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Following The Cost Conundrum: The Road To McAllen, TX, Through The Pages Of Health Affairs



June 4th, 2009

Last week’s New Yorker article by Atul Gawande highlighted the phenomenally high variations in cost of medical care and services between regions in the United States, specifically focusing on McAllen, Texas. Gawande’s spotlight on McAllen was based on many studies of our health care system. For Gawande’s readers, we would like to point you to the original studies that have appeared in Health Affairs.

Discussions about the size of the medical workforce in McAllen compared to the rest of the United States appeared in a study by David Goodman, “Twenty-Year Trends in Regional Variation in the U.S. Physician Workforce,” published on the Web in October 2004.

Katherine Baicker and Amitabh Chandra have collaborated on studies of regional variations in Medicare spending and in quality outcomes since 2004 when both were at Dartmouth; they have continued this collaboration at Harvard, where they both now work.  Some of their earliest work on this subject appeared in Health Affairs in April 2004: “Medicare Spending, the Physician Workforce, and Beneficiaries’ Quality of Care.” Their work also appeared in October 2004: “Who You Are and Where You Live: How Race and Geography Affect the Treatment of Medicare Beneficiaries.”

Gawande reported on a specific study conducted by Brenda Sirovich and colleagues, which looks at how primary care physicians in different regions make different and costly determinations about medical tests and diagnoses. The study appeared in Health Affairs last summer, in the May/June 2008 issue:  “Discretionary Decision Making by Primary Care Physicians and the Cost of U.S. Health Care.”

Finally, the prescription recommended by Gawande, accountable care organizations, can be found in Elliott Fisher’s work in 2007: “Creating Accountable Care Organizations: The Extended Hospital Medical Staff”; and this past January:  “Fostering Accountable Health Care: Moving Forward in Medicare.”

For more from Gawande, he was interviewed last night on “On Point” with Tom Ashbrook.

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6 Responses to “Following The Cost Conundrum: The Road To McAllen, TX, Through The Pages Of Health Affairs”

  1. acavale Says:

    Just for clarification, I was not “attacking” Dr. Gawande’s talent. I was only making an point that even a highly talented surgeon working at Harvard feels that he has to supplement his income by doing other things like writing for a magazine or publishing books, etc. It just goes to show that under current price-fixed reimbursement regime, once cannot make a decent living with honest practice of medicine alone. Unfortunately, not every other community-based physician/surgeon can do the same. So I was questioning his portrayal of those physicians that own strip malls, when carrying out similar enterprises himself, unless of course he comes out and declares that he donates all the proceeds of his books and writing to charity.

    We can all look up to Mayo and other giant organizations as examples, but it must be remembered that more than 50 % of the population gets its primary care from small community practices with less than 5 physicians. Such practices neither have the resources nor the expertise of a Mayo Clinic to be able to demonstrate high quality care. Besides, high quality care requires investment of time, which is the one thing that is in short supply, thanks to artificial price-fixing by Medicare and Medicaid, which are carried forward by private insurers. Unless this process is fixed or eliminated, only the Mayo’s and Geisinger’s of the world can afford to survive.

  2. Christopher Hughes Says:

    acavale’s rationalizing is not helpful, it merely provides cover for those who wish to hunker down and excuse inappropriate phyician behavior. It also fails to acknowledge that Mayo is not the only place in the country doing good work providing excellent care, rejecting the paralyzing fear of lawsuits succumbed to by so many, and focusing on patient care as their primary driving force in delivering care.

    Attacking Gawande because he is a multi-talented individual is also hardly helpful to the debate.

  3. Christopher Hughes Says:

    City Name/ State Medicare reimbursements for hospice services per enrollee (2006)
    National Average US $233.93
    Portland OR $306.30
    El Paso TX $126.19
    McAllen TX $ 22.00

    Another factor impacting McAllen’s outlier status, I’m sure!

    I know Atlas has a way of reporting expenses in the last six months of life as well. It would be timely to write about this, especially give this recent Archives of Internal Medicine article:

    http://archinte.ama-assn.org/cgi/content/short/169/10/954

    This also, perversely, can make the hospital statistics in mortality look good, as well. As an intensivist, I can get almost ANYONE out of the the ICU and subsequently out of the hospital if I ignore the true outcome for the patient and the family: additional suffering, minimal prolongation of a life at its end, and so on.

    My colleagues who do practice best EOL practices know that our ICU and hospital mortality numbers suffer, but I have no doubt that having honest discussions with my patients and families is the right thing to do. You may have heard this for your patients, “Thanks for the straight talk, Doc,” or “Nobody talked to me about my prognosis before.”

