Required White House Reading on Health Care
When President Obama says an article has “affected his thinking dramatically” you ought to read it. The underlying crux of the health care issue and - maybe, just maybe - how best to address it are explained in a very fascinating and well-researched article by Atul Gawande in this month’s New Yorker titled “The Cost Conundrum: What a Texas town can teach us about health care.”
Much of the current debate over health care has narrowly centered on whether a private or public payer system will fix the spiraling out of control costs/lack of adequate coverage for less wealthy Americans. Gawande suggests that the root of the problem, however, will still remain even if we figure out who pays:
Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.
Ultimately, the financial benefits of over-testing/treating/diagnosing/operating on patients are too significant to overcome for many doctors. The implication is not that doctors are necessarily greedy - although there are definitely some who view their practices are pure revenue generating operations - but that just as we have a defense industrial complex that continues to justify ballooning military spending, there are similar powerful forces and profit-incentives for doctors to induce more patient spending than necessary, whether they even realize it or not. Just ask a friend who is in med school these days how much in loans they’ll be graduating with. It doesn’t help either that patients will often feel more at ease with more superfluous tests and treatments that drive up costs, even demanding them over a doctor’s initial suggestions. This analogy sums it up beautifully:
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.
The idea then that the more treatment a patient gets the better off they will invariably be is what is slowly crippling health care in this country. And between doctors, hospitals, and patients this is the prevailing mode of thinking. The Mayo Clinic illustrates this point dramatically. Paying out $6,688 per Medicare enrollee in 2006, it ranks in the bottom 15% in Medicare hospital spending in America. Yet, with its top notch doctors and top of the line medical equipment, it is considered a mecca for medical treatment. Gawande extrapolates:
Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.
For me, the bottom line take away from this article is that we as consumers of health care services have a vital role to play in all of this. Rather than go full-blast into a hospital or clinic and demand every possible test and treatment administered, the approach ought to be to urge doctors to do what is necessary and nothing more for the time being. Consider that more people die in this country from surgery complications per year - 100,000 - than car crashes, so the notion that you’re not getting enough treatement is usually a fallacy. And of course, anything and everything should be done to alleviate and prevent the flaring up of an ailment if the situation merits. But as consumers, our approach should not be the kitchen-sink one, especially when all you need is a new faucet.
