It was New Year’s Day, 1929. Nearly 10 months before the infamous stock market crash. On a warm sunny day in Pasadena, Georgia Tech played the University of California in the Rose Bowl. In the second quarter, Georgia Tech’s Stumpy Thomason fumbled the ball near his own 40-yard line. Roy Riegels from California scooped up the ball, took a few steps, collided with several players, and spun around into the open. As he sprinted down the sideline, there was no one between him and the goal line. The only problem was that he was running the wrong way. His teammate, Ben Lom, chased after Riegels shouting and trying to turn him around, but Roy never broke stride and kept racing for the wrong end zone. Finally, at the 1-yard line, Lom tackled Riegels. It was still California’s ball, but now 99 yards in the wrong direction. They decided to punt the ball, but the kick was blocked for a safety, with two points awarded to Georgia Tech. That turned out to be the margin of victory, as California lost the game 8-7. For the rest of his life, All-American Roy Riegels would live with the nickname “Wrong Way Riegels.”
Over the past 10 to 15 years, health care providers have been consolidating at a rapid pace, forming multihospital systems in an effort to realize economies of scale, protect market share, and improve access to capital. Along the way, press releases accompanying health system mergers commonly promised patients the “right care in the right place at the right time.” Implied in those promises was the expectation that providers within a health system would rationalize clinical programs and standardize care processes, ensuring that patients would receive consistent treatment regardless of where in the system they made their initial encounter.
A review of Medicare claims data conducted in 2016 discovered that the promises of consistency made when health systems formed had been largely unmet. Startling variation in utilization of resources occurred between hospitals within the same health system. For example, three- or four-fold variation in the use of major imaging between hospitals in the same health system was common. The probability of repeat imaging, or the likelihood of post-acute care facility use following routine surgery was highly variable within systems. Across more than 200 health systems studied, the variation within systems was higher than the variation between systems. There were billions of dollars in untapped economic potential if avoidable variation was reduced or eliminated.
To determine whether health systems had made any progress with respect to variation reduction in the years following the original study, the Vizient Research Institute took another look at more recent Medicare claims data and compared utilization patterns across the same clinical marker events first examined in 2016. The findings were not encouraging. The use of post-acute care (PAC) facilities declined virtually everywhere, likely in response to bundled pricing for hip and knee replacements which put financial responsibility for PAC utilization on hospitals and physicians.
For the other clinical markers, intrasystem variation remained unchanged or even increased for the majority of the health systems in the years since the original study. Health systems were twice as likely to see their variation increase rather than decrease in the use of major imaging. The likelihood that a patient with back pain would receive a CT or MRI typically varied by 10 to 20 percentage points within a given system back in 2016; the same differential had grown to 15 to 25 percentage points in more recent experience. Repeat abdominal imaging – excluding cancer patients – showed higher intrasystem variation in the more recent data compared to the study done in 2016. Instead of reducing variation between hospitals in the same systems, we are moving in the wrong direction.
In November 1957, a high school player named Jan Bandringa intercepted a pass and ran 55 yards the wrong way into his own end zone. Again, the 2-point safety proved to be the difference in the game as Bandringa’s team lost 9-7. Not long after, a letter arrived in the mail, with a heartfelt message of compassion and an encouraging reassurance that he would eventually get over the disappointment. The letter was signed “Your friend, Roy Riegels.” Like those long-ago football players, we seem to be running in the wrong direction. Instead of running alongside us shouting to get our attention, our teammates should tackle us before we lose any more ground.
