Month: December 2009

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[quote]I have called David Goldhill’s How American Health Care Killed My Father a must-read for anyone who wants to speak up in the health care debate. The New Yorker also has a must-read article on the issue called The Cost Conundrum. In that article we are introduced to the town of McAllen, Texas where Medicare spends much higher than average amounts per capita than the national average ($15000 vs $8000) in an area with much lower than average per capita income($12000 vs $21500) and cost of living. Atul Gawande, himself an associate professor of surgery at Harvard Medical School, introduces us to the town and begins an attempt to discover why the costs of health care are so high in McAllen.

Are the people there less healthy? No, they have higher rates of some health conditions than average and lower rates than average of other conditions. Overall health fails to explain the cost differential.

Was the quality of health care being provided higher than average? While they were not lacking for available medical technology or facilities the quality of care was, once again, nothing unusual.

McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.

Gawande went to dinner with some McAllen doctors and showed them the data on health care costs in McAllen:

Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

He then asked them why they thought the care was so costly there. One suggested the cost of malpractice insurance but then they admitted that since Texas had passed caps on malpractice lawsuits they had virtually no lawsuits to drive up the cost of care.

Finally a general surgeon among the dinner party declared that the issue in McAllen was overutilization.

Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.

Anecdotal evidence and agreement is fine, but Gawande went in search of more concrete evidence.

To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice . . . I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.

Having identified the cause of the high costs the search was on for an explanation of why there was so much overutilization. The answer was in the culture of the medical practitioners in McAllen – they were very profit oriented rather than results oriented. I believe the one place that Gawande’s article falls short is that he stopped with exploring the cultures among the medical community and failed to examine whether the general community culture in McAllen helped to foster that inefficient mindset among the medical practitioners in the area. I’m willing to bet that such a short-sighted culture in the medical community might not need encouragement from the local culture, but could not survive if the local culture were one that actively discouraged a similar outlook in the community at large.

Talking to a surgeon from McAllen, Gawande concludes that whether we have a public option, single payer, or private health insurance will not matter if the culture in McAllen continues to become more common as it has been doing.

In contrast to McAllen, Gawande explores the cultures in the Mayo Clinic and the Medical community of Grand Junction, Colorado and finds that both of these low-cost, high-quality health care systems took very different approaches to each arrive at “accountable-care {organizations} . . . {where} leading doctors and the hospital system adopted measures to blunt harmful financial incentives  {and} took collective responsibility for improving the sum total of patient care.” He also lists four other high-quality low-cost health care systems each of which has a culture of accountable care – the Geisinger Health System, the Marshfield Clinic, Intermountain Healthcare, and Kaiser Permanente.

Whatever approach Congress tries to take to reform our health care system they and the American people need to understand that we cannot successfully plant a Health Care tree. The only workable approach will be to plant Health Care seed and help it to grow into a health new health care system.