The CECS researchers have found no medical reason to justify the differences. Fear of malpractice suits in particularly litigious states comes to mind as a reason why some doctors and hospitals might be more zealous in performing diagnostic tests and interventional procedures. But even proponents of tort reform say that malpractice caps would reduce hospital spending by only 5% to 9%—not enough to explain twofold differences in the cost of care.

By the 1990s, it was getting harder and harder to shrug off Dartmouth's findings. With the 1996 publication of the first Dartmouth Atlas of Health Care, the work began making headlines nationwide. Today, almost no one questions the team's evidence or its conclusion: "Less care can be better care."

"The fact that the work they are doing is so rigorous, and the reputation of those doing it beyond reproach," says Dr. George Isham, medical director of HealthPartners of Minnesota, "means that [it] brings issues to the table that we wouldn't be talking about otherwise—namely the fact that more care leads to poorer quality. We are not just talking about wasting money," adds Isham.

"What is so profound—and so scary—is that the data is so powerful, and it doesn't change," observes Dr. Christine Cassell, president of the American Board of Internal Medicine. "There is a stark correlation between reduced utilization and better outcomes."

Study after study has proven the case. Just last spring, for example, Fisher and Dartmouth economists Jonathan Skinner and Douglas Staiger published a study in Health Affairs revealing that while there have been tremendous gains over the last 20 years in survival rates following an acute myocardial infarction (commonly known as a heart attack), survival gains have stagnated since 1996—even as spending has continued to climb— suggesting that we may have hit a point of diminishing returns. And once again, the results contradict the conventional wisdom that more care is better care: the gains in survival rates have been the smallest in regions like Southern California, where patients received more

"The fact that the work [Dartmouth is] doing is so rigorous, and the reputation of those doing it beyond reproach," says Dr. George Isham, medical director of HealthPartners of Minnesota, "means that [it] brings issues to the table that we wouldn't be talking about otherwise."

expensive, intensive care, and the greatest in areas like Minnesota, where they received more conservative care.

Meanwhile, the citizens of Minnesota contribute the same share of their paychecks to Medicare as do workers in California. But, on average, Medicare spends far more per beneficiary in Southern California than in St. Paul.

"Minnesota pays for the hospital building boom in California," observes HealthPartners' Isham. "And as long as the number of representatives in

Congress coming from high-cost states [like New York and California] exceeds the number of representatives coming from low-cost states [like Utah and Minnesota], this will continue to be the case."

This uncomfortable fact helps to explain why politicians have been slow to act on the Dartmouth research—even though veteran members of Congress have been well aware of the data for years, according to Susan Dentzer, health correspondent for PBS's NewsHour with Jim Lehrer.

"We know that we're spending two and a half times as much to treat patients in Florida as in Minnesota—and we're killing them faster," says Dentzer, who is a 1977 graduate of Dartmouth College. "When [Florida's] Bob Graham was still in the Senate, I asked him about this. He changed the subject. A smart guy, he realized that it was politically impossible for him to tackle the issue."