Geographic variation was also observed for eye examinations and screening mammography but was less pronounced.
In an accompanying Invited Commentary in the same issue, Jerome Kassirer, MD, former editor-in-chief of the New England Journal of Medicine, and Arnold Milstein, MD, MPH, director of the Clinical Excellence Research Center at Stanford University, wrote that "financial incentives" are at the root of overtesting, "sustained by tacit intraregion physician practice norms."
"Many physicians privately acknowledge that financial reward is a major underpinning of these norms," they wrote. "When attempting to intervene, medical directors of healthcare systems or physicians' independent practice associations frequently face an underlying physician counterargument that they 'cannot afford' to cut back on current levels of resource use without an offsetting payment. Hippocrates and Osler would not be impressed."
And even though payment incentives and penalties in the Patient Protection and Affordable Care Act and other rules in recent years may discourage overtesting, they will not be enough, Kassirer and Milstein wrote. "We will have to swallow much stronger policy medicine."
The second study, also by Welch, with Archie Bleyer, MD, of the St. Charles Health System in Portland, OR, "raises serious questions about the value of screening mammography," and asks whether women are receiving too many mammograms and too many harmful interventional procedures that were not really required.