Saturday, May 30, 2009

Atul Gawande on Cost and the Soul of American Medicine

Atul Gawande's superb article - "The Cost Conundrum" - in the June 1 issue of the New Yorker magazine is long (7500 words) but brilliantly written and researched. It won't teach anything new to policy wonks like me who've been fulminating about health care costs ad infinitum, but Gawande makes his analysis wonderfully understandable and persuasive for non-wonks by developing it through beautifully realized stories. I especially recommend the piece to the 20% of the readers of this blog from outside of the U.S. - it's an embarrassingly revealing view of the pathology of our health care system.

Gawande's core argument is that we are largely paying for health care as individual piece work, and rarely provide support for coordinated, population-based care. He makes his point by comparing McAllen, Texas to the Mayo Clinic and Grand Junction, Colorado, which achieve superior results at 1/3 the cost. He quotes Dennis Cortese, CEO of Mayo:
When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing.
You also get better care, happier patients, and physicians who love their work!

Every doctor has stories to support this point. I think of an experience at the Harvard Community Health Plan HMO 25 years ago. A primary care physician was seeing a patient who described intense sensations she called "anxiety" and who feared she was "going crazy." He asked me, as a psychiatrist, to see her. After we had spoken for some time I said - "I don't know what you have - but I do know what you don't have - it's not anxiety and you're not going crazy." I called a neurologist colleague. He was in his office. I walked my patient over and we sat together.

The diagnosis was ultimately not a happy one - an unusual brain tumor. I was able to spend more time with her in the next few weeks. She helped us understand her. An adult child who had had a turbulent life had gone back to school and was getting a college degree at age 45. My patient said "Before the graduation I want everything done so I can be there to celebrate. After the graduation I just want to be comfortable." Everyone involved with her care understood what mattered to her and we could see her through to the end of her life the way she wanted.

Gawande's article made me think of another patient as well - a woman who was going through a particularly difficult phase of a severe psychiatric ailment that involved depression, psychosis and alcoholism. The alcohol problem had gotten worse and was intensifying her other symptoms like a blowtorch. During a two week period she was seen by nine clinicians at various emergency sites. Between an electronic medical record that linked most of the sites, and telephonic communication with the others, everyone had a common understanding and shared plan. At the end of the two weeks my patient said, with some pleasure - "I've seen nine people and they all said the same thing - maybe there's a point to what you've been saying about AA!"

Gawande's argument is that simply achieving universal insurance - whether it's a public single payer plan or a mix of private and public programs - costs will continue to run amok if we don't foster coordinated care for populations instead of giving physicians incentives to flog patients with unnecessary and often harmful treatments. Here's Gawande's final paragraph:
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. If we don’t, McAllen won’t be an outlier. It will be our future.
I hope every public leader involved with health care reads the piece!


Mei Lin Fung said...

We read the Cost Conundrum at our reading group on Saturday, no physicians present, and thought it brought important new insights.
Hal Luft has been proposing an antidote - see and The Baseline Scenario (James Kwak and Simon Johnson formerly of IMF and now at MIT) has also reference the Cost Conundrum -

Jim Sabin said...

Hello Mei Lin -

Great to hear that your reading group read Gawande's "Cost Conundrum" and found it a source of insights. And, thank you for the link to the excellent interview with Hal Luft. I hope that thousands of other reading groups do what yours did!