As I have traveled around the country giving talks to physicians about health care reform, I am often asked if the new law does enough to control costs - usually by doctors opposed to it.
As I wrote in a Perspectives article that appears in the current issue of the Annals of Internal Medicine, the jury is out, mainly because the most significant cost control initiatives in the law will first be launched on a pilot basis. Although initiatives like Patient-Centered Medical Homes, Accountable Care Organizations, bundled payments, wellness and prevention programs, quality measurement and reporting, and comparative effectiveness research might begin "bending the cost curve," well-respected experts disagree if they do enough.
The more I think about this question, though, the more I wonder if we are looking to the wrong place for the answer. Do conservative critics, especially, want Congress to do more to control costs? Especially since government cost controls usually involve blunt instruments like price controls, cuts in payments to physicians and hospitals, and direct and indirect limits on access to treatments?
Instead of looking to Washington to "bend the cost curve", perhaps we should be looking at the cultural factors present in many of our own communities. As Atul Gawande wrote in his now famous article about McAllen Texas,
"Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for."
Gawande argues that the differences between high cost areas, like McAllen, and lower cost ones, like Grand Junction, Colorado, have more to do with the culture of medicine - "whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue."
In an interview with Ezra Klein, Gawande was asked about the most effective counter arguments against his piece. Gawande replied:
"The idea that these people in McAllen are unhealthier. The idea that it's all malpractice ... [and] pointing out that McAllen is the poorest county in the country. They'd say you couldn't compare it to Mayo. But I didn't. El Paso, which I did compare it to, was the sixth poorest in the United States. They're very closely similar in poverty, in immigration, in physician supply, in rates of disease, and so forth."
(I would add that it is counter-intuitive to say that the malpractice suits are the culprit, since Texas has a state-wide cap on non-economic damages. And yet some parts of Texas spend much less than McAllen, even though the liability cap is the same.)
But is it really fair to pin the blame on physicians for how much the country spends on health care, when patients themselves create demand for more health care when they don't take care of themselves? This makes intuitive sense, until you look at Provo, Utah.
The Washington Post reports:
"If there is any place that should have medical spending under control, this is it. Residents of Provo, many of them Mormons who don't smoke or drink, are among the healthiest in the country... Until recently, Provo seemed to be a model for the nation. But spending on Medicare patients here has accelerated rapidly, as it has in many other areas of the country that are known for cost-efficient care. The culprit: a swift increase in the number of procedures and tests being performed - a trend that has coincided with the additions of new surgical and cancer treatment suites and diagnostic machines at hospitals and clinics throughout the growing region."
(National Public Radio headlined its story on Provo this way: "Provo Leads the Nation in Osmonds and Shoulder Surgery.")
Now, I am not picking on the undoubtedly good people, doctors and patients alike, who live in Provo or McAllen. But it does seem to me that the answer to "bending the cost curve" is going to have less to do with federal legislation than changing a culture of medicine that encourages over-use of health care services, which seems to be linked, at least in part, to physician ownership of diagnostic facilities - something found in both Provo and McAllen, communities that couldn't be more different, except that they spend more per patient.
Changing culture has less to do with the federal government than physicians showing leadership at the national and community levels to re-define what are acceptable practices - what Gawande calls "a battle for the soul of American medicine" - which when you think about it, is a fundamentally conservative idea.
Today's questions: Do you think we should look to Washington "to bend the cost curve" or to changing the culture of medicine in our own communities? And if is culture, how can it be changed?