This link has been bookmarked by 164 people . It was first bookmarked on 27 May 2009, by finnegas.
-
30 Jun 14
ruby1991Online version of the weekly magazine, with current articles, cartoons, blogs, audio, video, slide shows, an archive of articles and abstracts back to 1925
-
28 Apr 14
-
25 Feb 14
goldfdtn"The biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close. The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers."
-
15 Oct 13
-
09 Nov 12
-
Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”
-
-
-
Medicare spends three thousand dollars more per person here than the average person earns.
-
-
-
In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance.
-
-
08 Nov 12
-
other words, Medicare spends three thousand dollars more per person here than the average person earns.
-
Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’
-
-
07 Nov 12
-
But that rule doesn’t hold for health care.
-
-
17 Oct 12
-
McAllen has another distinction, too: it is one of the most expensive health-care markets in the country.
-
In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn.
-
“People are not healthy here.” McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate
-
Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too.
-
Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen.
-
An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high.
-
The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.
-
Doctors, he said, were racking up charges with extra tests, services, and procedures.
-
The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.
-
But research suggests that where medicine is concerned it may actually be worse
-
more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be.
-
After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.
-
Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines,
-
She wasn’t the only person to mention Renaissance. It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there.
-
a percentage of the hospital’s profits from the tests, surgery, or other care patients are given.
-
Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.
-
And which kind of doctor they were depended on where they came from
-
He offered a different possible explanation: the culture of money.
-
The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community.
-
Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up
-
It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.
-
Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients.
-
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.
-
When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town.
-
Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”
-
-
06 Oct 12
-
03 Sep 12
-
03 Aug 12
-
23 May 12
Boris .accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.
more diagnostic tests, hospital admissigovernment insurance medicine politics economics health healthcare
-
28 Apr 12
-
An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are.
-
We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism,
-
The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic
-
McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America
-
Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare
-
In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.
-
“Maybe the service is better here,”
-
Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.
-
“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.
-
Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?
“Practically to zero,”
-
“We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
-
The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”
-
Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.
-
I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?
Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.
And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.
“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.
-
Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice
-
two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen.
-
yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.
-
The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
-
Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be
-
In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.
-
They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.
That’s because nothing in medicine is without risks.
-
No other country does anything like as many operations on its citizens.
-
To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician
-
They got more of the stuff that cost more, but not more of what they needed.
-
Universal coverage won’t be feasible unless we can control costs
-
“Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated.
-
Physicians in places like McAllen behave differently from others
-
The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.
And, I realized, few people in their position do
-
Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for.
-
Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines
-
when it came to measures of less certain value—and higher cost—the differences were considerable.
-
“It’s a machine, my friend,” one surgeon explained.
-
No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it.
-
You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.
-
many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.
-
Agencies that want to compete on quality struggle to remain in business, the rep said.
-
About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine
-
I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country
-
The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues
-
“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers.
-
It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income.
-
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
-
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.
-
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
-
There is no insurance system that will make the two aims match perfectly
-
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
-
Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.
-
. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.
“I don’t have a problem with it,” he said. “But it won’t make a difference.”
-
How about doing the opposite and increasing the role of big insurance companies?
“What good would that do?” Dyke asked.
-
We will need to do in-depth research on what makes the best systems successful—the peer-review committees?
-
Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can.
-
we have to choose someone—because, in much of the country, no one is in charge.
-
many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue
-
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now.
-
-
15 Mar 12
-
28 Sep 11
-
18 Aug 11
Fred KaplanWhy health care costs so much in some places and not in others? It's the doctors.
-
05 Dec 10
-
13 May 10
thinkahol *ANNALS OF MEDICINE about health-care costs. Writer contrasts the high-cost health-care system in McAllen, Texas, with the lower-cost systems at the Mayo Clinic and in Grand Junction, Colorado. McAllen, Texas is one of the most expensive health-care market
Amitabh Chandra Brenda Sirovich Buisness Denis Cortese Doctors Hospital at Renaissance Elliott Fisher El Paso Gilda Romero Health Care Health-Care Costs Reform Jonathan Skinner Kate Baicker Lawrence Gelman Lester Dyke McAllen Heart Hos
-
29 Mar 10
-
07 Mar 10
-
04 Mar 10
clark updikeBig Rock Theory in action:
"Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible" -
02 Mar 10
-
Doctors, he said, were racking up charges with extra tests, services, and procedures.
The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”
-
-
26 Jan 10
-
05 Jan 10
-
26 Dec 09
-
25 Dec 09
-
-
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.
-
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.
-
have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.
-
We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.
-
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions.
-
-
18 Nov 09
-
06 Nov 09
-
failure. At McAllen Heart Hospital, I watched Dyke and a team of six do a coronary-artery bypass using technologies that didn’t exist a few years
-
-
15 Oct 09
avivajazz jazzavivaMcAllen TX is one of the most expensive health-care markets in the country. Only Miami-which has much higher labor and living costs-spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.
-
26 Sep 09
-
21 Sep 09
-
26 Aug 09
-
22 Aug 09
joe mcgillA brilliant article about health care that points out that the real problem with costs comes from when doctors stop seeing patients as people who need medical care, and start seeing them as revenue streams.
-
21 Aug 09
-
20 Aug 09
-
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.
-
-
17 Aug 09
Jarandhel DreamsingerInteresting article, especially with the current healthcare debate.
