose issues were less severe; that is, patients who might not have been good candidates for an operation. So the problems associated with the surgery probably outweighed the problems of their actual sickness. For them, more wasn't better.
But this essential dynamic — that more isn't better — applies to a lot more than just back surgery.
In 2003, there was an enormous landmark study published by a Jack Wennberg protege named Elliott Fisher, who works at Dartmouth College. Fisher compared Medicare recipients with similar levels of sickness in areas throughout the whole United States. Fisher looked at places where elderly people used relatively few health care services and compared them with places where elderly people used a lot of health care services.
"The patients in the high-spending regions were getting about 60 percent more care; 60 percent more days in the hospital; twice as many specialist visits," Fisher says. "And yet when we followed patients for up to five years, if you lived in one of these higher-intensity communities, your survival [rate] was certainly no better, and in many cases a little bit worse."
This is probably because of a something called fragmentation of care. In high-use areas, it's often the case that many different doctors play a role in the care of a patient; many specialists are responsible for overseeing only a small part of the person. This increases the amount of treatments, tests and hospitalizations that people get, and exposes people to more risk of harm from medical error and side effects.
For most Americans this is an incredibly difficult idea to accept: It's hard to understand that more care isn't necessarily better for you.
But study after study has borne out the truth of this completely anti-intuitive conclusion. In fact, Fisher and other researchers estimate that almost one-third of the care given in our country today is that kind of care — care that isn't really helping people.
The United States spends more than $2 trillion on health care every year. So the cost of that 30 percent unnecessary care annually? $660 billion.
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Part One: Doctor Decisions All Things Considered, Oct. 8
In the mid-1970s, an unconventional health researcher named Jack Wennberg discovered an unusually high rate of hysterectomies in a small town in Maine. If the rate continued, nearly 70 percent of Lewiston women would be without their wombs by age 70. That was just one of a series of studies conducted by Wennberg that led him to a very surprising conclusion about health care: a large portion of the medical care Americans get is unnecessary. And the structure of the health care system is the reason why. The system can push doctors to prescribe care that doesn't improve patient health.
Part Two: Patient Behavior Morning Edition, Oct. 12
The behavior of patients in the U.S. health system has changed dramatically over the last couple of decades. We've been transformed from passive patients who almost blindly follow the doctors orders into active and aggressive consumers of health services. A look at how that change came about, and how it affects the behavior of doctors. Read this story.
Part Three: Marketing Sickness Morning Edition, Oct. 13
Prescription drug spending is the third most expensive cost in the U.S. health care system. The average American gets 12 prescriptions a year, and this number only seems to grow larger. There are more medicines on the market today than in 1992, with Americans now spending $180 billion more per year. A look behind these numbers and what drove the increase in prescription drug consumption in America.Read this story.
MELISSA BLOCK, host:
This is ALL THINGS CONSIDERED from NPR News. I'm Melissa Block.
MICHELE NORRIS, host:
And I'm Michele Norris.
The health care debate centers around lots of things, but mostly it's about money. We've all heard that health care in this country is incredibly expensive. It takes up one out of every $6. NPR's Alix Spiegel has spent the last couple of months trying to understand why health care is so expensive by stripping the issue down to its most basic parts. Today, she has some answers, and her focus is doctors.
ALIX SPIEGEL: To understand the complex role of doctors in shaping the cost of medicine in this country, let's go back to 1974 to the small working-class river town of Lewiston, Maine, and a young woman with a sharp pain in her abdomen.
Ms. ROXANNE TREMBLAY: I was having a lot of problem, just a constant ache right here that never went away. And my boss kept saying, you should go get that checked. You should go get that checked. 'Cause I was like doubling right over. It was like a really, really deep ache all the time.
SPIEGEL: In 1974, Roxanne Tremblay was 29 years old, a frazzled single mom living in a modest, walk-up apartment. Roxanne was the only one supporting her young daughter, so she had to be able to work and the pain was getting in the way. So Roxanne went to see her gynecologist, a personable man who impressed Roxanne and made her feel at ease. The doctor did his examination then announced that Roxanne would need an operation. Three weeks later, Tremblay had her uterus and ovaries removed - a total hysterectomy, after which her doctor explained what he'd found.
Ms. TREMBLAY: It was what he called the seed of cancer. It wasn't cancer, but it had the potential of developing into it.
SPIEGEL: Now, Roxanne didn't mind having a hysterectomy. She never planned to get married or have kids again. But she was slightly surprised that her doctor had been so quick to operate, and before surgery, hadn't taken any X-rays or anything.
Ms. TREMBLAY: And no pictures. No.
SPIEGEL: He just felt your…
Ms. TREMBLAY: And based on what I told him then, it just come out.
SPIEGEL: Twenty-nine years old is pretty young for a hysterectomy, but in the mid-'70s in Lewiston, Maine, lots of women were getting them. Roxanne herself knew a bunch.
Ms. TREMBLAY: My boss that I had when I worked at Kmart, she had one shortly after I did. One of my friends that I've had since I was 6 years old, she lives right five minutes from here, she had one. Just about anybody you talked to would say, oh, I had a hysterectomy. Oh, yeah, so I did. So and so did mine. Or I just remember there was a lot of them. I do remember that.
SPIEGEL: Now, back in those days, most Lewiston women, including Roxanne, weren't suspicious about the number of hysterectomies. But there was someone, a health researcher in nearby Vermont, who was in interested - very interested in health statistics of every kind. His name was Jack Wennberg. And by the mid-'70s, he'd compiled data about health care practices in cities all over the State of Maine, including data which showed that in Lewiston, an unusually large number of women were having their uterus removed. He projected that if the rate of surgeries continued, 70 percent would have a hysterectomy by age 70.
Now, eventually Jack Wennberg expanded his research, and that led us to a clear understanding of what doctors and hospitals are doing with their patients all across America. So if you want to investigate doctor decisions, Jack Wennberg is a pretty good place to start, which is how I ended up in his living room.
Hello. Hello.
This is me trying to set the levels on my recording equipment. To do this, I asked Wennberg what I ask most people: could you say a little something. Usually, people count to 10. Maybe they'd tell me what they ate at breakfast. But for Wennberg, a lank 75-year-old, breakfast wasn't the first thing that came to mind.
Dr. JACK WENNBERG (Founding Director, Dartmouth Atlas of Health Care Project): (German language spoken)
SPIEGEL: Nineteenth century German poetry. Apparently, for fun in college, Wennberg committed German verse to memory. Wennberg is that kind of guy - the kind of guy whose projects tend to be unusually rigorous. This was certainly the case with his work on health care. You see, Wennberg started out in the late '60s with his federal grant to improve Vermont's health care system. But because he's such a thorough type of fellow, he made a kind of crazy decision. He decided he'd try to collect information about every medical transaction of every person in every town in the whole state of Vermont. That way, he'd know what was going on.
Dr. WENNBERG: What was going on in home health agencies, what was going on in nursing homes, hospitals, doctors' offices, and we need to know for each patient what their diagnosis is, what their treatment was, how much money was spent, and what the outcomes were in so far as we could actually measure them.
SPIEGEL: Now, to collect these records Wennberg hired a bunch of researchers, people dubbed The Pit Crew, who year after year were sent out to medical records rooms to collect records. It was a massive undertaking: every medical transaction in the State of Vermont. It took two years of road trips just to collect the records for 1969. But once he had all the information, Wennberg began to slice it and dice it in all kinds of ways. And what immediately jumped out was that from one town to another, medicine in Vermont was practiced entirely differently.
Dr. WENNBERG: As soon as we set out to do the analyses, we began to see these extraordinary differences.
SPIEGEL: People in one town might get their hemorrhoids removed five times more often than people in another town, only 30 miles away. Ditto with mastectomies, prostate operations, this was even the case in Jack Wennberg's own town.
Dr. WENNBERG: We live right on the boundary between Stowe and Waterbury Center, Vermont. And if my kids had been going to the school system in Stowe, they would have had a 75 percent chance of getting their tonsils out. If they'd gone to the Waterbury School — where they actually did — it was about 20 percent.
SPIEGEL: Wennberg, of course, wanted to figure out what was going on. And there was one explanation that almost everyone around him leaped to: it was the patients. People in some areas were just much sicker than people in other areas, or maybe they just wanted more services for some reason. Which takes us back to the city of Lewiston, Maine, and yet another Lewiston woman relieved of her uterus in the 1970s.
