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.
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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?
