By Evan Falchuk
Everyone is reading Atul Gawande’s article in the New Yorker about health care costs. But I think most people misunderstand Gawande’s major point.
Everyone's At It
The conventional wisdom on Gawande’s piece is this: our problems are caused by bad incentives in our health care system. They encourage doctors to overprescribe care. McAllen, Texas is the poster child of this problem. If we can change the economic incentives, doctors will behave better. They will follow medical evidence, not their bottom lines, and from this will emerge a rational, affordable system.
This isn’t what Gawande is saying.
Gawande went to McAllen expecting to see a microcosm of the American health care system. As expected, he found excessive, even abusive spending, and a culture that encouraged both. But he also found that in nearby El Paso, Texas, medicine wasn’t practiced this way, nor in most other places in the country. And so he came up with a surprising insight. Yes, McAllen is a reflection of what can happen based on the incentives in the system. But if every incentive works this way, why is McAllen such an outlier?
Gawande concluded it had to do with the “culture” of medicine in each community. Most doctors go into medicine to help patients. In Gawande’s visit to McAllen, he heard stories that money had become more important than quality care. What Gawande realized was how important this question of “culture” was to how McAllen became McAllen. It made him think of places that had a completely different culture, like the Mayo Clinic.
The doctors of the Mayo Clinic decided, some decades ago, to put medicine first:
The core tenet of the Mayo Clinic is “The needs of the patient come first” — not the convenience of the doctors, not their revenues. The doctors and the nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. . . . Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially feasible.
Gawande couldn’t believe how much time doctors at the Mayo clinic spent with each patient, and how readily they could interact with colleagues on difficult problems. While it is true, the Mayo Clinic has financial arrangements that make this easier, it is the culture of patient care that dominates, not questions of pay:
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” [Denis] Cortes [CEO of the Mayo Clinic] told me
And this is where Gawande is being misunderstood.
The “cost conundrum” that Gawande talks about is not about how to cut costs, or how to change who pays for health care and how much. It’s deeper than that. Gawande’s point is that we have been fixated for so long on the question of money in health care that we are starting to forget about medicine. By focusing on ever more clever ways to pay doctors, we have systematically undervalued everything that makes for high quality medicine. Things like time with your patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
We discount what he calls the “astonishing” accomplishments of the Mayo Clinic on this score. And instead of designing health care reform around ways to help more hospitals become like the Mayo Clinic, we choose instead to think about money, to focus our attention on how to cut costs in places like McAllen.
Politically, it makes sense – it’s convenient to have a poster child like McAllen to explain why one reform plan or another should become law. But the pity is that in this important time of reform we’re not talking about trying to put the needs of the patients first – to put medicine back in the center of health care. The pity is that in spite of the fact that everyone’s reading Gawande’s article, his most important insight is being misunderstood.
If we continue to be focused on money over medicine, we will lose the “war over the culture of medicine – the war over whether our country’s anchor model with be Mayo or McAllen.”
Evan:
Well done! What a seminal piece of writing to frame the debate in such a poignant way, i.e., “who will be the anchor tenant in medicine: Mayo or Mc Allen?”
The answer as well as the appreciation for the depths and nature of the question, is both inspirational and stimulative on many levels.
Candidly, I’m starting to feel a little sorry for the hapless McAllen medical community; though I suppose they’ll speak for themselves if they can find a vehicle. Yet, maybe an even more on point question is, are they even listening” and do they care?
Thanks again for the post!
@2healthguru
The real question isn’t “why are the egrigious capitalists of Mcallan, Tx doing this?”Instead it’s, given all the incentives in the Americah system “why are the losers in Rochester, MN, and Ft Colins CO leaving all that money on the table!”
Evan – Great interpretation of a great article! If the healthcare system is operating the way it should, physicians that base all of their decisions solely on the best interest of the patient will do just fine from a financial standpoint.
Thanks for the comments, guys.
Gregg – I hadn’t thought of those doctors in McAllen. The people down there were already probably suspicious of all things New York, this can’t help!
On those lines, it sounds like there is a representative from McAllen at the AMA meeting today ready to respond if the President brings up McAllen in his talk today.