(Soundbite of barking dogs)
Ms. CAROL BRADFORD: My little dogs are freaking here.
SPIEGEL: Oh, hi there, little dogs.
Ms. BRADFORD: Come in. Come in. You found me.
SPIEGEL: I did, not very hard.
Carol Bradford is a church lady, the kind of woman who takes in strays and carries food to elderly neighbors. Carol, like Roxanne Tremblay, had a hysterectomy in the mid-'70s and is perfectly happy with the results. She had some benign growths on her uterus. But when I asked Bradford a theory about why there was such a high hysterectomy rate in Lewiston back then, Lewiston, she explained, is mostly Catholic.
Ms. BRADFORD: Some women were having too many children. You know, there are families here with 10, 12 children. It's a possibility that women came to the point where they just really couldn't deal with any more children, you know, and were begging the doctors to do something about it. You know, that's my personal opinion.
SPIEGEL: Well, it's not just her opinion. Most people assume that when you go into a doctor's office, the doctor simply responds; responds to sickness in your body, responds to the needs and concerns that you have. But in his work in Maine and Vermont, Wennberg demonstrated that it's a lot more complicated than this. The women of Lewiston, Maine, weren't having more hysterectomies because more of them were Catholic or because more of them were sick. Wennberg showed that in terms of sickness and demographics, the populations of different towns in Maine and Vermont were actually remarkably homogenous, which according to Jack Wennberg could mean just one thing: it wasn't the patients.
Dr. WENNBERG: We could easily see that it wasn't that patients were different between regions. So it wasn't the illness that was driving this. This must be coming from the provider side.
SPIEGEL: That was the first insight; that it was doctors, not patients, that drove medical consumption. Sickness and patient preference played a role, but a much smaller role than we originally thought. So here is the big question: why do doctors make the treatment choices they make? Is it training, money? Well, the answer to that question can also be found in the state of Maine. You see, almost 30 years ago, inspired by the work of Jack Wennberg, a group of Maine physicians undertook this incredible experiment. They decided that they themselves would discover the reason why there were such strange variations in medical treatment. To do this, they decided that doctors from all over the state would gather together by specialty four or five times a year. The doctors were supposed to sit down together, look at Maine city by city, then hash out why the care they were giving was so different, a kind of Talmudic dissection of doctor choice. And so the doctors did meet. And in these meetings, there was one thing above all that they agreed shaped decisions.
Gordon Smith, who worked on this project and is now head of the Maine Medical Association, told me that initially, the doctors were absolutely convinced that the most important thing was training in medical school and residency.
Dr. GORDON SMITH (Executive Director, Maine Medical Association): The way you were trained. Maybe you were at a particular training program that does things a certain way, and then you bring that back to your community.
SPIEGEL: But what was strange, says Bob Keller, another doctor who participated in the groups, was that during the meetings, the doctors mostly seemed to agree on how to approach the medical conditions that their patients presented, seemed to agree on when it was appropriate, for example, to go ahead with surgery.
Dr. BOB KELLER: In a meeting, they'd all say, oh, we all - absolutely, I agree. That's what - you need to have three months of pain, for example, or you need to have a certain physical finding. And if you didn't have it, you wouldn't do it. Well, that may be what they would agree on, but in fact, when you were able to use data later, you would find that it didn't always work that way, that the standard got tilted sometimes pretty significantly.
SPIEGEL: In practice, in the privacy of their own offices, they were often doing something completely different from what they said that they should do, something completely different from what they themselves thought they would do when they talked in these meetings. So why were their behaviors in practice so different? One possible explanation was fear of lawsuits. When actually face to face with a patient, some doctors got worried that if they didn't do every possible thing, they might get sued. Temperament played a role. Some doctors were just much more eager to take action. And then there was the role of local medical culture. For instance, Bob Keller says that pediatricians in some communities feel they absolutely had to send even mildly sick kids to the hospital because that's what the doctors there had always done, and families had come to expect it.