-
16 Aug 09
-
14 Aug 09
-
11 Aug 09
Jim HolincheckThis is a companion link to the other healthcare link I posted today. There are examples of providing high quality care at lower relative cost. The challenge with healthcare is systemic. The incentives are for doctors to provide more care (more tests, more visits, etc.) not necessarily achieve better outcomes. Until that changes, it does not matter who pays (single payer, private health insurance), we will not have dealt with the root cause of the problem.
-
09 Aug 09
-
08 Aug 09
-
07 Aug 09
-
03 Aug 09
-
31 Jul 09
McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per e
mcallen tx healthcare health care costs economics medicine business newyorker reform
-
29 Jul 09
-
23 Jul 09
-
21 Jul 09
-
29 Jun 09
-
25 Jun 09
Evans ThompsonANNALS OF MEDICINE about health-care costs. Writer contrasts the high-cost health-care system in McAllen, Texas, with the lower-cost systems at the Mayo Clinic and in Grand Junction, Colorado. McAllen, Texas is one of the most expensive health-care markets in the country. Only Miami spends more…
-
24 Jun 09
-
22 Jun 09
-
-
In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.
-
An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)
-
The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
-
In an odd way, this news is reassuring. Universal coverage won’t be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with. So the idea that there’s plenty of fat in the system is proving deeply attractive. “Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated.
-
differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.
-
Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.
Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception.
-
About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
-
Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.
-
-
tabathas003Heading Hook, 3"
Model # 1007 by Kenney Manufacturing
$3.29
0In Stock - Estimate Delivery Date
ADD to CART & Estimate Shipping
Use as an end hook or as a pin-on hook. Holds draperies in an upright position. This Heading Hook is one of many top qu -
21 Jun 09
-
17 Jun 09
rdbarsonANNALS OF MEDICINE about health-care costs. Writer contrasts the high-cost health-care system in McAllen, Texas, with the lower-cost systems at the Mayo Clinic and in Grand Junction, Colorado…
-
16 Jun 09
-
infora dimeShe wasn’t the only person to mention Renaissance. It is the
newest hospital in the area. It is physician-owned. And it has a
reputation (which it disclaims) for aggressively recruiting high-volume
physicians to become investors and send patients th -
15 Jun 09
Blue RosesMcAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per e
McAllen health-care Medicare immigration politics health business economics healthcare medicine texas reform costs newyorker incentives accountability
-
14 Jun 09
-
13 Jun 09
-
12 Jun 09
-
11 Jun 09
-
10 Jun 09
-
-
McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.
-
Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn.
-
The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance.
-
El Paso County, eight hundred miles up the border, has essentially the same demographics.
-
et in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen.
-
n unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high.
-
we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)
-
providing unusually good health care?
-
And yet there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country.
-
Nor does the care given in McAllen stand out for its quality.
-
On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s.
-
McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America.
-
. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?
“Practically to zero,” the cardiologist admitted.
-
There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
-
Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere.
-
McAllen surgeons simply operate
-
And by operating they happen to make an extra seven hundred dollars.
-
To determine whether overuse of medical care was really the problem in McAllen
-
The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.
-
overuse of medicine.
-
For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country
-
per enrollee
-
In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.
-
some hundred thousand people die each year from complications of surgery—far more than die in car crashes.
-
To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.
-
If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved
-
revenues of five billion dollars last year
-
It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there.
-
also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given.
-
Romero and others argued that this gives physicians an unholy temptation to overorder.
-
What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen.
-
In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.
-
Local executives for hospitals
-
know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more.
-
Health-care costs ultimately arise from the accumulation of individual decisions doctors make
-
The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen.
-
he and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases.
-
But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.
-
But physicians from the most expensive cities did the most expensive things.
-
One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.
-
“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.
-
But he had often seen financial considerations drive the decisions doctors made for patients
-
No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it.
-
many physicians are remarkably oblivious to the financial implications of their decisions.
-
Others think of the money as a means of improving what they do.
-
Then there are the physicians who see their practice primarily as a revenue stream
-
so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work.
-
he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”
-
he had never been asked for a kickback before coming to McAllen.
-
The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.
-
Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too
-
She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone.
-
About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine.
-
Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.
-
Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country
-
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.
-
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 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. I
-
liminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income
-
almost by happenstance, the result has been lower costs.
-
It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing.
-
eventually they achieved the same high-quality, low-cost results
-
One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores.
-
years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together.
-
in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network
-
problems went down. Quality went up. And costs ended up lower
-
than just about anywhere else in the United States.
-
an accountable-care organization.
-
adopted in other places, too
-
we are witnessing a battle for the soul of American medicine
-
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.
-
having a system that does so much to misalign them has proved disastrous.
-
we pay doctors for quantity, not quality.
-
health care is like building a house.
-
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?
-
Here’s how this whole debate goes.
-
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.
-
“We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.
-
“Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”
-
cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering
-
We will need to do in-depth research on what makes the best systems successfu
-
we also need to fund research that compares the effectiveness of different systems of care
-
we would do well to form a national institute for health-care delivery
-
But a choice must be made. Whom do we want in charge of managing the full complexity of medical care?
-
savings will take at least a decade.
-
the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing.
-
many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.
-
“some of the doctors are beginning to complain about ‘leaving money on the table.’ ”
-
-
09 Jun 09
-
08 Jun 09
-
05 Jun 09
-
04 Jun 09
-
03 Jun 09
aminggs"Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like a
document article newyorker atul-gawande us healthcare politics economics health medicine business medicare medicalinsurance inlink:tim-oreilly import:delicious
-
02 Jun 09
-
Brenda Gleason"In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations
Would you like to comment?
Join Diigo for a free account, or sign in if you are already a member.