Thursday, June 25, 2009

Gawande Redux

Dr Gawande responds to criticisms of his McAllen piece here. What he's responding to is criticism that McAllen's overutilization is perhaps justifiable, or at least explainable (medical malpractice, patient population, etc). He easily parries these objections with some charts and numbers and then he writes this:
The biggest changes? A dramatic rate of overutilization during a period that saw a marked expansion in physician-owned imaging centers, surgery centers, hospital facilities, and physician-revenue-sharing by home-health agencies. Home-health agencies there, for example, spent more than $3,500 per Medicare beneficiary—not only five times more than in El Paso, but also more than half what many communities spend on all patient care. In the end, none of the criticisms address either the pattern of overtreatment found in multiple studies of high-cost communities or the specific instances I found of revenue-driven care among doctors and executives in McAllen.

In other words: doctors have been poisoned by the "Culture of Money" (CoM).

And this is where I diverge. No one involved in the practice of medicine would deny that overutilization occurs to a sickening degree. My grievance with Gawande has to do with how he perceives the cause of the overutilization. He avers that it is all driven by the financial incentivization of physicians, exemplified by surgicenters and physician-owned radiology suites.

There may be some element of that in McAllen and elsewhere. But I see wasteful medicine everyday, and a great deal of it doesn't financially benefit the doctors who are most profligate. The problem of overutilization is, in reality, far more complex than the McAllen article would have us believe. Sure it would be a lot easier to use the tenets of the "Cost Conundrum" as a blueprint for repairing our broken health care system, but physician greed represents but a small piece of puzzle. Complex solutions make DC policy wonks uncomfortable. It can't be packaged into an intelligible sound byte. Physician greed, on the other hand, gives Peter Orszag et al a definable target, a "problem" to redress. In medicine and mathematics, often the simplest solutions are the most elegant. In this case however, we need to wade deeper into the morass if we hope to equitably solve our inefficient health care woes.


Anonymous said...

Well said, sir, well said.

Dan said...

I understand where you're coming from, but arguing against a very well researched and cited argument like Gawande's with this post (and your last) is sort of like bringing a knife to a gun fight.

I think that Dr. Gawande makes a strong case that is consistent with what we know about the effects of perverse incentives on people (bankers and doctors alike).

I know I've worked with physicians that when I told them a patient had an occluded femoral artery the question I got was "Can you check the system and see if he has insurance?" I'm glad you're not one of them, but in the large hospital I worked there was probably a 50/50 split of doctors that were there for patients versus doctors there for money.

Fixing the incentives is a solid start, it doesn't have to be the end.

Jeffrey Parks MD FACS said...

There's a disconnect between the expository excellence of Gawande's piece and the conclusions he makes. No one is denying that physicians overutilize. The question is why. And my point is that attributing everything to mere "physician greed" is a deductive leap, at best. The motivations are far more complex.

Read the article again. I've read it five times. He zeroes in on this "culture of money" that infects McAllen, exemplified by strip mall owning docs who also run their own surgicenters. The data he supplies confirms that McAllen spends more than everyone else. But he never proves motivation. And how can you? All you can do is posit a reasonable guess. Financial motives certainly play a role but, my god, the waste I see in practice generally has little to do with docs working the system to pad their bottom line; mainly it's docs not thinking clinical decisions all the way through, docs being disconnected from any sense of the cost of medicine, and even docs being lazy.

Incentivize phyisians to be able to spend adequate time with their patients (rather than shotgun consulting half the sepcialists in the hospital). Fix malpractice. Inculcate in younger doctors an awareness of the cost factors in clinical decision making.

The Gawande article doesn't lend credence to these factors. By oversimplifying the problem, it just provides ammunition to healthcare wonks to say that we need to reduce physician payouts and disallow any medically-related entrepreneurial activities. That's why you see Obama quoting from it every other press conference.

Youre right about bringing a knife to a gunfight though. I have no chance against the literary, NewYorker-writing, Harvard surgeon. The article has already achieved mythical status. But someone has to dissent; might as well be a random, irrelevant gen surgeon in Cleveland, right?