Does More Health Care Spending Produce Better Health and Happier Doctors?

Over 3 decades, researchers at Dartmouth Medical School's Center for Evaluative Clinical Sciences, headed by Dr. John Wennberg, have produced a remarkable series of studies challenging the assumption that the more we spend on health care, the better health we get. They found more than a 2-fold difference in Medicare per capita spending across U.S. regions, particularly for patients with end-stage, chronic illnesses. Furthermore, per capita spending in a region is strongly correlated with the region's supply of physicians and hospital beds (1). More recently, they found no evidence that greater spending, more resource inputs, and more frequent use of hospitals and physician services are associated with improvements in survival, functional status, or patient satisfaction with care (2) or better performance on technical measures of care processes (3).

In this issue, Sirovich and colleagues (4) extended the Dartmouth group's analysis to include the topic of physician attitudes. Consistent with their previous research, they report that physicians in regions of high care intensity who have access to more resources feel no better able to provide quality care than physicians in other areas and are somewhat less satisfied with their practice environments. Conversely, physicians in lower-intensity regions do not experience more dissatisfaction with their careers or think they have inadequate resources at their disposal.

The purpose of this editorial is to address 2 issues. First, should policymakers now accept that higher health care spending does not improve health and act accordingly? The Dartmouth group's data are consistent—and insistent; they estimate that 30% of Medicare spending is wasted (1). Yet, despite the serious financial pressures facing Medicare as the baby boom generation approaches Medicare eligibility, the policy response to the Dartmouth research has been deafening silence (5). My second objective is to speculate …