"the best article you'll see this year on American health care"

[babylonsister]

http://voices.washingtonpost.com/ezra-klein/2009/05/atul_gawande_on_american_healt_1.html

Atul Gawande on American Health Care
Ezra Klein


I'm jealous of Atul Gawande's article on medicine in America. I wish I had written it. I wish I could write it. But I didn't, and I can't. You, however, should read it. It's the best article you'll see this year on American health care -- why it's so expensive, why it's so poor, what can be done.

Indeed, it's good enough that I'm not going to quote from its core point because I don't want to try to summarize the piece. I want you to read it. But I will quote from a discussion Gawande has with a couple of physicians in McAllen, Tex. He's asking them why health costs in their county are so high.

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

*****************************************
The Cost Conundrum
What a Texas town can teach us about health care.
by Atul Gawande June 1, 2009


Costlier care is often worse care. Photograph by Phillip Toledano.


It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.

McAllen has another distinction, too: it 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. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. “The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”

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.

more...

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

[underpants]

1. checking it out later

thanks

[Mythsaje]

2. Long article, but worth it.

Add that to my list of considerations when it comes to this. Eliminate quantity-based "for-profit" health care and health insurance red-tape and health care would become one HELL of a lot more affordable.

[frazzled]

4. I'm sorry you didn't read it

Because it has nothing to do with the evils of "for-profit" healthcare and health insurance red tape.

Please read this article. It is original in its research and conclusions, and quite enjoyably written to boot (rather in the "detective" style of the wonderful old Berton Rouche narratives of medical detection that ran for so many years in the New Yorker).

When you've actually read it, perhaps there will be a good discussion.

[Hissyspit]

7. This would be the "meat," I believe:

"When you look across the spectrum from Grand Junction to McAllen—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."

[Mythsaje]

9. I did read it... Which is why I mentioned "quantity-based" as well as "for-profit."

Eliminating one will bring down the costs considerably, as will eliminating the other. But eliminating BOTH...

[frazzled]

11. But he argues that it doesn't matter whether it's for-profit or not-for-profit (public)

It's the pay-per-treatment and paying to individual doctors. (Yes, you did mention quantity-based, but I think linked it inappropriately to an argument regarding non-profit vs profit).

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.
This last point is vital. 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. You get McAllen.

This is interesting especially in light of the article that appears in today's NYT regarding the Massachusetts "experiment," which chose to apply universality first and worry about cost-containment second. The studies have found that while MA has the lowest number of uninsured now (with a public and private plan system), people still can't get the health care they need, and too many practices aren't accepting people. One of the solutions the legislature is considering is to pay lump sums for a patient's ongoing care, rather than for individual procedures or office visits. Sounds just like what the doctor was prescribing in his New Yorker article (well, in part: it doesn't address the accountability issue in its totality). http://www.nytimes.com/2009/05/28/health/policy/28massachusetts.html?_r=1&ref=health

I had not understood these universality vs. cost-containment arguments before, but I'm getting a clearer picture. Universality in itself is not the major problem, though certainly that must be addressed; but it is the easier part. It is indeed the cost-containment that is critical. It's changing the compensatory structure, the incentives, and this is sort of secondary to public or private. I've experienced the problems myself in both our private insurance and when we were deeply involved in my mother-in-law's medicare and (at the very end) medicaid insurance.

[Juche]

12. Actually it did talk about that

It talked about how physicians having a financial investment in other medical services were causing them to overprescribe tests, hospital stays and other interventions that were not really important to health.

This video of Peter Orszag is also good.

http://www.youtube.com/watch?v=q4POIiNaG1M

[tnlurker]

3. for later

[D-Lee]

5. Thanks, very informative article -- a must read nt

[Blue_Tires]

6. marked for later

[Juche]

8. This is what we need

We need more research and transparency so medicine can provide the most health improvements and least risk per dollar spent. In the stimulus bill, 1.1 billion was put into researching the most cost effective medical treatments so doctors would have a centralized source of information so they would know the most efficient, cost effective treatments when they saw a patient.

http://www.ahrp.org/cms/content/view/528/56/

Peter Orzsag, who was mentioned in that article, says about 1/3 of all medical spenidng ($700 billion or so) does not seem to improve health. So we are wasting about 1/3 of our funds on ineffective or destructive healthcare. Combine that with the $400 billion a year we lose because we don't have single payer (extra $300 billion in higher administration, extra $100 billion because we cannot use bulk purchasing power via single payer) and we are wasting over a trillion dollars a year in our healthcare system on inefficiencies. No wonder we spend 16% of GDP on healthcare when other OECD nations spend 11% (some like Taiwan, Japan & the UK do it for 8%), we are wasting nearly half of our healthcare dollars.

THe same thing has been done for third world countries, A report called 'disease control priorities in developing countries' was written a few years ago, and it was researched to find ways to provide the most healthcare benefit per dollar spent, and makes recommendations based on that.

http://www.dcp2.org/pubs/DCP

We probably don't even have to do the research, the National Institute for Health and clinical Excellence (NICE) program in the UK is designed to do the same thing. We could probably just steal their ideas. I"m sure other OECD nations have similiar programs.

http://en.wikipedia.org/wiki/National_Institute_for_Health_and_Clinical_Excellence


Basically, we can easily solve this problem, but do you really think that physicians, drug companies and everyone else who works in the healthcare industry and is dependent on it for a job will sit back passively and accept a $1,100,000,000,000 a year pay cut?

[emsimon33]

10. This is why I like the UK system

The government pays the doctors, etc. Compensation is the main motivator for becoming a doctor, then the result is too often what has happened in McAllen, TX.