More health care musings

I've been reading the article about health care costs in the New Yorker that's been referenced a number of times in various discussions, both in the MSM and in the blogosphere, and it's pretty interesting. The author, a surgeon, went to McAllen, Texas, an area with the highest per capita medical expenses in the country. He wanted to find out what was going on there that made it different from a place like Rochester, Minnesota, home of the world-famous Mayo Clinic. Per capita costs in Rochester average about 60% what they do in McAllen.

It's an intriguing article. The first thing the author discovers is that the clinicians and health care administrators in the area had no idea they ranked first in the country for patient costs. As far as they all could tell, no one was going out of his or her way to push treatments that weren't needed. So they posit that perhaps the problem is that McAllen just has a higher than average percentage of unhealthy people. It is, after all, a poor area with an extremely low average household income, which in turn suggests lousy diets, obesity, and clogged arteries.

Well, that theory gets blown out of the water pretty quickly. Turns out that the while the local populace looks like they'd be key candidates for things like heart disease and its attendant high dollar procedures (echocardiograms, angioplasties, by-passes, etc.) the average number of procedures done in McAllen isn't noticeably higher than any some parts of the country and is actually lower than cardiac procedure rates in regions that have lower overall costs.

What it comes down in the end turns out to be pretty predictable: physicians, hospitals, and other providers who have come to see patients as a revenue stream. No one thought that he or she individually was pushing unnecessary procedures, but it turned out the overall culture with its emphasis on profits and revenue streams encouraged doctors to do just that. McAllen has high medical costs per capita because the system, both private insurance and public programs like Medicare, incentivize high dollar procedures. The more procedures that get done, the more patients that cycle in and out of waiting rooms, the more money the doctors make. (In contrast, the Mayo Clinic in Rochester removes the financial incentive by putting physicians on straight salary; there's no linkage between number of patients seen and the size of their paychecks.) In McAllen no one is seeing the system as a whole -- they're just viewing each patient, each procedure, as a unique cash transaction in itself. Ironically, despite having all this high dollar medicine available, the overall morbidity and mortality rates for McAllen aren't so hot. Turns out that as clinicians focus on revenue streams, they lose sight of prevention. So the elderly in McAllen get a lot of colonoscopies (over $3000 a pop) and echocardiograms ($1400) and not enough flu shots ($20 at the local Walgreen's?).

Plus, of course, the fact that a procedure can be done doesn't necessarily mean it should be done. Every invasive procedure introduces the risk of infection or other complications, every "routine" surgery carries with it the possibility of an allergic reaction to anesthesia, wounds that refuse to heal, blood clots, you name it. So between the de-emphasis on preventive health and the excessive ordering of various procedures, the folks in McAllens end up dying sooner than the American average.

I must say that conclusion floored me. At the very least, one would expect that if clinicians are ordering all sorts of tests and things there'd be a pay-off of some sort for the patient: better quality of life, increased longevity, whatever. Nope. No such luck.

The author basically comes to the conclusion that what the American health care system needs isn't a change in who's paying for what because switching who signs the checks isn't going to address many of the fundamental problems in the system now. What the system needs is to go back to being patient-centered. Unfortunately, in a culture that prizes profits above all else, that isn't likely to happen any time soon.

I did learn one interesting thing. In addition to the Rochester, Minnesota, area, there are some other parts of the country that stand out for putting patients first in the health care equation. One is Grand Junction, Colorado. It ranks really high in terms of both quality of care and patient satisfaction. That's were my mom lives. No wonder she never has anything bad to say about her doctors or Medicare.