Monday, July 06, 2009

My Late Take on Gawande...

I know I'm late with this.... McAllen, Texas is a city with a population of 101,604 people in the city proper and about 569,00 in the metropolitan area (2000 census numbers). It also has the cost for health care in the U.S. This was a topic of a New Yorker article by Atul Gawande who examines the situation.

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.
So why is this? Gawande compares McAllen to another Texas City, El Paso:

Yet public-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. Yet in 2006
Medicare expenditures (our best approximation of over-all spending patterns) in
El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy
population couldn’t possibly be the reason that McAllen’s health-care costs are
so high.

McAllen has a lot of nice stuff:

I was impressed. The place had virtually all the technology that you’d find at
Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital
on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns
get the new school buildings, fire trucks, and roads, not to mention the better
teachers and police officers and civil engineers. Poor towns don’t. But that
rule doesn’t hold for health care. At McAllen Medical Center, I saw an
orthopedic surgeon work under an operating microscope to remove a tumor that had
wrapped around the spinal cord of a fourteen-year-old. At a home-health agency,
I spoke to a nurse who could provide intravenous-drug therapy for patients with
congestive heart failure. At McAllen Heart Hospital, I watched Dyke and a team
of six do a coronary-artery bypass using technologies that didn’t exist a few
years ago. At Renaissance, I talked with a neonatologist who trained at my
hospital, in Boston, and brought McAllen new skills and technologies for
premature babies. “I’ve had nurses come up to me and say, ‘I never knew these
babies could survive,’ ” he said.
But don't get much from their investment:
And yet there’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, as far as one can tell, because
it’s delivering better health care.

Apparently the divergence in expenditures began in 1992, prior to that McAllen was in line with the national average. Dr. Gawande has dinner with several physicians in town. They are unaware of the cost difference, and come up with the usual suspects as to why: malpractice, sicker patients, and then:

“Come on,” the general surgeon finally said. “We all know these arguments are
bullshit. There is overutilization here, pure and simple.” Doctors, he said,
were racking up charges with extra tests, services, and procedures. The surgeon
came to McAllen in the mid-nineties, and since then, he said, “the way to
practice medicine has changed completely. Before, it was about how to do a good
job. Now it is about ‘How much will you benefit?’ ”

But Dr. Gawande makes his point with an unusual example:

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

I am unaware of this being a usual way of approaching this. If a patient is sent to me for a consultation to consider cholecystectomy, if they have been worked up adequately, and are a candidate, they get set up for their cholecystectomy. If I don't then the patient will find someone who will, and the next time the referring physician will send them to someone else. So the $700 dollars isn't saved overall, someone else just gets it. A similar example is the primary care physician who refuses antibiotics; the guy down the street will be happy to prescribe them and has just gained a new patient. Anyway, the citizenry of McAllen do seem to be voracious consumers of medicine:

The Medicare payment data provided the most detail. Between 2001 and 2005,
critically ill Medicare patients received almost fifty per cent more specialist
visits in McAllen than in El Paso, and were two-thirds more likely to see ten or
more specialists in a six-month period. In 2005 and 2006, patients in McAllen
received twenty per cent more abdominal ultrasounds, thirty per cent more
bone-density studies, sixty per cent more stress tests with echocardiography,
two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel
syndrome, and five hundred and fifty per cent more urine-flow studies to
diagnose prostate troubles. They received one-fifth to two-thirds more
gallbladder operations, knee replacements, breast biopsies, and bladder scopes.
They also received two to three times as many pacemakers, implantable
defibrillators, cardiac-bypass operations, carotid endarterectomies, and
coronary-artery stents. And Medicare paid for five times as many home-nurse
visits. The primary cause of McAllen’s extreme costs was, very simply, the
across-the-board overuse of medicine.

He writes of discussions with hospital administrators that are either ignorant of or are in denial of the facts on the ground. The culprit seems to be the physicians themselves:

“That is interesting,” she said, by which she did not mean, “Uh-oh, you’ve
caught us” but, rather, “That is actually interesting.” The problem of McAllen’s
outlandish costs was new to her. She puzzled over the numbers. She was certain
that her doctors performed surgery only when it was necessary. It had to be one
of the other hospitals. And she had one in mind—Doctors Hospital at Renaissance,
the hospital in Edinburg that I had toured.... .....It was a depressing
conversation—not because I thought the executives were being evasive but because
they weren’t being evasive. The data on McAllen’s costs were clearly new to
them. They were defending McAllen reflexively. But they really didn’t know the
big picture of what was happening. And, I realized, few people in their position
do. Local executives for hospitals and clinics and home-health agencies
understand their growth rate and their market share; they know whether they are
losing money or making money. They know that if their doctors bring in enough
business—surgery, imaging, home-nursing referrals—they make money; and if they
get the doctors to bring in more, they make more. But they have only the vaguest
notion of whether the doctors are making their communities as healthy as they
can, or whether they are more or less efficient than their counterparts
elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen
hospital for a CT scan, an ultrasound, three rounds of blood tests, another
ultrasound, and then surgery to have her gallbladder removed. How is Lawrence
Gelman or Gilda Romero to know whether all that is essential, let alone the best
possible treatment for the patient? It isn’t what they are responsible or
accountable for. 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.

A book of medical quotations given to me years ago had one that was appropriate for this discussion: "There is a difference between a physician and an entrepreneur with an MD". McAllen seems to have more of the latter:

“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..... ...Others think of the money as a means of improving what they
do. They think about how to use the insurance money to maybe install electronic
health records with colleagues, or provide easier phone and e-mail access, or
offer expanded hours. They hire an extra nurse to monitor diabetic patients more
closely, and to make sure that patients don’t miss their mammograms and pap
smears and colonoscopies. 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.

But would the situation be such if the payment for an office visit were sufficient. What if phone calls and emails were compensated in a fair manner? Would there be less incentive to pursue these other revenue streams? Again, treated like tradesmen and commoditized, physicians begin to act the role of tradesmen, often with great benefit. And what role do patients play in this? Undoubtedly there is some demand by the patients, a large number of them on government programs, for these services. Would things be better if patients had some "skin in the game”? Probably not:

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.”

Gawande compares the practice of medicine in McAllen to that at the Mayo Clinic, where all physicians are salaried, and Grand Junction, Colorado, where physicians have set up uniform payment schedules, peer review, and information sharing systems. While these have improved quality and reduced costs, in these economic times, the financial question becomes larger:

Something even more worrisome is going on as well. In the war over the culture
of medicine—the war over whether our country’s anchor model will be Mayo or
McAllen—the Mayo model is losing. In the sharpest economic downturn that our
health system has faced in half a century, many people in medicine don’t see why
they should do the hard work of organizing themselves in ways that reduce waste
and improve quality if it means sacrificing revenue. In El Paso, the for-profit
health-care executive told me, a few leading physicians recently followed
McAllen’s lead and opened their own centers for surgery and imaging. When I was
in Tulsa a few months ago, a fellow-surgeon explained how he had made up for
lost revenue by shifting his operations for well-insured patients to a specialty
hospital that he partially owned while keeping his poor and uninsured patients
at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told
me, “some of the doctors are beginning to complain about ‘leaving money on the
table.’ "

An excellent analysis of the demographics that can explain the differences can be found here. The Buckeye Surgeon does excellent analysis here, here, here, and, here. With a comment by Gawande himself!!

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