Rarely does a magazine article grab the attention of policymakers, like Dr. Atul Gawande's piece in the New Yorker Magazine on "The Cost Conundrum: What a Texas town can teach us about health care." The article, adorned with a photo of a physician wearing an ATM machine, examines the community of McAllen, Texas, which has the dubious claim of having the second most expensive health care in the nation (Miami, Florida, which has much higher labor and cost of living expenses, takes first place). President Obama has reportedly referenced the article in discussions with congressional leaders. Citing the same, Steve Pearlstein writes that "the central challenge of health reform, then, is to make sure doctors have the scientific evidence about what works and what doesn't -- and then to change the way they work and realign their financial incentives so that this evidence guides their practice."
Why all of the interest in McAllen? Because, as Dr. Gawande writes, "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." He concludes that the higher spending is a consequence of a prevailing medical culture fueled by money:
"Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.
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."
Gawande writes that the debate in Washington largely misses the mark. "Whom do we want in charge of managing the full complexity of medical care?" he writes. "We can turn to insurers (whether public or private), which have proved repeatedly that they can't do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone - because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world."
If it is true that culture largely drives practice, it will be exceedingly difficult to change. History is full of examples where Washington has passed laws to change entrenched cultural behaviors that are not considered to be in the public interest, without much success unless there is buy-in by those who they want to change.
I believe it will require an unprecedented degree of leadership within the medical profession itself to get every physician to accept the idea that they need to be just stewards of resources, as the ACP-endorsed charter on professionalism demands:
"While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."
Without such physician leadership, Washington almost assuredly will fail in its effort to control costs.
Today's question: Do you agree that there is a culture in medicine that leads to excess health care spending? If so, what should the profession do to change it?