Sunday, June 28, 2009

Cost Versus Quality

The New Yorker provides an interesting essay on the cost of medical care, and how high costs don't necessarily translate into high quality, penned by surgeon and author Atul Gawande. He seemed to take the doctors he interviewed a bit off guard, particularly when he didn't buy the standard excuses they trotted out.
“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“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.
How has technology affected practice?
I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?

Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.

And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.
The essay documents the high quality, lower cost approach of clinics like the Mayo Clinic, and how they've been able to export that model into Florida, a state associated with high medical costs. There are savings to be had, but apparently not if the "market" gets its way.
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.’”
Dr. Gawande concludes that, more important than a public option, we must decide if we're building toward a Mayo Clinic-style future. I suspect he's right - the doctors he described are making their fortune largely off of Medicare patients.


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