Today, most hospitals try to deliver every sophisticated medical service and procedure they can. In Philadelphia, we have at least seven hospitals that do heart transplants and many more doing liver, kidney and bone marrow transplants. That's a lot of redundancy.

A friend of mine was recently was diagnosed with multiple myeloma. This is a rare cancer that affects the bone marrow. I researched the care for the condition that is provided by various health systems to advise him where to go.

I found that the Hospital of the University of Pennsylvania has a special team dedicated to treating myeloma. He chose to go there for evaluation and treatment, and he has just undergone a bone marrow transplant with his own bone marrow stem cells.

This is an amazing technology. But my visit to him after the procedure was even more amazing. I expected to be asked to don mask, gown, gloves, etc. but was told that it was not necessary. The hospital's care had advanced to the point where those precautions were no longer needed. His unit was filled with patients with multiple myeloma. The nurses and doctors who work there were all incredibly knowledgeable about the disease because of their vast clinical experience in treating it.

When I left the hospital, I asked myself, "Why would anyone go elsewhere for multiple myeloma treatment?" The question made me think about how our health care services are organized in the United States. Why do we need more than one heart transplant program in a city like Philadelphia? Why shouldn't one hospital be the designated center for each high-tech service? How many stroke centers do we need?

The care of patients with complex conditions requires an extensive infrastructure with 24 hour access to skilled health care providers, technicians, imaging, laboratory and other services. Why should we allow some hospitals to dabble as dilettantes in the care of these patients when we can coordinate care in just a few major centers?

The big political question is how can we get hospitals to agree to this? Years ago, Pennsylvania required that hospitals receive a "certificate of need" from the state before they could begin to perform certain complex procedures. But about 15 years ago, the program ended.

Hospitals want to offer as many complex procedures as they can because they add to an institution's luster. However, if insurance companies reduced the number of hospitals that are eligible to receive reimbursement for performing these procedures, fewer hospitals would retain marginal programs.

Of course, we would need an independent panel of experts to decide which hospitals should provide which complex procedures based on quality, outcomes, and other objective factors. And insurance companies could only succeed in enforcing the panel's decisions with help from the government.

However, if we could accomplish this, we would decrease the cost of expensive high-end care, improve results, increase patient satisfaction, and perhaps have savings left over to provide care that is not so highly specialized but vitally important nevertheless.

This is not rationing health care. It is developing a rational approach to providing the best care for everyone. Consumer choice is great for some things, but for high-tech medical care, focusing resources on the best providers is the way to get the efficiency and quality we want and need.