Atul Gawande on health care costs

Bob Wachter, whose blog post first alerted me to Atul Gawande's brilliant New Yorker piece, notes that it is essential reading for anyone concerned with health care policy. Gawande has a unique and fascinating way of explaining health care variations. What he does in the article is explain Dartmouth Atlas data on health care variations by telling stories---stories about the organization (or disorganization) of health care delivery, mainly in McAllen, Texas, but also in places like the Mayo Clinic and Grand Junction Colorado.

The strength of Gawande's account is that it is vivid and experiential. (As you read it reflect on what's going on in your own medical community). Its major limitation is not only that it is anecdotal, but that its anecdotes represent the extremes in health care variation---only the best and worst in the U.S. are profiled. Although Gawande makes no pretense of offering a rigorous, comprehensive analysis of the problem his article has already caught the attention of policy makers, who may be tempted to overgeneralize. Concerning the piece Wachter drops this bomb:

He swats away the usual explanations (our patients are sicker, more obese, more addicted, more Mexican; our lawyers are nastier; our quality is better…) to unblinkingly zoom in on the real culprit: a culture in which providers’ greed trumps the patients’ interests.

I hope the medical education thought police don't run with that idea---next thing you know greed management classes will be required CME for doctors. (Hold on a minute while I search the web for a Dartmouth greed map.................Nope. Couldn't find one). Well, if a national greed map existed I think it would be homogeneous. It's an inherent human trait, such a constant, that what plausible explanation could there be for selective expressions of greed among health professionals in geographic regions?

Even if Bob's cynical explanation applies partially to Gawande's extreme anecdotes those “usual explanations” are not so easily swatted away when one looks at the big picture of health care in the U.S. (Juxtapose a national obesity map on one of the Dartmouth Atlas maps and you'll see what I mean).

Gawande, avoiding pat answers about greed, takes a nuanced look at complex cultural factors in the organization and delivery of health care. The Mayo Clinic figures prominently in his story. Rochester Minnesota, whose residents get almost all their care from the Mayo system, ranks in the bottom 15% for health expenditures. That's difficult to understand from a simplistic view of utilization. Mayo doesn't skimp on the best medicine has to offer, as anyone who has dealt with their system knows. Unfortunately public policy leaders who take a superficial view of greed driving health care costs may see the solution as merely one of denying services. But, as I noted before, the best research we have on practice variation indicates that underutilization is a greater problem than overutilization.

The real key, in Gawande's analysis, is organization and design. Mayo is a lesson in how efficiency and quality can be designed into a local system. Gawande observed it first hand during a visit there:

Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.

“I’ll be there,” the cardiologist said.

Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.

The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.

According to Wikipedia:

Mayo Clinic pays medical doctors a fixed salary that is unaffected by patient volume. This practice is thought to decrease the monetary motivation to see patients in large numbers and increase the incentive to spend more time with individuals.

That doesn't mean Mayo Clinic doctors are less greedy. They are paid handsomely. How else would Mayo recruit and retain the best and the brightest? What it does reflect is an enlightened view among the leaders about physicians' incentives.

Gawande talked with Mayo's CEO about how better alignment of incentives promotes efficiency:

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.

“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.

How can Mayo clinic be efficient and patient centered at the same time? If they had a motto for patient centeredness it might read: apply the best available knowledge and resources to offer patients what they need, no more and no less, and eliminate all conflicts of interest and institutional barriers that stand in the way. That, in contrast to Don Berwick's definition (give patients what they want, how they want it and when they want it), is a vision for patient centeredness that doesn't trump efficiency.

Gawande goes on to profile Grand Junction, Colorado, another community with low health expenditures. The medical community there is not structured like Mayo but has in common a level of organization and integration that promotes efficiency.

What's the take-away message from Gawande's article? That it's not just about greed. Greed is part of all of us, but it can't account for regional variations. It can be managed if the incentives are properly aligned. That's why organization is key. That it's not about who pays for it, nor is it about nationalization. He writes, in conclusion (my italics):

But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.

Organization and integration at the local level. Even if it's one community at a time. It won't be a quick fix, but we can make a difference if we start now. That's the message.