A roadmap for health system reform

As a newly qualified doctor in 1967 Jack Wennberg was employed to ensure that the citizens of Vermont had access to advances in treatment for heart disease, cancers, and stroke. His study of the delivery of healthcare, with the aim of identifying communities that were underserved, found extensive evidence of variation in the treatment of many medical conditions in the state. This was exemplified by the rate of tonsillectomy in children younger than 15 being 60% and 20% in two neighbouring communities with similar populations.

More than 40 years later Atul Gawande reported wide variation in healthcare delivery in a much cited article in the New Yorker (“The cost conundrum,” 1 Jun 2009, www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande). He compared two communities in Texas and found that one spent twice as much as the other per person on Medicare, a difference that could not be accounted for by population need and that was unrelated to the quality of care delivered. The higher cost community was among the most expensive healthcare markets in the United States, and Gawande argued that this was due to its overuse of most kinds of healthcare, driven by a payment system that rewarded doctors for doing more.

In fact, international comparisons indicate that financial incentives only …