What the McAllen pig trough says about the state of health care

(H/t to E)

If you're interested in understanding how one of the richest nations on earth can be bankrupting itself on health care - you could do worse than to read Atul Gawande's article in the New Yorker, The Cost Conundrum.

Armed with national stats on medicare expenses by county, Atul visits McAllen, Texas. McAllen is a city of about 100,000 that for some reason spends more Medicare money per person than almost any other American city. Only Miami spends more.

The obvious question is, why?

...there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. 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.

Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. 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. But not, so far as one can tell, because it’s delivering better health care.

So, what the hell? Gawande lays it out: (emphasis mine)

The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles.
     They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

He quotes a McAllen cardiac surgeon as saying "Medicine has become a pig trough here."

Makes you think all this public private discussion is a waste of breath. As Atul puts it:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. 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? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check

The good news, is that Gawande shows you places where medical centers have rolled up their sleeves and solved the issue for themselves. Mayo, Marshfield, Intermountain - places where facilities have severed the procedure/reimbursement connection, pooled all the Medicare money and just started paying doctors salaries. You get a set wage. Stop thinking about keeping them in treatment - your job is to keep people healthy.

Totally worth the read.

-------------------

Also, there's an interesting follow up on the Health Care Blog where a McAllen physician reflects on how the practice of medicine changed over time:

...in 1983 I'd see a patient with intermittent chest pain, and that day refer him to the cardiologist for evaluation. He'd call me on the phone and say, "David, I've seen your patient Mr. So-and-so, examined him, listened to his heart, and have done a tread mill stress test. Everything seems ok, so I'm sending him back to you for further evaluation for his problems." Fine.

But by 1987, I'd make the referral and never hear another word. Running into the cardiologist in the hospital hallway or locker room, and asking what happened to my patient, I'd get this response: "Oh, well if I remember correctly I admitted him to the hospital and we did angiography, which was normal. But he was having a headache, so the neurologist ran some CT scans, and I asked the gastroenterologist to do endoscopy because there was a question of some GI problems. As I recall, everything was normal, but I still see him every month for his blood pressure."