Thursday, May 28, 2009

Why our health care costs are so high and what we can do about it

In order to truly stabilize the economy and rescue Medicare from financial collapse, the Obama administration knows it has to do something about the elephant in the room: ever-rising health care costs. In this week's New Yorker, surgeon-writer Atul Gawande presents an eye-opening discourse on why American health care costs have ballooned in the last decade and what can done about it.

To make his case, Gawande visits McAllen, Texas, which is one of the most expensive health-care markets in the country. In 2006, Medicare spent $15,000 per enrollee in McAllen (almost twice the national average); only Miami, Gawande reports, spent more per person on health care. The reason? Too much medicine. Doctors in McAllen prescribe far more tests, treatments and surgery than doctors in a nearby Texas town and nationwide. Yet the quality of health care is no better in McAllen, and Gawande cites research showing that such overuse of medicine may actually make patients worse.

So why are doctors in McAllen so aggressive? After interviewing everyone in sight, Gawande concludes that many doctors in this Texas town, unlike doctors in more conservative cities like Seattle, Sacramento, Boise and even nearby El Paso, see their practice as a money-making "revenue stream." They recognize that the more tests and treatments they prescribe, the more procedures they do, the more money they'll make.

The solution? Gawande argues that rather penalizing the money-savvy docs of McAllen, the Obama administration should begin rewarding the doctors and non-profit institutions (hospitals like the Mayo Clinic and health plans like Intermountain and Kaiser) that band together to practice a more preventative, conservative type of medicine and discourage "overtreatment...and sheer profiteering."

Gawande notes that "we are witnessing a battle for the soul of American medicine" and concludes that unless we begin rewarding "the leaders who are trying to a build a new generation of Mayos...McAllen won't be an outlier. It will be our future."

This is a scary article and a must read.


Dan said...

Very informative post, Alison, and accurate.

Some time ago, I worked with a group of Urologists. They would look for any opportunities to perform diagnostic testing that was rather expensive, and at times rather traumatizing for the patient being tested.

For example, a patient may be seen by the urologist with slightly elevated frequency in urination, with mild pain during voiding.

A urinalysis would be performed on this patient, which is appropriate.

Often, the urine sample would show microscopic hematuria. This is to be expected in most if not all cases of a urinary tract infection (UTI), which is what the symptoms of the patient indicate. UTIs are common- particularly with women.

Yet microscopic hematuria may be present in more serious urological disease states, so this allows the urologist to do additional diagnostic testing, such as what is called a cystoscopy.

An invasive procedure, a device is inserted into the urethra into the bladder to examine the walls of the bladder for abnormalities.

The patient, who, according to standards of care and guidelines that exist, should have simply had a urine sample cultured while being prescribed appropriate antibiotics to treat what likely is a UTI.

But since any blood in the urine suggests the rare possibility of perhaps bladder cancer or cystitis, the urologist is allowed to order this invasive procedure.

And the urologist will be reimbursed for this unnecessary examination in order to acquire individual profit for this doctor who is concerned with personal financial gain more than the restoration of the health of their patient.

Government health care programs must not be depleted by acts such as what has been described. Most spending from these programs are for chronic diseases. It concerns me if these patients are unable to be treated in the immediate future.

And those who are opposed to universal government funded healthcare are ignorant, quite simply. Because government health care programs already provide health care coverage for about half the citizens in the United States.

The primary contingency with government funded healthcare for others is the unfortunate abuse of this system by those who fraudulently steal from taxpayers that fund government healthcare programs.

Speculated contingencies by those who are concerned about depletion of their profit from our health care system are baseless and without merit.

American citizens must be informed completely about such issues, and question what others say that are overtly deceiving upon assessing their conclusions.

Roy M. Poses MD said...

We have been heading in this direction for some time. I learned from Arnold Relman's article in JAMA (Relman AS. Medical professionalism in a commercialized health care market. JAMA 2007; 298: 2668-2670. Also see also my blog post here: that a US Supreme Court decision that seemed to make physicians especially vulnerable to anti-trust laws resulted in the AMA and other professional societies acquiescing to the commercialization of medical practice.

It seems that physicians are no longer legally able to hold themselves to standards that eschew commercialization, and hence standards that require physicians to put the interests of patients ahead of profits.

I don't think many physicians were aware of this history before Relman wrote his article.

It seems we need some sort of legal way to restore our professionalism, or all of us will end up like the doctors of McAllen.

beenthere/donethat said...

Thanks! This is an excellent article. Our local example (Massachusetts) was highlighted in a story about the Board Chair at Partner's Health (Mass. General and the Brigham) and his outrageous conflicts of interest in this Sunday's Boston Globe. Of course, given the local political and business culture, this kind of activity is perceived as just business as usual - which is, of course, sadly true!

Anonymous said...

What a great health article, this is really what I am looking for. Thanks.