Journal Club meeting I, 10/16/10
Present: Jordan Weil and Adam Rosman
Synopsis of article
(Dr. Atul Gawande’s “The Cost Conundrum”, The New Yorker, June 2009)
In his June, 2009 New Yorker article “The Cost Conundrum”, Dr. Atul Gawande visits McAllen, Texas to investigate why its Medicare expenditures per capita are so high. At nearly $15,000 per Medicare enrollee in 2006, McAllen’s spending rate is nearly twice the national average and much higher than the $6,688 spent in similarly situated El Paso, Texas where demographics and patient outcomes are similar. Furthermore, in 1992, McAllen’s per-enrollee expenditures were very close to the national average.[1] So what made McAllen
He ascribes the differences in spending rates largely to a culture in McAllen that is dominated by entrepreneurialism: many of the thought leaders in McAllen hold financial interests in imaging centers, doctors’ hospitals, and home health care services. While Dr. Gawande does hear reports of naked profiteering, most of the overutilization in McAllen appears to be driven by doctors’ opting to use specialty services more frequently than in other areas, with marginal benefit to the patient.
As one McAllen physician tells him, “young doctors don’t think anymore.” That is, they prefer expensive, invasive care to less expensive alternatives when similar health outcomes can be expected form either. Doctor Gawande does not address the claim that more experienced doctors are more discerning in their utilization of specialty referrals, but he does take a closer look at some data coming from the McAllen area. For example, the local doctors more frequently opt for gallstone surgery in cases that doctors in another area might treat with medicine and waiting.
Ultimately, Dr. Gawande ascribes the difference in spending to cultures among care givers that favor more expensive, intensive
Opening questions
Question/topic for discussion:
- What are the pros and cons from doctors’ perspectives on taking Medicare patients?
Responses
- It depends a lot on the doctor: some are glad to take them. Maybe this is more common among academic doctors or those who don’t have to rely only on patient fees for their livelihood. A lot of docs love Medicare because it’s something of an equalizer. Medical care stops being rationed according to the patient’s ability to pay. Other doctors, the viability of whose practice is a lot more contingent on income from patients, find the reimbursements too low to pay the bills and meet their profit expectations.
o Possible question for future discussion: what role should markets play in the allocation of health care? Given that doctors often effectively act as a decision making agent for the patient—because the patient has less knowledge about the technical aspects of medicine—what “fiduciary” responsibility might the doctor owe the patient to give them reasonably priced care?
Question/topic:
- How does Medicare spending differ from private insurers’ spending? How applicable are Dr. Gawande’s findings to whole market (rather than just the Medicare market)?
o Have the privates been less or more capable to contain cost?
o How has it affected insurance practices such as recission? Does McAllen have a higher rate than El Paso?
A brief discussion on motivation
- Adam: It seems a little far fetched that doctors are going into medicine for the money. There are, after all, many ways to get wealthy that don’t involve a decade of extra school and the emotional strain of being a practicing physician. Business and law come to mind as alternative paths to a high income.
- Jordan (thinking about this after the fact): yes and no. It seems to me that motivation stemming from"profit", broadly defined, can take many more forms than pecuniary rewards. A person could certainly be thought to take personal gain from receiving a high social status along with wealth. Being a physician can bring wealth AND a very high social rank.
- Adam: I think the days of doctors being looked as near gods is also on the decline, although it still ranks up there as one of the most prestigious career choices. However, I think the money and prestige thing go hand in hand and back in say the 50’s and 60’s being a doctor was far more lucrative than say banking or law. I think sometime in the 80’s though that changed and just as we’ve seen a change in where the money is we’ve seen a change in the social status of doctors. I think today’s society glamorizes entrepreneurs more than doctors, as can be seen with people’s obsession with people like Mark Zuckerberg who gets to go on Oprah while people like Atul Gawande are restricted to PBS. This trend can be seen very easily just by looking at what professions smart kids are going into. 30 years ago business schools where a joke and business majors where seen as unsophisticated. Medicine was the one profession that was near universally idolized. Now, most kids that can get a high profile job in consulting or banking would choose it easily over a career in medicine. I think the takeover of medicine by insurance companies and HMO’s also has do to with this decline in status. It will be interesting if we see if the recession changes this at all. On the one hand, people see medicine as a “safe haven” and therefore naturally flock into it in bad times. On the other hand, I don’t think anybody disagrees that med schools are gonna need to start accepting more students in order to meet the demands of baby boomers/health reform which could not only potentially depress doctor salaries but also impact their social status, as for years the Association of American Medical Colleges has purposely kept the supply of doctors low in order to ensure medicine was a profession strictly made up of the best of the best. It will be interesting to see what happens.
- What is a health care exchange? What would they look like?
- What is an accountable care organization? How do they interact with doctors in private practices?
- Culture is hard to change: how can medical education help to counter this trend?
[1] Note: because of Texas’s recently legislated cap on malpractice suit awards, lawsuits are much rarer in McAllen than they are in the rest of the nation. The rate is “virtually zero”, according to one McAllen-area cardiologist.
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