Friday, July 3, 2009

Gawande Rebuked?

For a while there I thought I was the lone voice of dissent on the Atul Gawande New Yorker article which determined that the profligate spending patterns seen in McAllen, Texas was almost entirely due to the "culture of money" that had infected its physicians. In three posts over the past two weeks I have countered Dr. Gawande's deductive leap of faith with an alternative interpretation--- that the etiology of overutilization is instead multifactorial (defensive medicine, patient expectations, lack of thinking, laziness, overemphasis on testing/algorithms in medical training etc.). In response to those posts I basically heard crickets. The viral spread of Gawande's article through the blogosphere and up to the steps of the White House had ingrained the tenets of the article into the national consciousness as the conventional wisdom. I can't tell you how many respected bloggers/columnists I've read over the past month who have called the article "the best piece of health care policy I've ever read". The medical community had apparently already made up its collective mind.

But then I stumbled across a post in the Health Care Blog. The author, Daniel Gilden, does some actual number crunching (rather than make generalized conclusions based on anecdotal evidence) and what he finds is that the patient population of McAllen is the biggest factor in driving up costs. When one accounts for the fact that people in McAllen are fatter and have higher rates of diabetes and heart disease, the difference in spending between McAllen and El Paso or Grand Junction disappears.
McAllen is different from many areas of the United States: it is sicker and poorer. The observed differences in the rates of chronic disease are highest for those conditions rampant in low income American populations: diabetes and heart disease. Further, Medicare beneficiaries in McAllen have significantly higher rates of co-occurring chronic conditions. As a result the costs of caring for McAllen Medicare population appears high in comparison to other areas but not abnormally so. McAllen suffers from a tremendous burden, but it not caused by its physicians: the care they provide leads to costs that are substantially comparable to the other counties in the article once adjustments are made for the magnitude of the health problems they face. The disturbing pattern of physician practices uncovered by Dr. Gawande sounds a warning not because it foretells a McAllen-like future but because it portrays the on-going crisis that affects both McAllen and Grand Junction and it is national in scope. Physician culture is only part of the McAllen story.

Patients with chronic disease, especially those with multiple conditions, are extremely costly to treat. Cost savings will not be realized by denouncing and penalizing medical systems because they treat patient populations with high rates of disease. Instead health care reform must develop policies that support streamlining and coordinating care for beneficiaries with multiple chronic conditions, wherever they reside. Policies that support lifetime continuity of coverage, disease prevention and early treatment, could reduce healthcare costs for populations who now reach Medicare eligibility with a history of under-service. Physician culture has a role to play: Accountable Care Entities are intended to reduce barriers to access by facilitating care coordination. The high costs of care in places like McAllen will not be dramatically reduced by transforming physician ethics and organization if the roots of the crisis are in the interaction between class, demographics and chronic disease.

Amen. Again, there's no doubt in my mind that the Gawande piece (however interesting, well written and provocative it may be) is one of the most dangerous acts of anti-physician propaganda to come down the pipeline in twenty years. We have our President waving it in front of reporters and Congress. Let's at least take 5 minutes and make sure the conclusions reached have a base in reality before we allow our national policy makers to use it as a blueprint for reform, shall we?


Resident Anesthesiologist Guy (RAG) said...

Completely agree that Gawande and the masses of politicians who, rather than attempting to understand why the cost is elevated, simply use it as an "aha" moment are missing the boat. I've heard lots of talk in the ORs and hallways of my big academic institution. Most actually decry the movement by Obama and the "culture of money" Gawande describes. Unfortunately physicians are not being asked, unless they wholeheartedly back the president's absurd plan.

HudsonMD said...


Anonymous said...

How would you respond to the criticism of Gilden's analysis that people are sicker because excessive testing by physicians discover these sick people.

The implication is that if Grand Junction's physicians were as "bad" as McAllen's, they too would have all of these sick people to deal with, and costs would skyrocket.

