The summary below comes from an article originally printed in the New Yorker on June 1, 2009 and written by Atul Gawande. Atul Gawande is a practicing surgeon in Boston, MA, frequently writes for New Yorker magazine, and has written his own books called Complications and Better.
I love this article. I highly, highly encourage you to read it yourself on the New Yorker website. I think Atul is a beautiful writer, and this article has been vetted by some of the best editors in the business, so this summary barely does it justice.
Atul compares two towns in Texas with similar demographics, incomes, population sizes, public-health statistics, illegal immigrant percentages, and unemployment rates. Basically, just about everything is the same, but the big difference between these two towns is that McAllen, TX costs twice as much as its nearby neighbor El Paso, TX and almost twice as much as the national average. In fact, Medicare spends $15,000/enrollee even though the per capita income of the town is $12,000! He explores many different possible reasons for such a big difference, but it boils down to one thing: overutilization of healthcare. There are too many tests, services, and procedures being ordered by physicians. Ultimately, Atul blames the entrepreneurial spirit and culture of McAllen that has infected the market since 1992 – the last time that McAllen’s costs were on par with the national average. Doctors not only own their own practices but may also be part equity owners in various specialized surgery centers and other provider facilities. The incentive to recommend too many procedures and tests proves to be too much.
I think my favorite part of the whole article is the sentence that states, “the real puzzle of American health care…is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone.”
Having read a lot of political opinions and listened to political pundits, it’s quite refreshing to see the correct conclusion being drawn from an example of two divergent healthcare costs. Many people point to the efficient exception asking – why isn’t everyone else just like this? I’m a big believer in motivations from incentives and conditioning through learned behavior. I studied a lot of economics, psychology, sociology, and statistics, so this education significantly influences my view the world. The fact is that our system today rewards the behavior in McAllen, so it should not be a surprise that McAllens exist in the US. Perhaps the degree is a bit amazing, but look for the outlier, and it will be found. Atul’s ending is a bit fitting and foreboding, “the decision is whether we are going to reward the leaders who are trying to build a new generation [healthcare delivery models]. If we don’t, McAllen won’t be an outlier. It will be our future.” I think he’s right.
We can’t continue to ask our doctors to be altruistic saints by choosing between what is right and what makes financial sense. If each doctor did what was best for himself, as they do in McAllen, the result is disaster. In a certain way, it is similar to a prisoner’s dilemma where the collection of individuals’ optimal decisions is the worst outcome for the group. Antibiotics is one example – physicians almost always prescribe the antibiotic for the patient because that patient will be better off in any individual instance, but over time this overprescribing produces antibiotic-resistant bacteria that is worse for the entire system. Of course if physician 1 does it, it’s not a big deal, but if physicians 1-10,000 do it, then it becomes an issue. Changing the incentives of physicians is not an easy task. However, there are a few places that have managed to change the way they delivery healthcare.
Next we’ll take a look at some of these places that seem to have achieved healthcare Zen – lower costs, better outcomes, happy patients, and happy doctors.
Sources: New Yorker http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande