Non-random thoughts on health care

Two articles have come to my attention in the past several weeks, each by a person for whom I have developed a profound respect over the years. Neither article appeared in the “medical” literature, but both are well worth reading.

The first of these is by Dr. Atul Gawande, a surgeon at the Peter Brent Brigham Hospital in Boston, who happens to have an interest in the prevention of surgical infections and has an appointment in the Harvard School of Public Health. His article, “The Cost Conundrum,” appears in the June 1, 2009 issue of The New Yorker magazine.

Gawande was interested in identifying the genesis of the wide geographic differences in the costs of health care in the United States, as measured by Medicare expenditures per person per year. Investigators at Dartmouth Medical School have studied these patterns for years and have found widely divergent figures in various geographic parts of the country. There are variations up to threefold or more in per-person Medicare expenditures from region to region. Why? This was the question that Gawande sought to answer.

The town of McAllen, Texas, was selected as a starting place, since McAllen had one of the highest Medicare expenditure rates in the country, more than $15,000 per year in 2006. This was just about exactly double the national average expenditure of about $7,500 in that same year.

In a number of interviews with physicians, hospital staffs and hospital CEOs, it became clear that patients in the McAllen area got more of virtually everything than patients in less costly areas. For example, according to Gawande, McAllen patients in 2005 and 2006 received 20% more abdominal ultrasounds, 30% more bone-density studies, 60% more stress tests with echocardiography, 200% more nerve-conduction studies and over 500% more urine-flow studies. Rates of cholecystectomies, knee replacements, pacemakers, implanted defibrillators, cardiac by-pass operations and a number of other surgical procedures were all similarly increased in frequency in McAllen, compared with another comparable community, El Paso, 800 miles to the northwest along the Rio Grande River.

Gawande was able to rule out several possible reasons for these findings. First, the McAllen population was not a less healthy population than that found in less costly areas. Further, there was no evidence that medical technology was more advanced in McAllen than other areas, nor that the McAllen population was made healthier as a result of all this medical care than people living in other less costly areas.

In fact, patients in the McAllen area actually were less likely to receive recommended preventive health care measures such as influenza and pneumococcal vaccines, statins for elevated cholesterol levels and the like. Nor was it related to that oft-cited concern — malpractice litigation. Other communities in Texas, eg, El Paso, with the same malpractice laws, had nowhere near the Medicare expenditures in McAllen. The physicians in McAllen were trained no differently than physicians in lower cost areas. McAllen’s excessive Medicare costs were due, very simply, to massive overuse of medical care that extended to virtually all areas of medicine.

Gawande used several hypothetical examples to illustrate his point. I’ll relate one such hypothetical here. A 44-year-old woman came in with a chest pain after a fight with her husband; EKG was normal. Her chest pain subsided and she had no family history of heart disease. Fifteen years ago (before costs rose well beyond the national average), McAllen physicians would have sent her home, perhaps with follow-up stress testing. Today, she would get a stress test, echocardiogram, a 24-hour Holter monitor and almost surely a cardiac cath.

A system with 'no breaks'

Space does not permit covering all of the points in the article, but in the last analysis, the McAllens of this country — and there are many — are the natural end-result of a medical care system that “has no brakes” and in which all the incentives are in the wrong direction, that is, favoring doing more rather than less. Although he didn’t use the word, “greed” is a huge intangible factor that enters into “professional judgment,” although few would admit it. Whenever one’s patients are thought of as profit centers rather than as a sacred trust, and in a system seemingly without accountability, the result is virtually guaranteed — so perverse are the incentives in the present system.

The preceding is not meant as an indictment of all the physicians in McAllen, Texas. Far from it. Rather, in a real sense, it is an indictment of the entire health care system, or in Gawande’s words, a battle for the very soul of medicine.

Gawande pointed out that no one in medical school teaches students anything about money or the culture of money. He described three approaches used by physicians to the issue of money: First are those who see their patients, make their recommendations, submit their bills, and if everything comes out OK at the end of the month, they are content. Second are those that use their income to improve their practice, such as hiring an extra staff member to do some office measures to improve patient care. Third are those who see their patients as profit centers or as a revenue stream and devise countless ways to enhance this stream. It is this last group that increases Medicare expenditures in an uncontrollable fashion.

Brighter side

On the brighter side, Gawande also identified a number of centers with normal or lower than normal Medicare expenditures, where patient-centered care is accorded the highest value, and where medical decision-making is fully accountable. These settings can be found in the Mayo Clinic model; in Seattle, Washington; Durham, North Carolina; the Geisinger Health System in Pennsylvania; Kaiser-Permanente in Northern California; and even communities without a major medical center such as Grand Junction, Colorado, These models are characterized by a patient-centered medical home, salaried (for the most part) medical staff, and accountability. The last point is perhaps the most critically important one.

Health care costs are easily the number one drain on our national budget, outranking social security, bank and automobile bailout monies and all the current recession-related spending. These costs must be controlled in any meaningful health care reform. Curbing excessive Medicare costs alone would go a long away to achieving this goal, but it will require a total revamp of the way in which physicians are remunerated.

The second article is by Dr. Abraham Verghese and appeared in The Wall Street Journal as an essay on June 20, 2009. It provided both a reinforcement and a counterpoint to Dr. Gawande’s article. I’ll write more about Dr. Verghese’s essay next month.

Theodore C. Eickhoff, MD is an Infectious Diseases in Children Editorial Board member.