US healthcare: Atul Gawande has some good news


Back in June of 2009, when Congress was just beginning to formulate and debate the Affordable Care Act, Atul Gawande wrote an article on the rising (and exorbitant) cost of US health care. He focused on how waste contributes to cost — not just the usual fraud, high prices, and administrative fees, but unnecessary care: Drugs that are not helpful, operations that do not make patients any better, scans and tests that not only have no benefit, but often lead to harm. Waste accounts for a third of health-care spending. More disturbingly, it can cost people their lives.

Gawande used the town of McAllen, Texas to illustrate his case. McAllen had one of the highest costs in the nation for Medicare — twice as high as El Paso, another Texas border town with similar demographics. And it’s not as if patients in McAllen were receiving better care. Compared to El Paso, patient care was similar or worse.

It turned out that many specialists in McAllen had financial stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital. One local doctor told Gawande: “Medicine has become a pig trough here. … We took a wrong turn when doctors stopped being doctors and became businessmen.”

Now, six years later, Gawande has revisited McAllen. His 2009 article had generated a lot of attention for the town, and he wanted to see if anything had improved. What he found was that things had changed significantly for the better. He writes about this in a new article, Overkill. What’s so heartening about the story he tells is not simply that costs have been reduced, but patient care has improved, and doctors are enjoying a more satisfying practice.

The good news for doctors

Gawande credits the Affordable Care Act for the change he observed in McAllen. In particular, he cites its provision for accountable-care organizations (ACO). He tells the story of a primary care physician, Dr. Osio, who agreed to see Medicare patients referred by the ACO WellMed. The incentive for participating in an ACO is that doctors can see fewer patients, for longer visits, but their income will increase if the quality of care improves.

Osio was skeptical, but he agreed to see some of WellMed’s patients. When he was in training, he’d been interested in geriatrics and preventive medicine. In practice, he hadn’t had time to use those skills. Now he could. With WellMed’s help, Osio brought on a physician assistant and other staff to help with less complex patients. He focused on the sicker, often poorer patients, and he found that his work became more satisfying. With the bonuses for higher patient satisfaction, reducing hospital admissions, and lowering cardiology costs, his income went up. This was the way he wanted to practice—being rewarded for doing right rather than for the disheartening business of churning through more and more people.

The good news for patients

As for improving patient care, it turns out the death rate for WellMed’s Medicare patients was half that of the average Texas death rate, even though the WellMed patients were older and had higher rates of diabetes and chronic lung disease. How could this be?, Gawande asks. He illustrates the answer with the story of one of Dr. Osio’s patients. “[H]is diabetes was so out of control that his body had developed a tolerance to big spikes in blood sugar. Unchecked, his diabetes would eventually cause something terrible—kidney failure, a heart attack, blindness, or the kind of wound-healing problem that leads to amputation.” As it turned out, this patient believed he did not need to take his medication if his daily blood-sugar level was normal. Dr. Osio was able to learn this because he could afford to spend 45 minutes talking to his patient. Osio’s nurse, who had been trained and certified as a diabetes educator, spent another 45 minutes with the patient and then spoke to him regularly by phone until his condition was under control.

Previously, Osio would not have had the time or the resources to do much for the man. So he would have sent him to the hospital. … The thousands of dollars spent on the hospital admission would have masked a galling reality: no one was addressing the man’s core medical problem, which was that he had a chronic and deadly disease that remained dangerously out of control. … But now WellMed gave Osio bonuses if his patients’ diabetes was under better control, and helped him to develop a system for achieving this. … Step by deliberate step, Osio and his team were replacing unnecessary care with the care that people needed.

Good news for costs, but the right to health care remains elusive

As for lowering health care costs, Gawande again credits the Affordable Care Act: (emphasis added)

[I]t has been five years since the passage of the Affordable Care Act. … [T]he cost of a Medicare patient has flattened across the country. … [Economist Jonathan] Skinner projects the total savings to taxpayers to have reached almost half a billion dollars by the end of 2014. The hope of reform had been to simply “bend the curve.” This was savings on an unprecedented scale.

In the US, there is no right to health care (see The Elusive Right to Health Care under U.S. Law). Especially since the 1970s, health care has been dominated by incentives for financial gain (see the next post, Academic medical centers: Education or profits?). Even the promise of saving billions of dollars would not be enough to overcome political opposition to universal health care. As George Packer recently summarized the dilemma, Americans believe “the country has fundamentally betrayed its promise (freedom, equality, a fair chance, the American dream),” but they also believe “the political system is too broken to offer hope.” So yes, it’s encouraging that there’s good news in McAllen, Texas, but the changes I’d really like to see remain all too elusive at this time.

Related posts:
Can better care for the neediest patients lower costs?
Profit-driven medicine: Satisfying patients at the expense of their health
Electronic medical records, for-profit medicine, and the doctor-patient relationship
For-profit medicine and why the rich don’t have to care about the rest of us
Creating an epidemic of cancer among the healthy
The downside of overly aggressive cancer screening
Are the most heavily marketed drugs the least beneficial?

Image source: HCMS Group


Atul Gawande, Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?, The New Yorker, May 11, 2015

Atul Gawande, The Cost Conundrum, The New Yorker, June 1, 2009

Jennifer Prah Ruger, Theodore W. Ruger, and George J. Annas, The Elusive Right to Health Care under U.S. Law, The New England Journal of Medicine, June 25, 2015, Vol 372 No 26, pp 2558 – 2563

George Packer, Revolutionary Roads, The New York Times Book Review, July 5, 2015


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