Myth Busters #3: Hysterectomies in Lewiston, Maine

One of the consequences of Roemer’s Law has been the idea of “provider induced demand,” and the general notion that everything that happens in health care is because some greedy doctor has deemed it. This means that patients don’t count. What patients may want is irrelevant.

Nowhere is this better illustrated than in Jack Wennberg’s early work on “small area variation” in medical practice.

One of the consequences of Roemer’s Law has been the idea of “provider induced demand,” and the general notion that everything that happens in health care is because some greedy doctor has deemed it. This means that patients don’t count. What patients may want is irrelevant.

Nowhere is this better illustrated than in Jack Wennberg’s early work on “small area variation” in medical practice.

I was working in the research department at Blue Cross Blue Shield of Maine from 1979 to 1984 and we offered the use of our claims files for his research. He had already done some work in Vermont looking at variations in the rate of tonsillectomies in various towns. He found that in some places physicians surgically remove tonsils at a much greater rate than they do in other places. He concluded that this was an example of Roemer’s Law in effect — scalpel-happy physicians were too quick to order up surgery in some places, but not in others.

The most startling variation he found in Maine — and the one that put him on the map — was the difference between the rate of hysterectomies in Lewiston and Wiscasset, just 35 miles away. The chance of a woman getting a hysterectomy in Lewiston by the time she was 70-years old was 70%. In Wiscasset it was a fraction of that.

Wennberg, in keeping with the narrative he developed in Vermont, decided that this was because physicians in Lewiston were eager to cut while their fellows in Wiscasset were not. Curious. Why should that be? He didn’t know but speculated that maybe they were trained at different medical schools, or somehow the profession in one town had grown to be more aggressive than those 35 miles away.

Hmm, is Maine so very isolated that doctors in Lewiston never talk to their colleagues just 35 miles away? That was certainly not my experience. In fact, Maine is not exactly crawling with physicians, so opportunities for professional bonding would necessarily include physicians from many different towns. In fact, in a recent search of a physician directory compiled by the Maine Medical Center, I could find only 45 Obstetricians/Gynecologists in the entire state. Is it really credible that those only 35 miles apart would not be talking with each other?

Completely missed in Wennberg’s analysis was the possibility that maybe it wasn’t the physicians who dictated what happened, but the patients. There are stark differences in the populations of the two towns. Wiscasset was an old fishing village with a largely Yankee (Protestant) population. Lewiston was an industrial mill town with a predominantly French-Canadian (Roman Catholic) population. It is far more likely that women in Lewiston were using hysterectomies as a form of birth control that was acceptable to the Church, especially in the early 1970s before birth control pills were widely available. Many of us who lived in Maine at the time, thought this was pretty obvious, and were surprised and amused at the attention Wennberg’s study got.

Even more surprising is that Wennberg’s study is still getting attention thirty years later. In 2009, National Public Radio (NPR) published a major article, “The Telltale Wombs of Lewiston, Maine.” The piece by Alix Spiegel is gushing about Wennberg, calling him, “a certified guru — a man whose insights underlie many of the arguments you currently hear about health reform….” It adds, “Over the past 40 years, he has completely transformed our understanding of what’s going on in the U.S. health care system.”

The article goes on to say there were two possible explanations for differences in medical practice — “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.” The article says Wennberg looked at the possibility of differences in patient demographics and level of sickness and dismissed it.

This is unconvincing because it doesn’t say whether he gave any weight to issues like religious differences rather than just differences in disease severity. It is a profound weakness in research that treats patients like statistics rather than fully developed human beings. Statistics fail to capture the most important aspects of human beings, such as personal values or emotional condition. This is precisely why medicine has always (until now) been centered on a personal relationship between a doctor and a patient.

Wennberg insisted that, “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.”

Actually, this reveals a bias among the educated elite that “common” working people are not bright enough or involved enough to have much effect on the world around them. An academic like Jack Wennberg assumes that all decisions must be coming from people like himself — other educated elitists. “The people” are just the raw material the elite uses in their machinations. So, to the extent “the people” have opinions, preferences, fears, hopes, values, or expectations, these are just characteristics that have to be managed by the people who know best.

After much discussion, the NPR article finally gets to the heart of the matter — money.  It says, “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.” It quotes Gordon Smith, the non-physician head of the Maine Medical Association, as saying, “If you pay people more, the more things they do, they’re going to do more things.”

That is the conventional thinking among academics these days, and it goes back, once again, to Roemer’s Law (“a built bed is a filled bed”) and the idea of “provider induced demand.” Once again, that notion is driving most of the thinking in health policy today.

But Wennberg’s research, if anything, contradicts that very idea. It does not support it. Physicians in Wiscasset and Lewiston were all under the same payment system. They were all subject to the same incentives. If it were the payment system that drove their decision-making, they would all be practicing in the same way. The fact that they practice differently strongly suggests it is not the payment system that drives behavior.

But once again public policy is driven by an idea that could fit on a bumper sticker — “Greedy Doctors rip out wombs for fun and profit” — even though the doctors in two towns 35 miles apart behaved very differently.

Still, Wennberg went on to create the Dartmouth Health Atlas, which lives on and continues to distort data and influence public policy, all based on this original idea that the payment system incentivizes greedy doctors to over treat hapless patients — but only in some towns.