Thursday, June 25, 2009

Atul Gawande answers objections

H/T to DB for pointing me to this follow up article by Atul Gawande concerning his earlier New Yorker piece on health care costs.

Here he elaborates and provides more data in response to objections and questions concerning his original article. He also re-emphasizes that it’s all about organization and leadership and gives another example, Scott and White Hospital in Temple, Texas which is part of an integrated medical group in many ways like Mayo Clinic. Despite having, purportedly, more physicians per capita than any other community in the U.S., Temple Texas has high quality scores and low costs.

One quibble. In answering the point about McAllen’s poverty as a possible driver of utilization he says:

By any measure, McAllen’s poverty and poor health fails to account for its differences from El Paso. St. Louis is located in another county that is just as poor as McAllen (it is the third-poorest county in the U.S.). Its cost per Medicare enrollee? $8,306.

St. Louis is not located in a county. It is an independent city. The surrounding St. Louis County, particularly its western aspect, is very wealthy. This leaves me wondering how well he checked his other “facts.” It is not clear whether his figure of $8,306 per enrollee represents St. Louis or St. Louis County. The demographics and culture are as different as night and day. (I grew up in the area).


Charo said...

Washington Post

An Interview With Atul Gawande

By Ezra Klein | June 23, 2009; 6:48 PM ET

You've gotten some pushback on your article about McAllen, Texas. Today, in fact, some doctors from the area held a press conference rebutting your claims, and you published a blog post re-rebutting theirs. What have you found to be the most convincing counterarguments against your piece?

See the rest of the interview:

Clinton said...

Just some fact-checking.
St. Louis County's Medicare $/beneficiary = 8,306.

Not sure if Wikipedia is a great reference, especially lacking an independent citation, but St. Louis does not show up as #3 (that spot belongs to Starr County, TX.)

Hidalgo County hits the list at #22, while St. Louis doesn't even hit the lowest 100 list. Something isn't quite right with Gawande's statistics. Maybe he is going off of a different set of measures than lowest income per capita or median household income?

R. W. Donnell said...

The figure you cite is identical to his. That's for St. Louis County, as he said. The problem is, St. Louis County is not among the poorest regions in the nation by any metric or any stretch of the imagination. The City of St. Louis (which is, I repeat, NOT in St. Louis County) may be. He doesn't seem to have any idea of what the cost per enrollee is for the City of St. Louis, but that's what he needs to cite if he wants to make his point about poverty and Medicare expenses.

My guess would be that the cost would be high in the City of St Louis. I think care is pretty fragmented and under served. Most of the hospitals (aside from ones affiliated with the two med schools) have moved to the burbs, so the picture there is pretty atypical.

I don't consider Wikipedia a very authoritative source but I know St. Louis is a city without a county from personal familiarity with the area.

Raises even more questions about his fact checking.