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May 25, 2009

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The Soul of American Medicine

If I ever meet Atul Gawande, I’m giving him a high-five, a hug, and then I’m going to try to talk to him for about fifteen minutes about why I think he’s special. From “The Cost Conundrum,” in the new New Yorker:

No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance…

When you look across the spectrum from Grand Junction [Colorado] to McAllen [Texas]—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems…

Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes.

Tim-sig.gif
Posted May 25, 2009 at 6:26 | Comments (6) | Permasnark
File under: Cities, Recommended, Science, Snarkpolicy

Comments

I'm finally looking at Better, and the mind reels at how one man can be good at so much. I can't even imagine being good at surgery--it seems unfair that is he is also so good at styling prose.

The common thread -- open-minded exploration of a problem, followed by precise, confident stitching.

You always get to watch Gawande think - but by the end, you always know what he thinks. Many writers give you one or the other, but he perfectly gives both.

Please add me to the list as a member of the Atul Gawande fan-club. His last couple New Yorker articles have struck me as supremely relevant and refreshingly sensible. He prefers cutting across lines of controversy, rather than digging in on either side. Also, like Gladwell, he is open to a rather sophisticated view of culture as the sum of institutionally bound and propagated ideas and practices that are powerful but not immutable.

This piece offers a beautiful solution to the dual health care/budget crisis that Orszag and others have brought to light, and it avoids the private/public health care debate. It's also refreshingly free of silver bullets. The solution he proposes would require a lot of sustained work from people invested in change. In short, it is a piece of journalism I yearn to love.

Yet, I'm not entirely convinced by the reasoning. Gawande figures out that the McAllen doctors prescribe more and costlier procedures than do their peers elsewhere and figures this to be the proximate cause of the area's absurdly high health care costs. He also shows that the main differences come in dealing with cases that do not have well-established best practices. So far so good. But he ultimately fails to make a convincing case for why this is true. He rejects arguments about training, but doesn't say why. I'd want to know where McAllen doctors went to school and how new doctors were recruited. Are there established recruiting networks that regularly bring in doctors from a small collection of training hospitals? Then I'd want to compare that network analysis with the origins of doctors in El Paso. Maybe he did that (he's a smart guy), but I see no evidence of such, and to do that study right would take a fair bit of rigor.

Ultimately, Gawande decides that McAllen somehow developed a particularly mercenary system of medical institutions with perverse incentives for doctors to order expensive procedures. But how and why? Why did McAllen succumb to these institutions while other areas did not? Which institutions became the "anchor tenants" of the patient-cash-machine culture?

I'm probably asking too much of what is more a think-piece or a call for further research than a sustained argument. Or, maybe I'm asking all the questions that Gawande intended the piece to elicit. Maybe the man really is a genius.

Also, I'm with Saheli: it's unfair that Gawande gets to be equally masterful in crafting organs and sentences.

He is a bit like Matt Crawford in that piece Robin posted the other day: a skilled manual laborer who writes well. (I'm not the first person to note the similarities between surgeons and mechanics.)

The real surprise with Matthew Crawford is that someone with a PhD from Chicago's Committee on Social Thought can write so well! (I kid, I kid.)

As for Gawande, it's true that he doesn't do a real statistical regression to find the "true" cause of high costs in McAllen. Again, it's a surgeon's method: get in there as close as you can, talk to the patient, explore, decide, act. But the virtue of it isn't that it identifies a single cause as much as it identifies practices that are clealry bad (my diet might not be the sole cause of my cholesterol count, but that doesn't mean it helps) so much as it says, wait a minute - here is a problem that nobody is even paying attention to, and here is a method (proven in context by someone who knows what they're doing) that reorients our thinking and practice with better outcomes.

@Dan I agree it's a (great) think-piece, and we're still just watching the previews before the EPIC HEALTHCARE BATTLE starts to roll.
I just kept thinking, Oh crap, this is the mortgage crisis all over again. A clusterfuck of perverse incentives, vested interests fed by captured government... Spell it out for me, Doc - what's the worst that can happen if we don't do anything? What if the operation goes wrong?

Posted by: Jake on May 28, 2009 at 09:18 PM
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