I've always been fascinated by how the guidelines for diagnostic testing are set up. You want to catch the diseases, but you don't want to catch so many that the false positive rate becomes significant. So they're, by design, willing to allow some "misses" and allow sick people to go undiagnosed in the name of cost and the adverse effects of false positives.

Two of my Aunts (Dad's sisters) have gotten colon cancer. But no colonoscopy for me until age 50 because it's not a first degree relative with the family history. Not even for peace of mind.

Anonymous said...

Any Y'all ever take Geography?? I mean a real course, not just memorizing State Capitals like they do in the Pubic School System... Geography drives history...its why America was discovered by Europeans and not Tibetan Monks, Germany invaded Russia, and why you still can't buy Beer in Georgia on Sundays...
What Major 3rd World Country is a 6 Peso Cab Ride from McCallen???
Love how the Mayo Clinic's gonna be the model for American Healthcare.... Wow, for your first appointment they bring every specialist to you!!! Bet that's gonna save money...


atul gawande said...

As a Buckeye surgeon myself (I grew up in Athens OH), I felt I should respond. I don't actually disagree that the story of what causes overutilization is multifactorial, complicated, and bound to vary from community to community. McAllen's has a strong revenue-driven component. Besides payment incentives, habit and fragmentation of care play a role in almost every community, as well. I agree the malpractice system is a mess too and have written and researched at length on this (although it is a much smaller factor -- nowhere with caps or other restrictions have seen lower cost growth).

But I don't think we in medicine acknowledge the revenue-driven component nearly as much as we should. This is a powerful factor. It reinforces leadership that treats medicine as a business. It also discourages leadership to organize care with greater collaboration and time for patients to produce less overtreatment and undertreatment when such work reduces revenues. Reform needs to reward and protect communities that nonetheless achieve success with lower cost and high quality. I gave a lecture recently at greater length on the value of studying and emulating communities that do this differently: I don't think we disagree on the fundamentals here.


Anonymous said...


How much pressure to over treat do you feel is facility driven?

A facility becoming a "_________________ center of excellence" (insert cardiac, ortho, onc, etc.) heavily marketing prospective patients to believe that hi-tech diagnostic/intervention is always best. While in many instances the patient will benefit, these decisions to expand are heavily revenue driven as you all know. How much facility-based pressure is there for MDs to utilize the more pricey route? How do you think the changes to come will impact facilities?


Jeffrey Parks MD FACS said...

Thanks for stopping by. As a practicing surgeon, there's no doubt in my mind that your enduring stance on health care reform is far more nuanced than to attribute the problem to one issue (physician financial incentives).

I guess I've felt the need to rant about this for the past 2 weeks because of the way I perceive the article has been received by the national media/blogosphere/policy wonks. The purpose of the article, as I understand it, was to highlight the heretofore unacknowledged role physicians play in driving up costs. I'm with you there. In my dissent posts I acknowledge that those MRI's and unnecessary cardiology consults don't happen unless a doctor orders them. But my point is that those overutilizers aren't always driven by revenue considerations. In fact, the things that lead to overutilization (laziness/neglect/fear of not doing enough) are far more nefarious than simple greed. We aren't doing a good enough job, no doubt, but attributing everything to greed misses a more important point; we have to be better doctors. In your commencement address you speak of fighting "for the soul of American medicine". I agree with you; fundamentally we see things similarly.

I just got riled up seeing the national media seize upon your piece, not as a focused spotlight illuminating an aspect of the healthcare problem seldom referred to, but as a sole diagnosis and prescription for the entire cost crisis.

Anyway, thanks for the response.

Anonymous said...

As an endocrine surgeon at the BWH, Dr. Gawande and his colleagues perform hundreds of thyroidectomies and parathyroidectomies yearly. Why don't you ask him why those aren't perfromed at the affiliated BWH-Faukner Community Hospital 5 minutes away for a fraction of the cost. Hippocracy is unflattering.