Sunday, May 31, 2009

Health Care Reform (6)

I have been asked by 20% of my readership (my friend Bob) to comment on Atul Gawande’s article on the cost of medical care in the current New Yorker. Besides being a great writer, Gawande is a great reporter. He went to McAllen, Texas, on the Mexican border in South Texas, Hidalgo country, one of the poorest counties in the country – where I was many times in 1968-70, when I was in the Public Health Service.

Statistics show that medical costs in Hidalgo County are the highest in the country, and he wants to find out why. He converses with lots of people and finds the answer to be that the culture of the medical community has become the culture of making money. Doctors look to their bottom line, and do everything they can for the patient preemptively, if it pays. [The old story, no doubt apocryphal, is that a cardiologist presented figures that showed that a newborn’s VSD (hole in the heart) generally closed naturally by 18 months, wherupon a cardiac surgeon went to the microphone and said, ”See? I told you. We have to get them early!”]

I recognize this thread in modern American medical culture; it exists in places right here in the East Bay. In Hidalgo County it has infected the greatest part of the culture and that’s why the whole county is high cost. In other areas the same culture exists but isn’t so predominant, perhaps; in some areas it is very little in evidence. But taken as a whole, Gawande says, this is the prime mover for the high cost of medical care in the US.

He is guided in his perceptions by the findings of the Dartmouth Group, which for over 30 years, starting with Jack Wennberg, has worked brilliantly on “small area variations” in medical care costs and frequencies of procedures. They showed initially that in small areas centering around different hospitals in Vermont, the rates of such procedures as tonsillectomy were very different. The differences could not be accounted for by different rates of illness, and the outcomes of such procedures were not noticeably different in different areas. In other words, more treatment might not have resulted in better health. It is true that the outcomes measures were crude and not very sensitive, so it is possible that the patients operated on got better faster, etc. But probably not significantly. The Dartmouth group concluded that the driver of procedures was the number of specialists who did this operation in the different areas. More surgeons equaled more operations.

There are other less quantitative studies in the literature of medical care sociology that show that small groups, often centered around hospitals, get to know one another and work into a culture where they get used to referring to each other, and treating diseases certain ways. Some of the drivers of behavior might be money, as in Hidalgo County; others can be other factors not economically related, such as friendship, not blowing the whistle on incompetence, etc.

In more recent years the Dartmouth Group has shown the stark differences in Medicare expenditures all throughout the country – Miami is very high, as is the UCLA area; Minnesota and North Dakota are quite low. In all these areas we can’t see differences in the health of the population; in all probability the high-effort and high-cost areas have no worse health before medical care, and no better results afterwards. In fact, given the predictable side effects of some treatments, it’s probable that the high-cost areas get worse results.

In identifying culture as the problem, Gawande says that simply changing payment mechanisms won’t be effective, because doctors and others will always find ways to game the system. What is needed is a change in culture. He identifies salaried groups such as Mayo, Geisinger, and the Marshfield Clinics as mechanisms that can enforce a culture. (I don’t know about them personally, but I do have some connections to Kaiser, which he also mentions, since it is in my Northern California area. To call their care excellent is not accurate. It does well on measurements, but I hear far too many anecdotes of unmeasured incidents of poor care to call Kaiser excellent. It has excellent propaganda.) He says that the forces within medicine can do this, but that insurance companies can’t. He says that this is the route to salvation in American medicine.

I yield to no one in my admiration of Atul Gawande, a brilliant observer, writer, reporter, and thinker. And his analysis is certainly right in a way. But it is not complete, and in its incompleteness, it might be somewhat misleading. Here is what I think.

Even the great have weaknesses, and sometimes their weakness is that they are so great. They believe unconsciously that if they can do it, everyone can do it. It’s like me and my natural forehand in tennis. I just can’t understand that others can’t do it the way I can, it just seems so natural. Gawande comes from a very elite hospital based culture at the Peter Bent Brigham Hospital in Boston. I’ve been in that culture as a student at Harvard Medical School and I know it. Getting to the Brigham is a very uncommon event for a doctor – the best of the best. Being so elite and excellent, they can psychologically afford to be quite pure. They just don’t need the money to regard themselves as wonderful. They can look at their medical excellence and their purity of motives and criticize others who don’t measure up. They can successfully buck the American culture of financial accomplishment and hold themselves to a different standard. And they can’t understand how others can’t do it, too. Or at least aspire to it.

