Do you know where the most expensive health care in America is being practiced? McAllen, Texas, the city that couldn't stop spending.
Yesterday at work I was speaking with a colleague about health care stuff when he told me a patient of his brought in an article for him to read. An article from a doctor by the name of Atul Gawande. "Have you heard of him?" he asked. "Yes, of course", I said. He told me about this article in the New Yorker called "The Cost Connundrum". A piece that needed to be read.
And wouldn't you know it, yesterday a reader of HH did my searching for me. Dr David, a frequent commenter on my blog had sent me the link. I figured it must be fate if two doctors recommended it, in the same day.
After returning from the horse races last night, barely missing a 200:1 $2 trifecta (I don't know a thing about horse racing), I sat down on my leather couch with a cigarette in hand (just kidding). I lit a nice romantic candle , put my iPhone in hand, placed my Italian greyhounds by my side and I clicked on Dr David's link.
I was not terribly shocked by what I was reading. It is not a local phenomenon. It happens nationwide in our fee for service delivery of health care. That is the reality of which we currently live in. And I am certainly not immune. Every time I have to code an E&M visit, I have to review my criteria to determine what level of service to bill. I have to make sure certain things are documented appropriately to not be accused of fraud in my high complexity level three hospital follow ups or my high complexity admissions and consults. Encounters which meet medical muster for the level of service I bill, but must also have specific ridiculous documentation to support it. Not a day goes by where I'm not actively documenting to meet third party insurance rules criteria that has no effect on patient care.
In the end, Dr. Gawande comes to the conclusion that physicians are to blame for the out of control nature of our health care expenditures. The blame rests solely on our shoulders. Our pen is the most expensive technology in health care today. Without our pen, we have only our minds for which to doctor. And our minds are compensated less than your community college tradesmen often are.
And why is the pen so expensive? I think he contends it's all about money. Follow the money and you follow the health care. This article is an exceptional piece of journalistic truth.
Dr Gawande hits the nail on the head when he writes "no one is in charge". Nobody is accountable. Not patients. Not doctors. Not hospitals. Not governments. Not taxpayers. Nobody. Nobody is accountable for anything. We are where we are today out of a natural selfishness for economic prosperity for every party in the food chain. To expect a result different than we have today is to expect all parties to strive for poverty.
We have gotten exactly what we have paid for. A very expensive, technology driven medical machine that strives to maximize economic profit at the expense of quality affordable health care. That's not to say profit in medicine is bad. Profit in medicine is actually very important. Profit drives innovation to reduce medical complications to streamline operating costs and compete with other institutions for the community dollar. But you can only get quality and cost control when the economic distibution pie is not infinity.
If you have no limits, you get no cost control. The issue isn't how much we are paying for health care. The issue is how much health care we are providing. Health care isn't expensive. Unnecessary health care is.
What we currently have is unchecked FREE=MORE at its worst. If you can't ration FREE=MORE you get the most expensive care in America.
In the current FREE=MORE, where no one is in charge, health care simply happens. Checks get written. Money gets transferred. No questions get asked. And it's all dependent on the actions of the doctor's most expensive weapon, the pen.
I see this mentality every day. I see it in outpatient notes. I see it in inpatient notes. I see it in how patients are worked up. How things are ordered. I am never surprised at the lengths we go to as physicians in our evaluations. I can spot economic medicine over quality medicine by barely blinking an eye. Because I see it every day. The clowns at the MNB are off making balloon animals while the people pillage the largest and most unstable bank in the history of our country. As we teeter on the brink of financial collapse, the MNB sputters along, writing checks for everything, with barely a question being asked as to why.
Want to bet what happens? I'll tell you what would happen. Your patients would see far less action in the hospital, ASC, radiology suite, clinic and any other health care site you can imagine. And they would experience no drop off in quality. Why? Because the doctors would take care of patients for the right reasons.
ReplyDeletethat experiment is a reality in my country, you know venezuelan doctors are payed on public service, not for the amount of patients or test we see or do, we got an standard income regarless the cuantity of patients and test.
this is my work from 480 to 570 patients for 400 dollars monthly. i agree that testing shouldnt be charging, in my work most of doctors will ask for unnecessary testing, not because they are gonna be payed more, because the patients and the doctors are used to it, because they lack of knowledge when to order the right test, lack of physical examination, but I agree with you if you eliminate money as a motivator unnecessary testing should be reduced, still you wont eliminate overtesting 100%, but is gonna get reduced. on the other hand, having standard incomes, despite of the number of patients, make doctors feel less interested on them, i have endless examples, of this Pneumo and Cardio Docs arguing, its not my patient is yours CardioD says: "he got COPD" PneumoD says: "He got CHF", if it was a private service is different, you get payed for each patient, you would see specialist taking patients beyong their scope of practice, just to earn more money.
i guess it would be interesting compare your hospital rates of testing with ours, but i bet our populations would be so heterogenous and there are many variables involved to even compare or make a proper conclusion. very interesting post.
Very well written.
ReplyDeleteI've checked and double-checked, concerned for my sanity -- but it's true:
ReplyDeleteGreat post, Happy.
I read that last week.
ReplyDeleteI want our president to respond to that article and tell us how his brilliant ideas for reform are going to change that equation.
What's only briefly mentioned in that article is that McAllen (and South Texas in general) was previously one of the most toxic malpractice climates in the nation. Now we have outstanding tort reform in Texas, but those practice patterns were formed during the worst of the crisis. So my theory is that the local standard of care evolved from a suffocating need to practice defensive medicine to the extreme. Thus the overtesting and overtreating.
ReplyDeleteWell written. A colleague and I were discussing this article, and it reiterates for the me the fundamental thing about our health care system - that it is for profit - will prevent it from being "reformed." I like your ideas. The only way to change behaviors and create a paradigm shift for HC in this country is to make people pay more for what they "want" or get. No it's not "fair" but hitting people in the check book is the only way you make them change.
ReplyDeleteAs an aside, this article has apparently caught the attention of the Democratic leadership in the House and Senate and a copy of it sits in the President's desk. I suspect the bludgeon against all of the "greedy doctors" (read: all doctors) is coming.
ReplyDeleteThe Gawande article is off the mark. I rambled on about why on my stupid blog. The ER doc isn't financially motivated to order MRI's on patients with chroinic back pain. The GI consultant doesn't get money from the HIDA scans, CT angiograms, and gastric emptying studies he orders. The ID guy doesn't get paid off by the pharm company for recommending the most expensive broad spectrum antibiotic.
ReplyDeleteThe problem is overutilization but it isn't (for the most part) driven by physician greed. Mostly, we just don't think. Some of it is laziness, some fear of lawsuits. But what we need to change is how we go about practicing the art the medicine in such a way that is both medically appropriate and socially conscious (i.e cost effective).
Take care.