Fri 10 Jul 2009
Masterful sleuthing on health care costs
Posted by Kirsten under Health
[2] Comments
My uncle sent me this link and I’m glad he did: a piece by Atul Gawande, published in the New Yorker, that compares health care in McAllen, Texas with health care in El Paso, Texas.
He chose McAllen because it has some of the highest per capita healthcare costs in the country: $15,000 per Medicare enrollee in 2006.
El Paso’s healthcare costs are about half of that.
Gawande rules out a number of variables that you’d think might account for the discrepancy.
[P]ublic-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed.
Nor can the high costs of healthcare in McAllen be attributed to better care:
[T]here’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.
Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.
So what’s going on?
You’ll have to read the whole article to see how Gawande lays out his case, but bottom line: physicians in McAllen have decided to make money, and they’re doing it by consistently erring on the side of delivering “more” care — even when “more” doesn’t do anything for the patient.
Example:
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.
How’s that for a gotcha?
Now that the gotcha’s out of the bag, tho, the real reckoning will come. Because the next question is: who’s going to tell the physicians to stop?
If we go with nationalized healthcare, it will be a government bureacracy.
Today, it’s often private insurers.
Without insurance in the picture at all, it’s the patients.
Pick your poison.
As a small-l libertarian, I’d just as soon do the picking myself. But that takes a measure of metaphysical chutzpah that most people, apparently, don’t care to acquire. Because when faced with decisions about medical care, the plain truth is that there often isn’t a “right” answer. For example. Suppose you’ve got a cancer that’s been pronounced terminal. Do you elect for oncology when the odds are it will at best only prolong your life for a few months? And live with the side effects?
Most people would rather abdicate responsibility for choosing — let a doc do it.
In my opinion, that’s what’s really at the heart of the healthcare debate. We don’t want to be sick, we don’t want to die, we don’t want to be frightened — and we want someone else to protect us from all of those things.
It’s an existential question, but we’re debating it as if it were a policy issue.
Which is why it is, and will remain, unsolvable.
And will also, in the meantime, become increasingly muddled.
Quite the show . . .
K, I too read that article a couple of weeks ago. McAllen is less than 200 miles from where I live. One of Gawande’s key points, to me, was that it makes no difference who writes/signs the check to pay for the care (private insurance, the government, or the patient); we can’t control the costs by limiting payment without affecting the quality of care and the outcomes. The issue is almost one of morality: in the Mayo model of collaboration and a flat salary for the doctors without respect for the tests and procedures ordered, the profit motive is eliminated. In the McAllen model, it’s all just a business where I make more money if I order more tests, whether or not they improve the patient’s care or outcomes.
Like you, I prefer to be educated about options and costs, about price vs. outcomes, about quality of life . . . and then make my own choices. Alas, many people simply want someone ELSE to tell them what they “need,” and then get it for them, and then have “somebody else” pay for it.
But (back to morality for a moment) how do you limit entry into the medical profession to those who are altruistic — who will toil for a flat salary and have no profit motive (dare I say “greed”)?
And yes, to have these difficult decisions further muddled by introducing them to the political process where everyone has conflicting agenda and favors and debts to repay to different groups . . .
Quite the show, indeed!
The morality issue is definitely an important aspect of the whole thing, John.
But I don’t think the answer is screening for altruism. Instead we need to reward doctors who do the best job of treating/healing people.
The problem is that if we did that, people with more money would be able to afford better care than people with less money.
Ultimately, that would raise the level of care for everyone.
But it flies in the face of what Thomas Szasz, in a recent WSJ op-ed, called the “vainglorious delusion” that we can enact policy guaranteeing everyone receives the same kind of optimal medical care.