Gawande rebuked?

Dr. Jeffery Parks is a board certified general surgeon working in Cleveland who writes regulary at Buckeye Surgeon.

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For a while there I thought I was the lone voice of dissent on the Atul Gawande New Yorker article which determined that the profligate spending patterns seen in McAllen, Texas was almost entirely due to the “culture of money” that had infected its physicians. In three posts over the past two weeks I have countered Dr. Gawande’s deductive leap of faith with an alternative interpretation— that the etiology of overutilization is instead multifactorial (defensive medicine, patient expectations, lack of thinking, laziness, overemphasis on testing/algorithms in medical training etc.). In response to those posts I basically heard crickets.

The viral spread of Gawande’s article through the blogosphere and up to the steps of the White House had ingrained the tenets of the article into the national consciousness as the conventional wisdom. I can’t tell you how many respected bloggers/columnists I’ve read over the past month who have called the article “the best piece of health care policy I’ve ever read”. The medical community had apparently already made up its collective mind.

But then I stumbled across a post in the Health Care Blog. The author, Daniel Gilden, does some actual number crunching (rather than make generalized conclusions based on anecdotal evidence) and what he finds is that the patient population of McAllen is the biggest factor in driving up costs. When one accounts for the fact that people in McAllen are fatter and have higher rates of diabetes and heart disease, the difference in spending between McAllen and El Paso or Grand Junction disappears.

McAllen is different from many areas of the United States: it is sicker and poorer. The observed differences in the rates of chronic disease are highest for those conditions rampant in low income American populations: diabetes and heart disease. Further, Medicare beneficiaries in McAllen have significantly higher rates of co-occurring chronic conditions. As a result the costs of caring for McAllen Medicare population appears high in comparison to other areas but not abnormally so. McAllen suffers from a tremendous burden, but it not caused by its physicians: the care they provide leads to costs that are substantially comparable to the other counties in the article once adjustments are made for the magnitude of the health problems they face. The disturbing pattern of physician practices uncovered by Dr. Gawande sounds a warning not because it foretells a McAllen-like future but because it portrays the on-going crisis that affects both McAllen and Grand Junction and it is national in scope. Physician culture is only part of the McAllen story.
Patients with chronic disease, especially those with multiple conditions, are extremely costly to treat. Cost savings will not be realized by denouncing and penalizing medical systems because they treat patient populations with high rates of disease. Instead health care reform must develop policies that support streamlining and coordinating care for beneficiaries with multiple chronic conditions, wherever they reside. Policies that support lifetime continuity of coverage, disease prevention and early treatment, could reduce healthcare costs for populations who now reach Medicare eligibility with a history of under-service. Physician culture has a role to play: Accountable Care Entities are intended to reduce barriers to access by facilitating care coordination. The high costs of care in places like McAllen will not be dramatically reduced by transforming physician ethics and organization if the roots of the crisis are in the interaction between class, demographics and chronic disease.

Amen. Again, there’s no doubt in my mind that the Gawande piece (however interesting, well written and provocative it may be) is one of the most dangerous acts of anti-physician propaganda to come down the pipeline in twenty years. We have our President waving it in front of reporters and Congress. Let’s at least take 5 minutes and make sure the conclusions reached have a base in reality before we allow our national policy makers to use it as a blueprint for reform, shall we?

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Tags: Atul Gawande, US healthcare reform

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I vote for the greedy physician explanation (I’m a scientist). I like the Mayo clinic model where physicians are salaried, and salaries are reviewed.

Gawande has responded to the criticism:

http://www.newyorker.com/online/blogs/newsdesk/2009/06/atul-gawande-the-cost-conundrum-redux.html

Gawande’s data come from the Dartmouth Atlas project. Gilden’s main point is unconvincing. He is basically saying that McAllen spends more because it is poorer and sicker (twice the rate of dementia? 55% more arthritis? hard to believe). How to explain the obscene level of home care expenditure in McAllen? I don’t see the home care issue addressed by the critics.

As “James” points out in his comment on the health care blog, McAllen has low hospice rates. McAllen also has the highest hospital care intensity score in the Dartmouth Atlas data corpus. It is an outlier any way you slice it.

Here is a strong point from the above link:

McAllenâ€™s spending was almost identical to El Pasoâ€™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.

Clearly something is going on here. McAllen’s spending doubled in a short period of time. I doubt the health stats correlate in the same time period.

Comment by John P — July 9, 2009 @ 12:33 pm

Hard to see how higher rates of gall bladder and knee surgery or more tests for carpal tunnel in McAllen are related to higher than average rates of diabetes and heart disease. How to explain the much lower costs for the Mayo Clinics that treat patients with similar diseases from across the country? The conclusions in the Gawande article were not anecdotally based. In fact, he had to wade through the anecdotal explanations from McAllen doctors and administrators to reach a viable conclusion. I’ve yet to read a reasonable fact-based refutation of what he learned.

Comment by Ellen — August 1, 2009 @ 6:59 pm

Medicare data, what Gawande used in his article, shows that McAllen is both cheaper and produces better results than the Mayo Clinic and Brigham Womens and most other hospitals that Gawande mentioned. One should note that as an incentivized program medicare reimburses based on the size of the medicare population. While McAllen has an indigent patient population of over 80%, the Mayo Clinic has one of about 15%. The rest of Mayo’s reimbursements are made up of commercial insurance used by affluent clients from around the world. Of course Mayo will appear cheaper because of the omission by Dr. Gawande of the difference in patient populations. Did you know, for instance, that Mayo is so affluent that in can charge $90,000 to $100,000 for open-heart surgery? That’s unheard of in McAllen!

El Paso is cheaper than McAllen but Gawande’s failure in this portion of his explanation is that he doesn’t itemize healthcare in either population. Home Health, for instance, is very lucrative in McAllen and many think that their services are superfluous. Rather than investigate the different components, Gawande put all healthcare providers into the same pot and under the same cloud of suspicion exacerbated by unconfirmed stories of kickbacks by nameless, faceless physicians that could be anybody and are implied to be everybody.

I don’t know why El Paso is cheaper than McAllen. It’s worth studying. It should be noted that the medical community is exploding in McAllen and services are being provided that were not available only a few years ago. This we do know, while McAllen has its failings, its new-found fame as the face of corrupt medicine is unfounded. Gawande makes explains nothing of Medicare’s methodology or of DRGs, which Medicare uses to determine reimbursements, making hospitals and providers eat the costs of extra and ‘unnecessary’ tests and procedures. Dr. Gawande’s article is pseudo-science at best. It lacks context and purposefully omits information that could be used to explain high costs.

Comment by Alex — September 22, 2009 @ 12:13 pm

NOTE:

The first part about Medicare reimbursements is exclusively in regards to hospitals and physicians.

Comment by Alex — September 22, 2009 @ 12:58 pm