Geographical Variations in Medicare Spending

In this issue, the editors have taken the unusual step of asking three experts to comment on the two lead articles. They did so because they thought that these articles contribute new and important information to our national dialogue about one of the great dilemmas of American life: the high cost of medical care. The articles provide insight into the reasons for variations in costs of care in different parts of the United States and help us to understand what we gain from greater expenditures. These articles are pertinent for us as internists because they decide whether to order many of the services whose frequent use distinguishes higher-spending regions from lower-spending regions. They asked Kenneth Shine, MD, to discuss the implications of the study findings for physicians. Dr. Shine is a cardiologist. He recently completed 10 years as the president of the Institute of Medicine of the National Academies. He now works on health security issues. Charles Phelps, PhD, discusses the issues from the perspective of a health economist. He helps us to understand the strengths and the limitations of the methods used in the two articles. Dr. Phelps is the provost of the University of Rochester in Rochester, New York. The editors asked Gail Wilensky, PhD, to discuss the articles from the perspective of a Medicare administrator and health policymaker. She was the administrator of the Health Care Financing Administration (now the Center for Medicare & Medicaid Services) from 1990 to 1992. More recently, she chaired two expert panels that advise the U.S. Congress, the Medicare Payment Advisory Commission, and the Physician Payment Review Commission. The editors expect these articles to generate a vigorous discussion, and we're grateful to our three editorialists for setting the stage.