Dr. KELLER: People were very clear on that, that families in small Maine communities were used to the fact that if their kid had a temperature of 102 and had nausea and vomiting, they were going to go down to their primary care doctor, their pediatrician, and that kid was going to go into the hospital, and they've been doing it for years. And so they would be aghast if they took little Tommy down, and he had a temperature of 102 with nausea and vomiting, and the doctor said, well, go home and take this. Nobody did that.
SPIEGEL: Now, it's probably safer and less expensive not to put the kids in the hospital, and the doctors knew this. But doctors, like the rest of us, are people, and therefore, subject to subtle influences.
Here's another example: One of the many doctors I talked to while I was in Maine was an eye specialist named Frank Read, another doc from the study groups. He told me this story.
Dr. FRANK READ: My old partner that I joined here in 1971 was asked by a friend of his, you know, at what level of vision do you do a cataract operation? And he said, well, if there's one ophthalmologist in town, it's 20/200.
SPIEGEL: 20/200 is pretty bad vision.
Dr. REED: If there are two ophthalmologists in town, it's 20/80.
SPIEGEL: Not so bad.
Dr. REED: If there are three ophthalmologists in town, it's 20/40.
SPIEGEL: Pretty good vision, actually. In other words, when there are more doctors, surgery is being done on patients that are less sick. According to later work done by Jack Wennberg, the number of doctors in a town can influence the amount of medical services consumed across the board. If there's one doctor in a town with 100 patients, then he might schedule your heart checkups for once every six months. If another doctor comes to town, and now the first doctor has 50 patients, he'll just schedule your heart checkups for once every three months for a very simple reason, Frank Read says.
Dr. READ: I don't want to be sitting on my thumbs all the time. I want to be busy. And that may unconsciously loosen my criteria for doing a particular procedure.
SPIEGEL: Which brings us finally to the subject which incredibly was never, ever directly discussed during the nearly 20 years the doctors met: money, the way money affects medical decisions. Frank Read and Bob Keller told me that this subject was completely verboten.
Dr. KELLER: We didn't want to talk about money. That's something that we wouldn't want to acknowledge because it would have been a showstopper. I mean, it would have then gone right to the question of greed, and you're not going to keep a doc at the table if you say you're greedy.
SPIEGEL: Doctors are uncomfortable acknowledging the role of money, but every person I talked to admitted it affected medical decision-making, including Gordon Smith, head of the Maine Medical Association.
Dr. SMITH: Of course, it does. That's just common sense. That's human nature. The payment system is an important influence.
SPIEGEL: As you might know, most of the doctors in this country are not on salary but are paid basically like pieceworkers in a clothing factory. It's called fee for service. And the way this affects their behavior is clear. Gordon Smith.
Dr. SMITH: If you pay people more the more things they do, they're going to do more things.
SPIEGEL: And not all kinds of services are paid the same. See, on the most basic level, your doctor is either thinking, talking, advising you, or doing something to you, the procedure. For years, public health experts have agreed that when doctors have the time to do stuff like counsel you about your health behaviors, keep track of your medications, it's better for patients. Still, between talking and procedures, there is no question about which activity is better rewarded by our current payment system. Gordon Smith.
Dr. SMITH: Procedures. Procedures. That produces revenue.
SPIEGEL: And the more complicated the procedure, the higher the payment. Makes sense. But it has this unintended effect on care. Bob Keller points to his own specialty. He's a back doctor and says that one of the most frequently done operations among back doctors these days is this complicated and pretty expensive procedure called an instrumented spinal fusion. When a patient has degenerative disk disease, the doctor can go in and insert medal rods. Keller says in the old days, doctors used a much simpler and safer operation, but the more complicated one has a clear advantage for doctors.
Dr. KELLER: The surgeons could charge more because they were doing these complicated procedures. And so they were putting the screws in. They bill for putting the screws in. They were putting the plates in. They bill for putting the plates in - doing all these things. So you had a whole new high-tech procedure that was enormously attractive to spine surgeons, and it literally took off in this country. At the same time, as most good spine surgeons will admit, they had no research to support what they were doing.
SPIEGEL: In fact, says Keller, one of the few high-quality studies that did exist showed it wasn't so positive.
