When We Really Do Health Care Reform They'll Know It In McAllen Texas
In recent posts I have expressed my concern that the Congress has all but given up on real health care reform and seems more interested in entitlement expansion.
I worry that the Democrats have found the path to paying for a health care bill (note that I did not say health care reform).
I will suggest that path includes a little cost containment window dressing so they can spin that they have a way to bring costs under control, shaving some provider payments but not too much that it actually hurts, and lots of new taxes.
Real health care reform, on the other hand, would be about crafting unambiguous changes in incentives that drove providers—doctors, hospitals, drug and device makers, and insurers—toward sweating that 30% of the waste out of the system thereby paying for universal care and making the system sustainable.
Just what do all of these words—waste, cost containment, unambiguous changed incentives—mean in real world?
Atul Gawande has an article in The New Yorker that is worth your time: The Cost Conundrum—What a Texas Town Can Teach Us About Health Care.”
Here is a piece:
One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.When we have a health care bill that starts to change things in McAllen Texas then it will be worthy of the label, health care reform.
“Medicine has become a pig trough here,” he muttered.
Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.
We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.
“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.
How about doing the opposite and increasing the role of big insurance companies?
“What good would that do?” Dyke asked.
The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”
He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”
I highly recommend you read the entire article here.
7 comments:
Bob,
Well said. I like how you distinguished between health care bill and health care reform. As a member of the National Physicians Alliance, I am actively advocating within the grassroots community for "health care reform". It is important that we educate the public so that don't "Snowe" us into passing a health care bill. I would appreciate it if you could get the word out that there are thousands of doctors who join Atul Gawande in the fight for reform.
Thanks for a great blog!
Nina Agrawal MD
New York City
National Physicians Alliance - NY Local Action Network
After reading Gawande's article, I think the best first step would be for CMS to implement Gail Wilensky's proposal made in Congressional testimony. Medicare should identify the Docs whose use of expensive high-tech procedures exceeds some predetermined standard associated with best practices or maybe even the national average and require them (through medical records) to prove the procedures were necessary.
Definitely read the entire article. Here is one particular passage that predicts the theme:
“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
Fee for service arrangements encourage this sort of thing, which is one reason Medicare is in such difficulty.
The author trends toward the "solution" as one involving collaboration, but notice the examples he cites are in very localized environments.
Being familiar with Grand Junction, which he cites, here is the environment there: the community is slow growing and somewhat isolated in economic terms; the health landscape is dominated by one local insurance company,Rocky Mountain Health Plans; RMHP has worked to encourage collaboration and bring government and private programs into a workable financial model.
The other cities the author cites as "low cost" are very similar. Would these models work in Denver, Dallas, LA etc. It seems a long shot, but perhaps permitting localized associations could help. In addition, the large metro areas have other distinctions that need to be taken into account, like very large hospitals.
It would seem the major culprit the author attacks is the "greed" of providers. Regardless of the locale, this is most often a moral and cultural matter -- and how do you want to deal with that?
The hypothesis is that doctors stopped being doctors and became businessmen. I suggest that it was a slower process. As the fees for doctors rose higher over the seventies and eighties, more and more businessmen were attracted to medicine, and, in our imperfect world, more of them managed to outcompete the less money-oriented among the pre-meds.
Gawande's assessment falls in line with Arnold Relman's (former editor of NEJM) warning about the profession of medicine becoming the business of medicine. Doctors are human beings susceptible to the perverse incentives in our fragmented healthcare industry.
The fact the hospital administrators were clueless, isn't surprising but it is inexcusable. What are we teaching in MHA programs?
I am afraid if we don't change the incentives to change the way care is delivered, organized, and coordinated reforming healthcare is just rearranging the deck chairs on the Titanic.
Lynn Bailey
Health Economist
Columbia, SC
I practice in McAllen. The answer to why it cost double the national norm is GREED by overutilization. It's not a cultural issue but a moral and ethical one. Providing care is secondary to the revenue generated to provide the care. Everyone in the medical field is aware but deluded in naming it "good business". Many believe they are practicing GOOD MEDICINE by ordering extra procedures. It's good for the patients. Others do it for the higher revenue. Red flagging the overutilizers is one way to curb the high cost of health care in McAllen.
Yes, where is the true "health care reform"? I hardly hear a word about lawyer tort reform, or the cost of medical malpractice insurance. Let's change the standard of care from whether the physician acted like a "reasonable physician"... to to whether the physician was "clearly incompetent" or made "gross errors".
Right now 25% of the cost of health care is eaten up by malpractice insurance, or doctors "overtreating" a patient to protect himself against a lawsuit.
What about allowing nurses more power to treat the 95% of the illnesses that do not need a doctor, but MUST see one to get a prescription. For example, every kid that gets strep throat.
Let's start thinking about solutions, not about how the paper work moves.
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