It seems, from what I have read, heard and seen in the media, that the health care reform initiative that President Obama would like to see implemented boils down to whether or not the government expands its role in providing health care insurance benefits to the entire populace, as opposed to just those who are currently eligible for Medicare, as an alternative to for profit (non-government) insurance providers, which are selective in those consumers they will insure. The two major goals of the Obama initiative are to make health insurance available to the entire populace (the so called public option), not just that segment subsidized by deep pocketed employers, and to, theoretically drive down the costs associated with health care services using the leverage of a government managed and government scaled reimbursement system.
That the public option is an important moral imperative for our country should be a given, everyone should have access to adequate health care, no matter where they fall on the economic spectrum. However, no one should be so naive as to believe that universal access to health insurance will cure all of the ills of our health care system. Access to health insurance is no guarantee of quality health care or cost effective health care.
Atul Gawande, a surgeon and staff writer for the New Yorker, has a piece in the recurring series ANNALS OF MEDICINE, titled “THE COST CONUNDRUM“, which anyone with an interest in acquiring a complete picture of how health care is delivered, and abused, in the United States must read. In trying to get a grasp on the causes of the explosion in health care costs in the United States, Gawande traveled to McAllen, in Hidalgo County in Texas. Hidalgo County has the lowest household income in the country, just $12,000 per capita, the other record that McAllen holds, is that it is the second most expensive city, behind Miami, in the United States for the delivery of health care services. Gawande took his time and was quite thorough in his quest to learn about what makes the health care economy in the McAllen area tick, interviewing business people, average citizens, doctors, hospital administrators and other health services providers and touring medical facilities.
The article goes in to quite a bit of detail covering the gamut of what Gawande found, with the unavoidable conclusion, that the delivery of health care services in McAllen is dominated by an economic agenda, focused on over use of the available technology which has dumb’d down the diagnostic processes used by doctors while increasing revenue for the providers, rather than a public health agenda, that would be focused on providing the most effective health care in terms of cost and outcome, to the patients. In one passage in Gawande’s article he describes sitting around a dinner table with other physicians who practice in McAllen, and some of the conversation that resulted:
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.
“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.
Gawande did not just talk to doctors, he also spent a lot of time interviewing hospital administrators, and gained admissions such as the following:
“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.
He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.
At the very extreme end of the medical practice spectrum, Gawande learned:
Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.
In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.
In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”
“How much?” I asked.
“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.
He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.
When Gawande left McAllen and returned home, his conclusion was that:
About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
The health care delivery climate in McAllen, is all too familiar to myself, and is likely becoming more of the norm throughout the country. I reside in Southern California, in 2006 I had my first major hospitalization and spent 10 days as a patient in a major hospital in Los Angeles County. During that time I was subject to a wide range of diagnostic tests including multiple X-rays, ultra sounds, CAT scans, EKG’s, blood tests six times a day, analysis of urine and stools, etc., very few of which found anything but the pneumonia that I was admitted for. In a hospital of this size they have a full staff around the clock, and they would utilize all of that staff time, day or night, to administer their diagnostic testing and monitoring. There is an axiom, that if you want to get some sleep, a hospital is the last place you want to be, and I can attest to the validity of that.
Upon reflection. it seems to me that a lot of the testing that was performed on me was overkill, but while it is occurring, when you are not well, running fevers, when you are drugged up, you are on oxygen and receiving inhalation therapy every few hours, when lab technicians have poked the veins in your arms and hands so much that they are just a mass of black and blue, from shoulders to finger tips, you just sort of “go along with the program”, you are not capable of removing yourself as an impartial party, away from the fray, observing and making value judgments, you just turn yourself over to the professional care givers.
So they did cure me of the pneumonia, but I ended up with a really nasty infection in my digestive tract (due to the hospital doctors’ choice of drug therapy for the pneumonia) that stayed with me for the next eight months. And my insurance carrier received a bill from the hospital for $100,000 for their services. The insurance company negotiated a settlement with the hospital for about $30,000, which might shed some light on how much of my treatment in the hospital was diagnostic overkill as opposed to being curative. And I still incurred eight months of the joys of multiple daily occurrences of explosive diarrhea and the costs to deal with it, outside of the initial hospital bill.
In comparison and contrast to what Gawande found in McAllen, and my own personal experience, Gawande also discussed his experiences with the Mayo Clinic:
I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.
“I’ll be there,” the cardiologist said.
Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.
The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients.
Gawande makes the point that the Mayo Clinic (originally in Minnesota, but which now has a footprint in Florida), and also others who embrace similar values in how they deliver health care services are not the unique exceptions that some would think:
The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.
Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.
The message that we all should take away from Gawande’s observations is that the segment of our population that represents our health care infrastructure is no different than the rest of us, some are driven by altruism and a need to heal, comfort and care for their fellow man, some are excited by the science and their ability to devise ways to attack that which afflicts human life, some may be to some extent disillusioned and feeling trapped in to working only to repay the high cost of their medical education and the cost to maintain their families comfort; and some may be giving in to human greed, unable to resist an opportunity to make a quick buck. That to varying degrees, the medical profession has lost sight of its fundamentals.
It seems to me that the current emphasis of President Obama’s health care initiative is too simplistic. While providing access to health insurance to all Americans is of course a “must have”, we cannot ignore how we fundamentally deliver health care in this country. We cannot allow the practice of medicine to morph from patient education, prevention and healing in to the application of technology, at the cost of losing the doctor patient human connection.
The Obama health care initiative would better serve the people if it included mandates for the provision of health care modeled after the Mayo Clinic. With reimbursement rules that rewarded ethical, effective medical practice and which penalized medical practice based upon volume and revenue generation. One way to provide incentive would be for the government to fund medical education, to create a system where those considering entering the medical profession not have to be held back because of the high cost of a medical education. In return, newly trained doctors would be required to join medical practice groups that replicate the Mayo Clinic model, and remain there for a set minimum number of years.
Medical practice groups that emulate the Mayo Clinic model, that can demonstratethat they provide medical care superior to the norm, at costs that are less than the norm, could be incented with tax rebates. Medical practices that rely upon diagnostic testing as their primary revenue source should be taxed at a higher rate. Medical practices that deliver cosmetic services, should assessed sales taxes.
The Obama administration, through its health care initiative, should go the extra mile, not just working to assure all Americans of health insurance, but to actually contain costs and to require the delivery of quality, effective health care that focuses on the well being of the patients, not the revenue streams of medical service providers.