THE ALLEGORY OF THE CONVEYOR BELT
TOEXPLAIN WHY THERE ARE SO MANY highcost cost variations in medicine, Wennberg has come up with an allegory in the spirit of Plato and his cave.
Imagine that a physician stands beside a conveyor belt, which carries toward him a continuous stream of marbles colored black, white, and gray. The doctor's job is to place these marbles on an adjacent shelf, symbolizing the hospital, according to a few strict rules. All black marbles must be picked up and put on the shelf; they stand for critically ill patients, afflicted with such conditions as heart attacks or strokes, who must always be put into the hospital. Other rules require setting aside the white marbles: these symbolize patients with illnesses like sore throats and colds who don't need hospital care. Next come the gray marbles people with illnesses such as gallstones and pneumonias for whom there aren't any strict rules at all. As a result, the doctor must carefully examine these marbles sorting among the various' shades of gray, in effect, to find the sickest patients and place as many as possible in the hospital.
According to Wennberg who remembers having to face similar "sorting" decisions when completing his own medical training this allegory symbolizes the way the health-care system really works. If there is sufficient room on the shelf in other words, if there are available hospital beds it's much easier simply to steer sick patients to a hospital bed than to arrange other alternatives, such as home care or transportation to a nursing home. And because doctors admit thousands of patients into the hospital who may not need to be there, they may inadvertently be doubling the amount of money that the nation spends on health.
The problem is traceable to what Wennherg and his colleagues view as a major defect of the health-care system. The supplies of hospital beds and medical specialists in the nation bear no logical relation to real medical needs:; instead, they are a function of politics, ad hoc decisions by doctors and hospitals, and outdated medical manpower policies stemming from die 19605. Yet for many procedures, such as surgery and certain tonus of radiology, there is more than sufficient "capacity" to meet genuine needs. The answer: assess the distribution of doctors, beds, medical equipment, and even healthcare workers and then take broad-based steps to "reallocate" them where needed.