But look at those who have less elite abilities. People who had to work very hard to get into medical school to begin with, and then worked very hard to graduate from a mediocre school that they barely got accepted to, and then continued to work very hard throughout residency because they are really not that smart. They succeed in becoming doctors, but they know they won’t excel in the eyes of their peers. By definition, we are talking about the majority of doctors.

Induction into the medical ranks is powerful, and the code of ethics is meaningful. Many will adapt well to the priestly function of medicine not only in the way they treat patients, but also in their self-regard as men or women of the profession. As I look around me in my own professional world I see many doctors, even most, who fit in here, as members of the chosen.

Yet inevitably, others will be ambitious to succeed in the eyes of the world, and the business people they associate with. These doctors are not going to be seduced by the siren song of excellence. That they compare their worth to other individuals by comparing their financial assets is understandable. To get these doctors to join up and take salaries and work together will not be easy. The proffered Gawande solution won’t work with them.

A second objection to grouping doctors is simply that not everyone can stand being in a group. Groups can be oppressive. People who prize initiative will not want to be in initiative-suppressing groups. And groups are not necessarily excellent – the tyranny of the mediocre is often prevalent. Similarly to these group-avoiding doctors, many patients avoid large groups, understanding intuitively that in a large institution, incentives for individual doctors are inevitably led away from serving the individual sensitively. Geisinger has a way of integrating small groups of doctors somewhat, but the others don’t. Again, a prescription of a big group is not going to fit everyone.

A third objection is that Gawande is a doctor and thus sees things from a doctor’s point of view. He sees that decisions of doctors trigger events with patients. No patient goes into the hospital without a doctor initiating the admitting order. No MRI gets done without a doctor’s order. This is true. Other health analysts have seen the same thing and said, if only we could intervene at this point! What if doctors were aware of alternatives to their activist decisions? Or, what if we could outlaw such decisions? The current recommendation is for assembling a panel of experts to determine what is best practice and forbid payment for non-standard interventions.

This is OK as far as it goes. But total expenditures = volume x price. Gawande looks only at volume. What about price? Typically, a trip to the operating room might pay the surgeon $750 and the hospital $25,000. Why not put the hospitals in competition on this? They are so, so guilty of enormous inefficiencies. We could count the ways. What about the price of MRI’s and other studies? We could continue the same rate of services and save cost if only we put them in competition and got the price down.

It is truly amazing to me that all the prescriptions for health care reform do not talk about aggressive steps that could be taken here. I don’t know why. It is so clear to us in practice how profligate hospitals are, how poorly managed, how manipulated by nursing and service unions, and how they just pass on costs to consumers. Why, oh why are they not on the block?? Why is price not an issue?

One final point and I’ll quit for today. Gawande points to the integrated groups as the answer. Conventional wisdom also tells us that managed care worked from 1993-2000 but then failed as consumers and doctors revolted. In fact, this widely acknowledged fact ain’t exactly so. The East Coast version of managed care is poor. This is the version whereby the doctor contracts directly with the large insurance company. The large and distant company cannot manage care well, cannot determine which procedures to approve, and how to structure care.

The West Coast managed care version, however, has worked to a certain degree, and could be built upon to work even better. This is called the IPA, or Independent Physician Association model. In this model, described in my 1995 JAMA article, the physicians are contracted by an intermediate organization, the IPA, which then contracts with the insurance companies on their behalf. Insurance companies can do diddly in medical care administration, but IPA’s can do a lot, coordinating care, and most importantly doing exactly what Gawande wants done – outlawing procedures that are out of line. (Not they all have done so - many were poorly run, and others were run by their leaders unethically, enriching themselves. But some survive and improve the system.) Gawande could just as well recommend that such organizations be strengthened, and better subjected to competition, by allowing more IPA’s to emerge and compete.

So, OK – Gawande is great and everything he says is true and the medical culture of Hidalgo County and other such counties throughout the USA is to be strongly condemned. But it is only part of the picture. Why reformers don’t focus on the hospitals, where the real money and the real savings are, is beyond me.

Budd Shenkin

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