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Decision Makers Differ on How to Reshape Nation's Medical Services Into Better System

Part of the problem is cultural, said Rand's McGlynn.

"People tend to demand the new thing even if there's not much evidence it will make a difference in the length or quality of life," she said.

Few patients or physicians have any idea who delivers good, or bad, care, because few organizations track results. Consumers have more information to evaluate their cars than they do their surgeons.

"It's like a doctor flying the plane without instruments," said James N. Weinstein, a spine surgeon who directs the Dartmouth Institute for Health Policy and Clinical Practice.

Obama set aside $19 billion in his economic stimulus package to promote the use of digital records, on the belief that they reduce duplication, produce more consistent care and cut down on errors.

Because the fee-for-service payment system rewards quantity over quality, there is little incentive -- and there are even disincentives -- for doctors, nurses and hospitals to improve, Corrigan said.

"Is it a surprise we have lots of extra imaging tests and lab tests?" she said. "Not at all."

The consequences are especially glaring in regions with larger numbers of specialists and pricey technology, the Dartmouth data show.

Take the case of Miami vs. La Crosse, Wis. In 2006, using inflation-adjusted figures, Medicare spent $5,812 on the average beneficiary in La Crosse, compared with $16,351 in Miami. Yet an examination of health status in both places, adjusted for age, finds no evidence that the extra spending resulted in better care, Weinstein said.

"That's the enigma here," he said. "Less is more, and more isn't better."

Physician behavior and spending patterns in Medicare have been good indicators of broader trends across the nation, Dartmouth has found.

Even the best physicians cannot stay current with all of the drugs, tests and treatments available today -- another reason to digitize modern medicine, Corrigan said.

Many fear that the push to contain costs will result in rationing.

In today's system, "we don't ration care, we ration people," said Donald M. Berwick, president of the independent Massachusetts-based Institute for Healthcare Improvement. "We know that if you are black and poor or a woman, there are all sorts of effective interventions you are not going to get."

Though the transition would be painful and the politics treacherous, Berwick said it is possible to spend less on medical care and have a healthier nation.

"If we could just become La Crosse, think of how much better off we would be," he said.

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