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By Thomas C. Rosenthal

With the introduction of online health insurance exchanges comes great attention to increasing access to care, particularly for the uninsured. While access to care is critically important, equally important is how care is provided. How do we make the system sustainable? Medicare spending in Miami is two times that of Medicare spending in Western New York. Why are costs in some areas of the country different than other areas?

Dartmouth’s School of Medicine conducted a study to learn more about how physicians practice and how they decide on treatments. The study offers the best explanation for regional variations in health spending. The study classified physicians who discuss palliative care options with the sickest patients as “comforters.” Physicians who preferred interventional care were labeled “cowboys.” Certainly, the two categories are not mutually exclusive.

By way of example, one patient was diagnosed with severe congestive heart failure and advanced dementia. Sixty-five percent of the cardiologists in the study recommended an implantable cardioverter-defibrillator, a very aggressive treatment approach and one that is contrary to accepted clinical guidelines. Twenty-seven percent of physicians trended toward the “cowboy” category and 29 percent toward the “comforter” category.

Physicians who generally perceive medical interventions to be highly effective tended to recommend interventions. The second most common factor in selecting interventions involved financial incentives for the physicians.

This study underscores the need for research comparing what treatments are the most effective, evidence-based practice. It also suggests a role for primary care physicians. It is not uncommon for specialists to express relief when aggressive interventions are not selected for patients unlikely to benefit.

The process of determining the most efficient treatment for a patient is many times a three-way avenue, between primary care physician, specialist and patient. Since many physicians are somewhere between comforter and cowboy, it is important that all patients, and their family members, have open and frank conversations with their physicians as they seek treatment.

Health care encompasses multiple decision points. Patients should ask: “What are my options?” or “Is there a less aggressive way to treat this?” All physicians should view these questions as reasonable and they will likely welcome the dialogue. Asking such questions can be intimidating for some patients, so ask your primary care physician to join the conversation, check the literature and provide advice. Doing so will improve your satisfaction with care and improve the satisfaction physicians have with caring for you.

Thomas C. Rosenthal, M.D., is chief medical executive of Optimum Physician Alliance.