* Atul Gawande in the New Yorker (6-1-09): there is no solution to our healthcare dilemma if we don’t first understand the problem

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…

Atul Gawande’s article in New Yorker

is the best statement of the healthcare problem I have ever read

…

I recommend you go to http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande and read the entire article.

Here are some extracts …

• McAllen, Texas is one of the most expensive health-care markets in the country.
• Only Miami—which has much higher labor and living costs—spends more per person on health care.
• In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average.
• Our country’s health care is by far the most expensive in the world. The question we’re now frantically grappling with is how this came to be, and what can be done about it.
• McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.

LMW: What follows reads like a detective story, as Gawande hears and explores one suggested reason after another, rejecting them all until …

• The Medicare payment data provided the most detail.
  • Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. I
  • n 2005 and 2006, patients in McAllen received
    • twenty per cent more abdominal ultrasounds,
    • thirty per cent more bone-density studies,
    • sixty per cent more stress tests with echocardiography,
    • two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome,
    • and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles.
    • They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes.
    • They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents.
  • And Medicare paid for five times as many home-nurse visits.

The primary cause of McAllen’s extreme costs was

the across-the-board overuse of medicine.

• I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country.
  • The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues.
  • … decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers.
  • It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income.
• The Mayo Clinic is not an aberration.
  • One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores.
  • years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients.
  • Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization.
  • The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

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.
  • 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.

These arguments miss the main issue.

• 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. You get McAllen.