The Obama health reformers seem all to be depending on an article in the New Yorker written by Atul Gawande, a Harvard surgeon. I’ve read the article, which is titled “The Cost Conundrum.” He uses as an example, the town of McAllen, Texas. He writes about an entrepreneurial spirit among physicians in this Texas border town.
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 first seven pages of this article, I agree with. He tells stories of excessive testing although some of his theories are in conflict. At one point, he dismisses the idea that defensive medicine could have anything to do with cost.
“But young doctors don’t think anymore,” the family physician said.
The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.
Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.
I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?
Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.
And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.
This sounds to me like there is some defensive medicine there. In a population that is obese and heavily Hispanic, a first episode of gallstone colic is an indication for surgery. I completely disagree with him on this. We see asymptomatic gallstones on routine x-rays. Those cases can be safely watched but a patient who is having symptoms may show up yellow from a common bile duct stone the next time. Ditto for the woman with chest pain. We read articles about higher mortality in women because male doctors fail to identify female heart patients correctly. This is because they wrongly assume women don’t get coronary artery disease.
The other place where I disagree is in his solution. I can see why the Obama people liked his prescription.
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.
His prescription is an end to fee-for-service. Every bureaucrat’s prescription is the same. The control of health care will be centralized and both doctors and patients will lose control.
The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”
He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”
Yup, that is us doctors; the wolves. No wonder Obama likes this article.
