HJBR Sep/Oct 2025

WHAT’S WRONG WITH HEALTHCARE 12 SEP / OCT 2025 I  HEALTHCARE JOURNAL OF BATON ROUGE   ing better outcomes and longer lives, and that care in New Haven must be rationed. However, his research subsequently confirmed that the patients in Boston were not living longer than those in New Haven, and that the problem was indeed overutilization in Boston and not ration- ing in New Haven. Wennberg’s earliest research, conducted in Vermont during the late 1960s and early 1970s, revealed striking regional variation in the rates of common surgical procedures such as tonsil- lectomies, hysterectomies, and cholecystecto- mies. These differences could not be explained by variations in patient demographics, disease prevalence, or clinical need, what epidemiolo- gists refer to as “case mix.” Instead, Wennberg found that the variation was driven largely by local medical practice patterns, physician preferences, and the sup- ply of available resources, rather than by robust scientific evidence or standardized guidelines. In some towns, for example, children were sev- eral times more likely to undergo a tonsillec- tomy than in neighboring communities, even though there was no corresponding difference in health status or outcomes. This work challenged the long-held belief that medical decisions were consistently grounded in objective, evidence-based criteria. Instead, it suggested that subjective judgment, profes- sional norms, and even geography played a dominant role in shaping healthcare delivery. Wennberg coined this phenomenon “unwar- ranted variation,” and he later categorized it into three types: effective care (which should be universally applied), preference-sensitive care (where multiple treatment options exist), and supply-sensitive care (where the availability of resources drives utilization). His early findings in Vermont became the foundation for what would evolve into a decades-long career dedicated to health services research, culminating in the creation of the Dartmouth Atlas of Health Care, a seminal body of work that mapped these practice variations nationwide and exposed widespread overuse, underuse, and misuse of medical services across the U.S. healthcare system. When Evidence Isn’t Enough William Shrank, MD, MS, a former Robert Wood Johnson Clinical Scholar and the former chief medical officer of Humana, co-wrote an article in 2020 in which he tried to describe the difficulties providers have in changing es- tablished practice, despite scientific evidence that the practice confers little or no value for patients. In “De-adopting Low Value Care: Evi- dence, Eminence, and Economics,” Shrank as- serted that the de-adoption of low-value care would have to begin with evidence that a cur- rent practice is providing little or no value. But he also asserted that this evidence typically comes to bear long after the current practice patterns have become widespread, making them hard to change. Since evidence alone does not drive changes in these well- established practice patterns, he cites “emi- nence” as a possible mode to drive change, such as when specialty societies publish guide- lines built on a solid foundation of randomized controlled trials, meta-analyses, and systematic reviews. However, both evidence and eminence are still often inadequate to drive widespread de- adoption. Even when data and broad expert consensus support abandoning low-value ser- vices, many of these remain common practice. The reasons are multifactorial, but chief among them is economic. Fee-for-service reimburse- ment creates a strong financial incentive to continue delivering low-value care. Take the case of arthroscopic surgery for knee osteoarthritis (OA). It was once a com- monly performed procedure, but a sham- controlled, randomized trial in 2002 found that arthroscopic surgery for knee OA conferred no benefit over placebo. However, after that trial was published, rates of arthroscopic lavage and debridement in one state barely decreased, from 12 cases per 100,000 adults in 2001 to 10.5 in 2003. New scientific evidence did not drive widespread de-adoption. When the Centers for Medicare & Medicaid Services (CMS) decided to stop covering and paying for the procedure in 2004, only then did rates of the procedure decrease more signifi- cantly. In this case, the American Academy of Orthopaedic Surgeons did not issue a recom- mendation against the procedure until after the CMS coverage decision. This case demonstrates the relative ineffec- tiveness of evidence- and eminence-driven de- adoption, relying instead on the power of eco- nomic forces. But imagine the frustration that a patient might experience if their doctor, whom they trust, tells them — wrongly — that a sur- gical procedure could help them, but that the payer (in this case Medicare) will not pay for it. Another example is population-level vitamin D screening in average-risk individuals, which became commonplace in the past 20 years, but in the absence of any good evidence to sup- port the practice. In February 2013, the American Society for Clinical Pathology added population-level vita- min D screening to its list of low-value services, as part of the American Board of Internal Medi- cine’s Choosing Wisely campaign. This cam- paign is a physician-led initiative that promotes conversations between clinicians and patients to reduce the overutilization of low-value medi- cal tests, treatments, and procedures, encour- aging evidence-based decisions that improve care quality and avoid unnecessary harm. Among commercially insured U.S. adults, the recommendation did not lead to reduced rates of screening. In Canada, the government- sponsored health plan in Ontario took a more drastic approach to addressing low- value vitamin D screening and eliminated reimbursement for the test in late 2010, which then led to a substantial reduction in use. Yet again, economics was the biggest driver of reducing clinically unwarranted care, much more so than evidence or eminence. ImprovingWisely Wennberg was a giant in his field who in- spired many others to pursue health services research. One of these individuals is our current FDA commissioner, Martin Makary, MD, MPH. His first book, Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Rev- olutionize Health Care , challenged the health- care industry to look in the mirror and examine its own role in what’s wrong with healthcare. His second book, The Price We Pay: What Broke American Health Care — and How to Fix It , provides several examples of the tension that exists between clinically appropriate and clinically unwarranted utilization. One example he wrote about was Mohs surgery, a procedure that is very effective at surgically curing certain types of skin cancer. A Mohs surgeon starts by cutting out a skin cancer as a block of tissue, followed by ex- amining it under a microscope to see if there are clean margins. If microscopic examination of the tissue reveals cancer cells on the edge, that means not all the cancer cells have been successfully resected on that first cut, which