When you look across the spectrum from Grand Junction to McAllen-and the almost threefold difference in the costs of care-you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Changing who writes the check to a provider, Gawande maintains, will not fix the problem with our healthcare system.
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.
This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.
I can’t do full justice to Gawande’s 10 page piece in just a few paragraphs here, but I hope I can steer some readers his way. I have worked in information technology in the insurance industry for over a decade and see many of the claims made for single-payer health care reform from the skeptical vantage of someone who knows just how complex the claims payment and utilization management systems have to be, and just how many administrative staff are needed, to prevent fraud and provide payment to the maze of independent healthcare providers who furnish care. Gawande makes the argument I have been trying to articulate about why single-payer alone will not solve the health care mess – how reforms are also crucial to how providers are incented and paid for care. Good stuff.
stephgm says
As somewhat of an aside, I find almost anything Dr. Gawande writes to be insightful, gripping, and important.
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p>If any of you have become (sadly) like me and find that — because you’ve allowed the internet to damage your patience and willingness to be led by a single author — you rarely can make yourself read a whole book all the way through anymore, pick up one of Gawande’s: “Better” or “Complications”. Both made cross-country flights seem to pass quickly, and they left me with plenty to think about.
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p>Also of note are Gawande’s direct impact in using rigorous science toward improving medical practice, for example, this:
bean-in-the-burbs says
I’ll check them out. He apparently lives in the Boston area – wonder if he ever lectures for a general audience. I’d be very interested in hearing him – seems like a remarkable guy.
stephgm says
If and when he should be scheduled to speak before a general audience, the event will probably be listed on his website.
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p>In the meantime, you motivated me to see what I could find on-line, and I enjoyed watching this talk that he gave in the UK on the day the NEJM study was released.
annem says
but never had looked for his website–thanks for the links
jhg says
Very interesting article. Gets to cost issues that the health insurance debate doesn’t get to.
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p>I know the HMO system was at one time an attempt to address this issue. Why didn’t that work?