Thursday, July 09, 2009

Healthcare costs: the Atul Gawande New Yorker essay

Do expensive state of the art medical facilities correlate with better health outcomes? In this superb essay, surgeon and writer Atul Gawande tells us how, in certain places in the United States, technology can collude with strange monetary incentives to increase health care costs and reduce the quality of care. Physicians are leaning towards more tests, more scans, more surgeries -- all of which generate revenue -- when simpler wait-and-watch alternatives would have been preferable. And there is no conspiracy here: the system in the United States seems to have subconsciouly evolved this way because of the incentives in place. Atul Gawande travels to the city of McAllen, Texas and makes the argument that the overutilization of medical resources has sent costs skyrocketing. And he tells us that only by trimming the fat from the system will Obama be able to finance healthcare reform.


Sam D said...

You have missed the point of Gwande's article. You say:

...the system in the United States seems to have subconsciouly evolved this way because of the incentives in place.

The system as a whole hasn't evolved that way; some doctors in some areas seem to have developed a culture of money and the good of the patients are not the top priority.

The article makes the point that not all doctors practice that way, and that it is not a healthful way to practice medicine.

Gwande never said anything about watchful waiting being preferred. Some times it is and sometimes it is better to treat but less expensive, less intrusive care is much better for the patient.

The patients in the high cost areas are not better off and don't have better results with the lavish use of high tech imaging and treatments.

Read some of Gwande's other articles; they can be found in the New Yorker. They was an interesting follow up to the McAllen article.

Hari said...


The points you raise are correct. My errors are largely because of my poor (or lazy) paraphrasing, since I did take away the essence of what you say while reading Gawande's article.

My point about incentives is a generalization -- it's true that not all doctors are like that, but isn't it true that many places, even if they don't have the rampant culture of money that McAllen has, tend follow the "more procedures, more revenue and also less chance of getting sued" line? That's what I meant when I said the system has evolved subconsciously.

Again, with the watchful waiting, I was trying to explain the tendency to unnecessarily overdo, but your clarification is definitely more precise.

Thanks much.

Sam D said...

Thanks for your reasonable response.

I am not sure how sub-conscious the excess treatment decisions are. Look at the bit in the Gawande article about the lunch he had with a group of doctors to whom he asked about the way above average number of procedures done there. The docs fairly quickly came to admit that maybe it was an economic interest.

I think the all out over "treaters" fight off their self-knowledge with an easy out of "well we don't know he can't recover if we do one more thing" or "I know this has fixed up some of my patients."

One of the reasons that hospitals won't reveal information about their error or infection rate is not just to hide possible malpractice but to hide from themselves how poorly they are serving their patients.

I don't know. How can there be so many good doctors who are dedicated to doing the very best for their patients. Most doctors who work on a salary basis at a good collegial place, like Mayo, Intermountain in Utah, the entire VA system, and numerous other places, are generally well pleased with their situation and don't tend to leave.

Read some more of Gawande's work. He is very balanced and doesn't think he has all the answers. This is good:

A bit: "One last point worth remembering here: McAllen’s spending was almost identical to El Paso’s in the early nineteen-nineties. By the late nineties, however, it had become one of the most expensive regions in the country for Medicare and it has continued that way. Yet, public data show no sudden decline in health status or income for the McAllen population.
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."

And go to the New Yorker site and search on Gawande; he has some recent articles that are pertinent.

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