Rural vs. urban? Or something deeper? A provision in the House health care reform bill (HR 3962) instructs the Institute of Medicine to take two years to look at why health care costs so much more in some areas than in others in the last two years of life – twice as many doctors involved, days in the hospital, re-admits, and dollars spent – and make recommendations to change that. Unless Congress instructs otherwise, the IOM's recommendations are to become law. This NY Times article, and some politicians, are framing it as rural vs. urban issue, Iowa vs. Manhattan. But is it? Look at the map that goes with the article. What's up with big urban centers (and medical research and teaching powerhouses) like Boston, Atlanta, San Francisco, and Seattle, that are on the low end of the cost curve?  This is about something deeper in the structure of how you organize health care, how you compensate people, how institutions make their living. It is absolutely fair and reasonable to study this matter. We will never begin to get a handle on soaring health care costs unless we change it.