    Of course, this is not new information, but we still need to do better as physicians:
    http://www.chestjournal.org/content/128/1/465.full?ck=nck

  4. Christopher Hughes Says:

    Dartmouth Atlas Data (2006)
    City Name, State ($) Medicare reimbursements for hospice services per enrollee

    National Average US $ 233.93
    Portland OR $ 306.30
    El Paso TX $ 126.19
    McAllen TX $ 22.00

    Another factor impacting McAllen’s outlier status, I’m sure!

    I know Atlas has a way of reporting expenses in the last six months of life as well. It would be timely to write about this, especially give this recent Archives of Internal Medicine article:

    http://archinte.ama-assn.org/cgi/content/short/169/10/954

    This also, perversely, can make their statistics in mortality look good, as well. As an intensivist, I can get almost ANYONE out of the the ICU and subsequently out of the hospital if I ignore the true outcome for the patient and the family: additional suffering, minimal prolongation of a life at its end, and so on. Some cardiac surgeons will do virtually anything to make their patients survive 30 days to make their numbers look good.

    My colleagues who do practice best EOL practices know that our ICU and hospital mortality numbers suffer, but I have no doubt that having honest discussions with my patients and families is the right thing to do. You may have heard this for your patients, “Thanks for the straight talk, Doc,” or “Nobody talked to me about my prognosis before.”

    Of course, this is not new information, but we still need to do better as physicians:
    http://www.chestjournal.org/content/128/1/465.full?ck=nck

    Cheers,

  5. acavale Says:

    Very thoughtful article by Dr. Gawande, although quite disturbing to a conscientious physician. It reinforces the public notion that all doctors are out to enhance their revenue from every patient. Atul provides a classic viewpoint of a very intelligent, young physician practicing in a prestigious institution; but hardly understands nor reflects the reality of physicians in private solo or small practices.

    While most of the examples cited in this article seem outrageous, he fails to fully explain the real reason for this change in physician behaviors since 1992. The reason can actually be found in one of his own examples, that of building a house using a contractor. Since 1992, medicine was converted from a profession to a business by both governmental and private payers, because of artificial price fixing, resulting in stagnant revenues resulting from providing conventional medical care. However, the costs of running a business are much higher than being a professional, and these costs kept climbing, while reimbursements kept falling through the 1990s and much of this decade. It would have been fair and balanced for Atul to admit that Medicare reimbursement rates have remained flat since 2001. Therefore those that thrived financially were those that were willing to take the steps to keep revenue up to par with expenses, while those that did not perished. Imagine telling the building contractor that you would pay him/her only 50% of his charges, and he had no choice but provide the service, or he would be banned from working in your area for 2 years.

    Mayo clinic is an exception because it has its own revenue sources (not dependent on payers) and gets federal funding being an academic institution. It was easy but extremely unfair for Atul to use Mayo as an example in this article. Again, this points to his roots in an academic institution.

    I am sure he would have a very different perspective if he were ever in a situation where he was the sole person responsible for the livelihood of 2 or 3 or perhaps more individuals as well as the sole breadwinner for his family. Perhaps then he would understand the need to run a profitable business while providing high-quality care at the same time. Let’s not forget that doctors did not make medicine into a business (as he incorrectly points out); it was the insurers and the government that did it. Besides, nowhere did he point out the complete lack of incentive for consumers of care to make better choices about utilizing services, even though he gives his own example of over utilizing a particular service.

    And finally, if he were so involved and satisfied with his role as a surgeon at his own institution, I wonder why he chose to be a Staff writer at the New Yorker or publish books for profit? I see no difference between these actions and those of doctors in McAllen that own shopping malls. Perhaps, it helps supplement his own revenue stream, and I have no objection to that. Perhaps, people who live in glass houses should not throw stones…

  6. Michael D. Miller, MD Says:

    This was another great article by Atul. I found it particularly interesting in comparison to the NEJM article by Elliott Fisher, Don Berwick and Karen Davis, “Achieving Health Care Reform — How Physicians Can Help.” I wrote a piece discussing these two articles – essentially “theory v. practice” in health reform – which can be read at http://www.healthpolcom.com/blog/2009/06/01/theory-v-practice-in-health-reform/

    Atul’s ground level view of how physicians are acting and what is driving their practice behaviors is exceptionally important for the real world success of whatever legislative or regulatory actions Federal or State governments might take.

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