I was blessed to have parents who were physicians. Their dedication to their patients was the kitchen-table soundtrack of my early life. We lived in Seattle and I can still hear my mother, a pediatrician, and my father, a surgeon, worrying about people who couldn’t afford health care, kids who’d never had a medical exam or been to the dentist, and mothers dying because they couldn’t get the hospital care that would have saved their lives.

As if it were this morning, I recall their frustration over disconnects and disputes between the people who required care, the people who provided care, and the people who paid for the care. It sounded sometimes as if they didn’t have anything to do with one another at all.

Much has changed in a generation. There have been tremendous gains, but something has also been lost. Back then, doctors like my parents were the real linchpins of care; they literally held the whole thing together. Ask your own parents or grandparents and they’ll tell you that the relationship between patient and physician was everything. When I was growing up, patients were a personal, physical presence in my family’s life. They are what drew me to medicine in the first place.

It was a time when doctors, mostly old-fashioned fee-for-service solo practitioners, provided patients with a medical “home” where they could count on compassion, comfort and, yes, even house calls. Families often stayed with a single doctor across generations, with the same physicians birthing the babies and attending to the end of the grandparents’ lives.

Insurers, bureaucrats and technology had yet to take over. Nor was “quality” the data-driven model of measurement and evaluation it is becoming today. Instead, patients considered care to be pretty good so long as it anticipated their needs and was sympathetic to that intense vulnerability we each feel when we’re really sick.

Hospitals for the most part were local, autonomous and nonprofit. Their own bosses, they set their own agendas, catering to special constituencies and functioning much like a self-protected local cottage industry.

Beneath this rose-colored veneer was a “non-system” that was capricious, complicated and seeded with the problems of quality, cost and unfairness that still confound us today. Policy and academic specialists were convinced that the biggest problem facing health care was not that people were getting too much care but that they were getting too little care. The real problems—uneven performance, subpar quality, variations in patient care—were unknown, ignored or overlooked.

This was the health care world that awaited me when I went off to medical school in the 1970s, not yet realizing just how much things were about to change.

The small Vermont towns of Middlebury and Morrisville are separated by a two-hour drive up State Road 100 through the heart of the state’s historic Green Mountains. These mountains are made for exploration.

On peak fall foliage weekends SR 100 is jammed with tourists. In the winter, it is skiers headed for Sugar Bush, Mad River Glen and Stowe. One bygone year it was a restless group of my fellow Harvard medical students, eager to scale something other than the jagged academic peaks back in Cambridge.

Middlebury is the quintessential upscale New England village (pop. 8,100), a famous college town complete with covered bridges, a classic country inn and enough year-round residents with postgraduate degrees to fill an 800-seat theater. Most folks who live here work here; it’s been that way for a long time.

Morrisville (pop. 2,000) is less picturesque and more hardscrabble, with less money, less education and more kids per household than Middlebury. Many local residents work in the state capital, some 30 miles away. Higher education here is a branch of the state’s community college, with offices in a former hardware store just before you get to the Price Chopper on the way out of town.

Something else beneath the surface separates the two towns. To find it, you might have to dig deep into research that feels complex and dry at first, but holds some fascinating stories.

A landmark study of medical care in Vermont conducted more than 30 years ago found that only 7 percent of the kids in upscale Middlebury had their tonsils removed. But in Morrisville, a whopping 70 percent of all kids had tonsillectomies.²

Why the big difference? Something to do with different levels of income and education? Did an epidemic of tonsillitis sweep through the Morrisville schools? Did parents in Morrisville take better care of their children than parents in Middlebury?

The answer turned out to be none of the above. In Morrisville a small medical practice of only five doctors was unusually aggressive in removing youngsters’ tonsils. It was that simple.

With that 10 to 1 removal ratio, you would think that the kids in Morrisville would be healthier than all those kids in Middlebury. But they weren’t any healthier; they just received more health care.

The two investigators were puzzled by the disparity; it had to be an anomaly. To find out, they eventually examined health care practices throughout the state’s 16 hospital service areas spread across 251 towns and villages.⁴

Wherever they turned, the researchers found variations like the tonsillectomies that had nothing to do with patient need or demand. Instead, many doctors and hospitals practiced the principle that more care is better care, without scientific follow-up to test if that was, indeed, the case. As we now know, all that extra care often results in the delivery of care that is not needed, that wastes resources, and that can be dangerous.

The startling discovery of irrational variations in care set off shock waves that continue to ripple through the worlds of patient care, health care research, and our own philanthropic efforts to improve the quality of health care across the country.

The medical detective-scholars were earnest young graduates of Johns Hopkins School of Hygiene and Public Health named Jack Wennberg, a physician, and Alan Gittelsohn, a biostatistician.

They were disciples of the godfather of health services research in America—Kerr Lachlin White—himself a physician, epidemiologist, economist and early giant in the study of medical care utilization. He’s the one who initially showed the University of Vermont how to install a system to harvest patient data from hospital discharge summaries all across the state.

