Variation in the Delivery of Health Care: The Stakes Are High

A generation ago, the remarkable variation in the delivery of health care across populations was brought to light [1]. Since then, numerous articles have documented variations across small and large areas of the United States in surgical procedures, health system capacity (such as physicians per capita), use of pharmaceuticals in chronic conditions, and intensity of diagnostic testing [2-6]. The principal finding of these studies has not changed: For medical care, geography is destiny.

However, one thing has changed. Although clinicians may have had difficulty in finding implications in these studies for their personal practices, variation can no longer be seen as a mere intellectual curiosity. Almost all of the other stakeholders involved in the delivery of health care recognize variation as a fundamental challenge. Who are these stakeholders? They are insurers, employers, the government, and the populations for which physicians provide care. In this editorial, I examine what is at stake for each stakeholder and look at how the concept of variation has been “operationalized” in ways that affect physicians' day-to-day activities. I also argue that physicians must participate in the debate about variation.

Insurers' interest in variation is the most apparent. In almost every clinical context, from therapeutic interventions to outpatient diagnostic testing, physician practice styles diverge widely. Variation in practice styles has a profound effect on the cost of insuring enrollees. This observation has fueled the new industry of managing physicians. The tools that are used, from profiling to guidelines, are aimed at reducing variation.

Almost every physician involved with managed care companies now receives routine practice profiles intended to reduce variation in use of services. Most profiles assess differences in per member, per month costs across providers compared with a benchmark (often the lowest-cost provider). Currently, profiles have several deficiencies. First, cost may not be …