Evan
Gregg – you are asking exactly the same question that I was trying to answer when I found this post. What comments are coming from McAllen? I’d love to come across a venue for their discussion.
Thank you, Evan, for your explicit summary of Dr. Gawande’s main point. I would love to see this article drive a larger sea change in the public discourse about healthcare reform, rather than getting stuck as an argument on one side or another. As someone starting medical school next month, I am on the edge of my seat to see how medicine will change during this administration.
[...] No, it is because these things things actually interfere with the doctor’s ability to think, process and decide with their patient on the right things to do. [...]
[...] problems of McAllen make easy talking points. But they are also a convenient way of avoiding dealing with the enormous complexity of the health care system. There are nearly 650,000 doctors in America, millions of patients, thousands of hospitals, tens of [...]
[...] Berwick is one of the most respected advocates for patient safety and health care quality. Like me, he worries that focusing on money over medicine misses the bigger point: To get the care we need [...]
[...] It’s an interesting read, because Gawande directly responds to Klein and the others who misunderstand his [...]
You ask the right question, but I’m not sure what your answer is. In a privately developed and independent provider world, each community develops its own models for care and payment. If you go around the country and look deeply into the provider communities and how care is delivered and paid for, it is astonishing how much variation there is. That’s part of the problem. How do you develop a better system when the one that we have is fractured and built one community, one payer, one patient at a time?
In point of fact, there is no real market reward for being a high qualty, low cost provider. The Mayo clinics aside, most communities have average health care systems that produce average results at high cost.
The only way that we can get to a better system is to create a “real” system by reducing the number of funding sources (preferably to one) and setting standards for providers at a national level.
If we do this, we can all then focus on quality instead of payment and those who produce better results will remain in business and those that don’t won’t. If we continue as a country to allow thousands of payers and thousands of independent and unregulated providers, we’re going to continue to get average quality at a high price.
In a single payer world, quality improves not because the providers somehow get better but because resources are allocated in a utilitarian way–thus diabetes and other chronic conditions get the lion’s share of funding while acute episodes that are not life-threatening have more limited access.
In a world where a budget is set, a nation can spend its time worrying about where to allocate limited resources and thus focuses those resources where they will do the most good.
This is how quality is improved across a population. You’re right to question whether we should be talking about quality or money. I don’t know how you’d change that conversation, but I know I would. It’s single payer, it’s regulated providers. It’s that simple. Whether we ever get there is anyone’s guess, but we’re stumbling toward it by pricing everyone out of the market.
[...] Falchuk included a link to another article he wrote about how people are misunderstanding Gawande’s ideas. This gave me a bit more insight into his views on the topic, but it left me scratching my head a [...]
Great summary – I am not sure why the subject keeps getting changed – we have to fix the funding AND the overutilization aspects. Can you concentrate on one and not the other? No but if you concentrate solely on utilization that will NOT solve the funding – when your insurance compan denies payment for your current problem because a pre-existing condition is now evident, you’ve certainly solved the problem of overutilization but the patient may be dead!
[...] I think we are seeing the real world effect — on patients — of what Atul Gawande called focusing on “money over medicine.” [...]
[...] seen the practice of medicine as a simple economic transaction. We’ve prioritized money over medicine. And by focusing on ever more clever ways to design economic incentives, we have systematically [...]
[...] long pre-dates this latest reform effort. Its impact was well documented in Atul Gawande’s (thoroughly misunderstood) article in the New [...]
I think Gawande IS saying the system incentives are systematically wrong, and that only in places where the culture happens to be about patients are those incentives corrected, and quality and cost improves. However if we were to tackle this nationally, we don't need to rely on the contingencies of local “culture”, we can substitute that with legislative carrots and sticks that change the incentives to be the right ones.
I think Gawande IS saying the system incentives are systematically wrong, and that only in places where the culture happens to be about patients are those incentives corrected, and quality and cost improves. However if we were to tackle this nationally, we don't need to rely on the contingencies of local “culture”, we can substitute that with legislative carrots and sticks that change the incentives to be the right ones.
[...] been blogging about this for months and months and months and months. You don’t mess with people health benefits. Benefits [...]
[...] been blogging about this for months and months and months and months. You don’t mess with people health benefits. Benefits [...]