White was applying what he was teaching at Johns Hopkins, where he was training the advance corps of a whole new type of medical researcher, including Wennberg and Gittelsohn. He equipped them to assess both the medical and the social conditions of health care and its effects on real patients in real hospitals and community settings. And, with National Institutes of Health grants, he made sure they had the technological hardware and software to do the job.

I tell this story because Dr. White was one of my early heroes as I came to understand the complex relationships between medicine, health care delivery and health policy. His thinking continues to inform my own in shaping new ways the Robert Wood Johnson Foundation can help improve health and health care.

It has also helped inform a radically different approach to bettering the delivery and the quality of health care that is outlined in this message. It is an evidence-based approach that calls on communities to bring their own local health care forces into a new alignment of mutual interest and effort to help people get better care.

The intellectual roots of our work trace directly back to Kerr White, who saw clearly that localized patient care research was the key to understanding how health care works, or does not work, in a particular locale with a particular population.

Perhaps it is no coincidence that the same year Wennberg and Gittelsohn started their breakthrough work door-to-door in Vermont, Nobel scientist and transplant trailblazer Peter B. Medawar wrote, “If politics is the art of the possible, research is surely the art of the soluble.” ⁶

It follows, I would add, that philanthropy is the art of investing where the returns are measured in benefits to society—often because useful learning and action are achieved when special interests, political complexities, inadequate leadership or a hodgepodge of players put up barriers to resist change.

Which brings me to the rest of the Vermont story. Once the findings from Wennberg and Gittelsohn’s work began to soak in, a “don’t blame us” faction of organized medicine and individual physicians pushed back against the findings. They counter-argued that any inconsistencies in care merely reflected different patient conditions and needs. As a result, the Wennberg-Gittelsohn paper, “Small Area Variations in Health Care Delivery,” was rejected by every major medical journal in the country.

Not until six years after they began their work did Science magazine finally publish their manuscript⁷ (scrunched between articles on the authenticity of the Nixon Watergate tapes and the link between birth order and IQ among young Dutch males). The paper endures as a seminal work of social-scientific discovery. It still reads with the crisp relevancy of unvarnished scientific truth.

Gittelsohn eventually returned to Baltimore, while Dr. Wennberg’s worn and wrinkled road map led him to Hanover, New Hampshire, and Dartmouth Medical School, where he invented the now-famous Dartmouth Atlas of Health Care.

RWJF over the years has invested heavily in the Atlas, helping provide the resources and staying power for the team at Dartmouth to refine the once-struggling art of health services research into high science.

At first their data stream was a trickle, then a torrent. Complemented by the efforts of others, they continue to sharply map the realities of America’s health care landscape and make clear the best pathways to improvement. We rely heavily on the Atlas as we push hard against the quality frontier.

Three things stand out when you examine the map. No matter the terrain, most roads lead to regional and local solutions. Obstacles and pitfalls blocked early progress. Visionary pioneers like White, Wennberg, Don Berwick and Ed Wagner have cleared much of the way by challenging, disrupting and then changing the status quo.

For example, Berwick’s Institute for Healthcare Improvement directs our national programs to show doctors, nurses and hospitals how to make significant improvements in caring for patients. The result: People receive better, safer care and have closer relationships with their doctors.

Wagner heads Improving Chronic Illness Care (ICIC), another RWJF national program. Right now, ICIC-trained medical and nursing teams in hundreds of hospitals and clinics are following Wagner’s evidence-based Chronic Care Model to keep people healthier and out of the hospital in the first place.

Pathfinders like Berwick, Wagner and others are showing the country how to shift from a system of incredibly expensive acute or “sick” care to a more effective, less costly, higher-quality system of chronic care.

The going has not been easy or swift. Health care’s status quo has long been suspicious of innovation related to quality improvement, distressed by scrutiny and dead-set against public accountability. Truly transformative change demands a different approach, one based on tested, proven and trustworthy evidence of what it takes to demonstrably improve and sustain the quality of medical treatment and patient care.

Health care in America has reached its own tipping point, what Malcolm Gladwell describes as “the moment of critical mass” preceding explosive change and TIME Magazine calls “the levels at which the momentum for change becomes unstoppable.”⁸

It is evidence—the data—that builds the critical mass. Until recently, extensive data on how hospitals and physicians actually meet patient needs was nonexistent. No wonder that “health care” and “quality” have been so mysterious to most people for most of their lives. The professionals who provided it couldn’t explain it themselves.

In the past decade, however, data streams measuring quality matured and deepened from sources as varied as Dartmouth, Medicare, the U.S. Department of Veterans Affairs, the federal Agency for Healthcare Research and Quality (AHRQ), state governments, business groups and consumer advocates.

Also new on the scene is the public-private National Quality Forum (NQF), comprising nearly 500 organizations representing most major players across the health care sector’s full spectrum. Through NQF, they are agreeing to act together on priority health quality issues where the need to measure and improve care is most urgent.

Put it all together and the once-barren quality landscape is becoming an abundant field. As a result, “quality” has become an evidence-fueled engine for the improvement of every aspect of health care delivery and financing. And it doesn’t always have to be high-tech.