A Health Care Review

Dr. Atul Gawande has written an article in The New Yorker which is a must read for any who are interested in the discussion about health care in the US. He delved into the cost of the health care delivery in McAllen, Texas. A location which is "one of the most expensive health-care markets in the country", second only to "Miami--which has much higher labor and living costs. 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. The explosive trend in American medical costs seems to have occurred here in an especially intense form."

Dr. Gawande spent a lot of time digging into what's happening in McAllen, interviewing a lot of people at different levels and locations in the health care industry there. He spends some time comparing it to activity in Grand Junction, Colorado and the Mayo Clinic which now has a satellite clinic in Florida, one of the most expensive health care states, which has become "the most efficient one in the [Mayo] system" with the "same high-quality, low-cost results as Rochester".

The story Dr. Gawande tells of the fragmented, for-profit activity, unregulated activity in McAllen in a frightening one for US health care consumers. It's a very grim picture if it represents the future of our health care system. He concludes with this recommendation.

...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.

This will by necessity be an experiment. 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.

Dramatic improvements and savings will take at least a decade. But a choice must be made. 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. But we have to choose someone--because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.

Go read the whole thing. It will be time well spent in gaining a better perspective on what's at stake and what can be done about it.