Dr. KELLER: It showed that it isn't so great, actually, as people thought it was. And they also showed that interestingly enough, that the old-fashioned, non-instrumented fusion was as successful as the instrumented fusion, which was a real blow.
SPIEGEL: So it's pretty clear that doctors exist in a fee-for-service system that encourages, and really, because of malpractice and having to battle insurance companies, in some ways, actually forces them to do more, more and more complicated surgeries, more elaborate tests, more stuff of every kind. But while most Americans just assume that more care is good, it turns out more isn't always better for patients. This is a problem health policy experts have dubbed more is not better, and it brings us back to Lewiston, Maine, again.
Ms. NATASHA SAINT AMAND: I'm Natasha Saint Amand. I'm 25.
SPIEGEL: When I met Natasha Saint Amand, her brown hair was curled into loose ringlets and her make-up was picture perfect. I wanted to talk to her because of her experience with back surgery. You see, the rate of lower back fusions in Lewiston was much higher than in the rest of the state. Between 2003 and 2007, around 107 higher. On paper at least, Natasha was a candidate for high-tech fusion. That's because she got into a car accident five years ago and after that had serious pain in her back several times a week. Her doctor strongly recommended a fusion, so she got one, and then another, and then another, and then neck surgery. Now, she's in pain every hour of every day. She can't bend at her waist or at her knees, not from the original sickness, she says, but from the cure.
Ms. SAINT AMAND: I think it really hit me after my third back surgery and after I had my neck surgery. I think it really hit me that, wow, there is really not much I can do between the two. My leg is all nerve damaged. My lower back is nerve damaged. I have nerve damage in my left arm. There's really not much left that doesn't hurt.
SPIEGEL: It's easy to dismiss what happened to Natasha as poor quality medical care, surgeries that failed because they were poorly done, but it's probably more complicated than that.
A couple of years ago, Bob Keller and some colleagues did this really elegant study of one kind of back surgery in Maine, a procedure called discectomy. He found communities in Maine that had high rates of the surgery, communities with low rates, and communities that were somewhere in the middle. Then he followed patients who had surgery in those communities over a five-year period to see how they fared. This is what he found.
Dr. KELLER: In the high rate of surgery, overall, the patient outcomes were the least good of those three categories. In the middle rates, the outcomes of the patients were in the middle. And in the low rate areas, less frequent operations per capita, the outcomes were the best.
SPIEGEL: The reason that areas with more back surgeries did worse, Keller says, is because doctors in those areas were operating on people whose issues were less severe, patients who might not have been good candidates for an operation. So the problems associated with the surgery probably outweighed the problems of their actual sickness. That's why more wasn't better for them.
But this essential dynamic, that more isn't better, applies to much more than back surgery in Maine. In 2003, there was this enormous landmark study published by a Jack Wennberg protege named Elliott Fisher, who works at Dartmouth College. Fisher compared Medicare recipients with similar levels of sickness in areas throughout the whole United States. He looked at places where elderly people got relatively few health care services and then places where elderly people got a lot of health care services. Here's Fisher.
Mr. ELLIOTT FISHER (Dartmouth College): The patients in the high-spending regions were getting about 60 percent more care, so, you know, 60 percent more days in the hospital, twice as many specialist visits. And yet, when we followed patients for up to five years, the mortality rate, whether you were poor, rich, urban or rural, you know, if you lived in one of these higher intensity communities, your survival was certainly no better and, in many cases, worse.
SPIEGEL: This is probably because of something called fragmentation of care. In high-use areas, it's often the case that many different doctors play a role in the care of a patients. Many specialists are responsible for overseeing only a small part of the person, which increases the amount of treatments and tests and hospitalizations and exposes people to more risk of harm from medical error and side effects.
Now, for most Americans, this is an incredibly difficult idea to accept, that more care isn't necessarily better for you. But a number of studies have borne out the truth of this completely anti-intuitive conclusion. In fact, based on their studies, Fisher and other researchers estimate that almost one-third of the care given in our country today is that kind of care, care that isn't really helping people, almost one-third, care delivered by a system that pushes doctors towards more when less is probably better, care that costs the U.S. $660 billion a year.
Alix Spiegel, NPR News, Washington. Transcript provided by NPR, Copyright National Public Radio.
