By MATTHEW HOLT

The concept of practice variation raised its ugly head again this weekend in the northern California news media. And buried in the stories are several themes for our ages. But the conclusion is, the power of individual health systems and very small numbers of physicians to change patterns–and the cost–of care are enormous.

First the stories. Both about health care but also both revealing the future of investigative reporting. The BayCitizen is a non-profit blog about the San Francisco metro, created as response to the local papers cutting their reporting. It also provides stories to the NY Times–I’m unaware about how much of its revenue comes from the Times, but it’s part of  the Times’ entry into non-NY competition with retreating local papers.

For this story on heart program readmission Katharine Mieszkowski picked up on an older UCSF press release and showed how UCSF used a $500K+ donation from the Gordon & Betty Moore Foundation (that’s the Moore of Intel & Moore’s law fame) to create a very sensible program that gave in-home support to newly discharged elderly cardiac patients. It cut readmission rates by 30%. The BayCitizen though will upset Gary Schwitzer as it did not include the actual numbers but the UCSF press release does, and yes this is a relative not an absolute cut. Here’s the key graf

Over the past 11 months, only 16 percent, on average, of the hospital’s heart failure patients were readmitted within a month of discharge, down from 23 percent in 2006. That’s well below the national 30-day readmission rate of 25 percent. The average readmission rate was 11.6 percent during the first four months of 2011.

So UCSF was about average and got much better and seems to be getting better still–but there’s quite a way to go. But it is an indication that at least one AMC is capable of moving the ball in the right direction. Of course UCSF is a leader in the pro-Dartmouth “use resources sensibly” camp, and we may or may not see the “keep em alive at all costs” folks at UCLA follow suit.

Meanwhile up in rural northern California it looks like the same Dartmouth data set is about to bring a series of visits from the FBI. You may recall the trials and tribulations of Tenet and Drs Chae Hyun Moon and Fidel Realyvasquez at Redding Medical Center–who ended up settling for more than $450m while incredibly not facing criminal charges for unnecessary surgery and Medicare fraud. It seems that basically the same thing is happening again.

What’s interesting is that back in 2002 when the Tenet Redding story was blowing up, it was a qui tam suit from another physician and a patient that revealed the mess. In 2011 the San Francisco Chronicle reported that basically the same thing is going on in Clearlake, another backwater in rural northern California best known for putting on concerts by has-been 70s rock stars. A small hospital with three cardiologists has been using angioplasty and stents at five times the state average. But it wasn’t the Chronicle or a QuiTam suit that exposed the goings on Adventist Health-owned St. Helena Hospital–it was a combination of an academic–Stanford’s Lauren Baker–and the California Health Care Foundation-funded Center for Health Reporting, that tracked down what was happening using the Medicare Data via the Dartmouth Atlas. And the exposure is now producing a furious rearguard action from the hospital, using the “our patients are sicker” line. Good luck guys. Oh, and unlike in the Tenet case, some prosecutors are now going after “unnecessary stenting” with criminal charges such as this possible 35 year sentence on the way for one Maryland cardiologist.

But the big picture is this. Stenting and other debatable procedures are coming under the microscope. And Foundations and academics broadly favorable to the Dartmouth view are going to be playing a bigger role in both exposing the hidden activities of the health care system–a la Clearlake–while other Foundations are going to help promote new ways of care coordination, as at UCSF. And the nature of the new media means that transparency into how health care is delivered will continue to increase. Finally what we’re realizing is in medicine the actions of a limited number of professionals–whether promoting a new system or overusing stents–are highly influential. So we can expect more regulation and interference in individual medical decisions in the future.

(FD-I know Lauren Baker though haven’t worked with him & the CHCF funds some of Health 2.0’s conference activities, although I had no contact with them about this story)