In one of the great comedy skits of the 20th century, Geraldine Jones, played by comedian Flip Wilson in drag, delivers chicken to football player Jim Brown. Geraldine holds up the bucket of fried chicken, wiggles her hips and says, “No fancy ribbons on our meat. What you see is what you get!”
In medicine, it’s not so much what you see as who you see that determines what you get. In a new report (by the Health Policy Program’s Shannon Brownlee and Vanessa Hurley, based on analysis by Stanford’s Laurence Baker), the California HealthCare Foundation argues that who you see for your care (and where you live) have a huge effect on the likelihood of receiving a broad variety of elective medical procedures. The variation can’t be explained away by levels of illness in different communities—the study controlled for a number of factors related to illness, including income, level of education, and rates of heart attack and diabetes in the area, as well as typical controls like age, sex, and race. Even after adjusting for all of those factors, the variation didn’t disappear. Areas with the highest usage of angioplasty*, for instance, had rates ten times as high as areas with the lowest use.
Some readers of this blog have heard this before, but it bears repeating: Poor patient understanding of treatment options is a primary cause of such unwarranted variation. When patients don’t have enough information, or information they can understand in order to participate fully in their treatment decisions, the choice of how to manage a condition falls to their doctor.