A Battle for the Soul of American Medicine

In the New Yorker, Atul Gawande told a story: It was the best of times. It was the worst of times. No truer Dickensian words were better inferred. Gawande told us the story of McAllen, Texas, a town whose doctor's got bit with the entrepreneurial bug.

"[A] medical community [who] came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers."

Gawande's article goes to the heart of the health care reform battle. He cites is as a tale of two cities: McAllen versus El Paso, Texas. Two towns with similar demographic make up and populations of about 700,000, yet significantly disparate Medicare per enrollee costs. Turns out McAllen on average charges Uncle Sam for about $15,000 per Medicare enrollee, twice their income per capita as well as twice the national average, and about half as much as what is spent in El Paso. (The data is from 2006, the best available for the analysis performed.)

Why? Because they doctor's can. The incentive pay structure is per exam performed, not for overall quality of care given. In McAllen, doctors stopped being doctor's and became business men. Are they providing better health care for all these tests? The data simply says it: no.

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.

So what to do? Change the payer-playbook, charge for overall quality care, rather than quantity care. It goes back to a wise old saying, "patient care should always come first." So Doc, don't pay-a-hate, coordinate.

Thanks Gawande!

The Afterw@rd