The United States leads the world, by a substantial measure, in its monetary commitment to medical care. If, as we have long believed, more care is better care, then American medicine must surely be the best in the world. But where is the “best” of American medicine? Previous editions of the Atlas have demonstrated conclusively that in American health care, geography is destiny.

Both the amounts and kinds of care provided to residents of the United States are highly dependent on two factors:

the capacity of the local health care system (which influences how much care is provided) and the practice style of local physicians (which determines what kind of care is provided). Variations in the intensity of use of hospitals, the striking differences in care at the end of life, and the nearly random patterns of elective surgery all raise questions about the outcomes and value of care—about quality. Is more in fact better? What is the value received for the money spent? What, as Joseph Juran asked, is the cost of poor quality? These questions are receiving increasing public attention. The National Academy of Sciences convened the National Roundtable on Health Care Quality to assess the problem of quality of care. Reporting its findings in the American Journal of Medicine, the Roundtable concluded: “Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as underuse, overuse and misuse, occur in small and large communities alike, in all parts of the country and with approximately equal frequency in managed care and fee-for-service systems of care.” The Roundtable estimated that “very large numbers of Americans are harmed as a direct result” of poor quality care: “Millions of Americans are not reached by proven effective interventions that can save lives and prevent disability. Perhaps an equal number suffer needlessly because they are exposed to the harms of unnecessary health services. Large numbers are injured because preventable complications are not averted.” The concern about quality is not restricted to experts or to those who speak on the part of patients or the American public. Ordinary citizens are concerned. The American Hospital Association’s “Reality✓” investigation revealed that patients have significant problems with “The way the ‘system’ works (or fails to work), and the way decisions are made about their care.” Patients interviewed by the Picker Institute for this study reported that they “see a confusing, expensive, unreliable and often impersonal dis-assembly of medical professionals and institutions.” Moreover, patients expressed a strong concern over their own roles in making health care decisions. Asked who should control decisions about health care in an “ideal world,” AHA focus group participants answered that they, themselves, should call the shots, along with their doctors. Patients are more aware than they have been in the past about the variations and alternatives in treatments for many disorders, and they are more likely to question doctors about decisions regarding their treatment ... [a] senior citizen who had recently drawn up a living will with the help of her seniors’ group commented, “I didn’t know before that I could refuse! Now I know!” These findings call into question the underlying assumption that more care is better care, and that access and cost are the most fundamental problems of the American health care system. Patients as well as health services researchers have begun to ask whether more really is better, and whether the “system” really is a system. Until we can answer those questions with any certainty, we will not be able to achieve real quality in American medical care.