"I could never practice medicine. It would be like saying to your patient: Your money or your life."
--Alexander Yersin
Atul Gwande is a very pleasant fellow, charming even, the sort you can imagine inviting over for dinner. President Obama's reaction to his recent New Yorker article, he remarked in his guileless way, was a dream come true. You write articles like this hoping to have an effect, to be part of the thinking which guides great events.
The fact is, Gwande was preaching to the choir. President Obama had his staff read the article because Gwande was singing his song, to the tune composed by one of his two most which important economists, Peter Orszag, who decided long ago the road to cost control of the nation's health care is through behavioral modification, through those "incentives" economists of a capitalist system hold so dear.
Orszag has the orthodox training (Exeter, Princeton, London School of Economics) which may have marinated his brain in the theory of incentive, reward, as a way of engineering economies. A month before Gwande's article, a profile in the same magazine quoted Orszag: "I spent several months in very intense study."
Exactly what he learned isn't too hard to discern: He discovered American health care costs are higher than costs in other developed countries because American doctors are unaware or unwilling to practice medicine to take advantage of "comparative effectiveness." Orszag believes if only American doctors would educate themselves, steep their practicees in all the research about using only the options for diagnosis and therapy which result in good outcomes and high quality care, then the whole cost thing would evaporate.
Orszag's solution is direct and simple, see--all you have to do is set up a system where, "You get paid more if the treatment has been shown to be effective and a little less if not."
Gads, why didn't the doctors think of that?
Of course, what the doctors know is, there is no such research for 80% of the patients and problems they face every day. Even after years of training, they wing it a lot, trying to figure out what is wrong with patients and what to do about it.
Enter Gwande, who finds two towns in Texas, one, McAllen, where the doctors are pretty venal, caring not at all about their patients but only about increasing income and fattening hospital balance sheets. Dr. Gwande believes the statistics about quality of care generated by Medicare (and he must be one of the few American doctors actually practicing medicine who does not laugh at those "measures") and what the statistics tell him is there are these two towns, which are identical in all demographics, and in one town Medicare has to spend three times the national average per patient and in the other, El Paso, the cost per patient is just at the average. But the quality measures show the outcomes for patients is about the same, it just costs three times as much to get the "same" care in McAllen.
Bravely, Gwande flies out to talk to the doctors and hospital administrators in McAllen to find out why they are such crooks.
Not unsurprisingly, the doctors there are a little stunned to learn they have been ripping off the system. Actually, and this is the key part of the article, Gwande manages to get some of the McAllen doctors out to dinner, backstage, guard down, and there he produces a Perry Mason like confession scene, where one of the doctors says he thinks the cost difference results from the McAllen doctor's willful attempts to maximize profits by doing more tests and procedures.
By now, of Mr. Orszag is jumping up and down in his White House office saying, "I told you so."
Of course, when you get right down to it, it's never that simple. Gwande points to doctors in high cost cities insisting patients see them monthly to quarterly whereas low cost doctors bring those hypertensives in twice a year. Who is doing better medicine? Who knows? Low cost doctors handle patients' questions over the phone. High cost doctors insist on office visits. Are the low cost doctors better or simply less willing to face the patient and painstakingly take a question or complaint seriously?
I was taught when you are on call and a patient calls with a complaint like abdominal pain, you go to the emergency room and evaluate the patient yourself. When I did, I almost always discovered whatever the patient or the ER doc had told me over the phone was at least partially, often significantly, wrong.
But the patients occasionally thought I was an ambulance chaser, coming in myself and billing for the two hours I spent. Was I a cost raiser or a conscientious doctor? Eventually, I stopped going in. I felt guilty about that at first, but I had to follow the incentives the way Orszag might have predicted: Go to the ER and you might make the right diagnosis but you were exposing yourself to a high risk fo a malpractice suit with an unfamilar patient in that setting and while some patients were profoundly grateful, others could not understand what you offered the ER doc didn't offer.
I recall many a patient advertised as a diabetic ketoacidosis who had something else, hypercalcemia or even inebriation, and I only discovered this when I actually laid hands on the patient and his lab.
Which is not to say Gwande is all wrong. We all know docs who make more money from stuff which has nothing to do with the real practice of medicine: They have an in office lab, a "consultant" position at some unit in the hospital to which they funnel patients, or they sell skin and hair products or even drugs in their office. "So here along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime mortgage lenders treater home buyers: as profit centers."
But think about that. Does the gastroenterologist who does nine colonoscopies a day think of his patients as human beings? No, they are his source of income. He wants to do those procedures on people he barely knows, and be on his boat by four p.m. But if he finds a pre malignant polyp in one and a colon cancer in another, which he snips out, is he a subprime villain?
And come to think of it, does any banker not think of the person he is going to lend money to as a profit center?
The most competitive residencies are the Road to happiness: Radiology, dermatology and opthalmology. In each of these specialities the average practictioner either never sees the patient at all (radiology) or sees them briefly, knows little about them and moves on as quickly as possible. Patients are profit centers. But do they receive bad care?
The system as we have set it up in this country rewards the assembly line doctor who is "Productive," i.e. he sees lots of patients, reads lots of X rays. If I were the benign dictator, I'd have technicians doing all the colonscopies and endoscopies, and biopsying the skin lesions and doing the LASEK eye surgeries and not allow billing above a level a technician might expect. Doctors have been going to medical school, passing strenous board exams just to get to the position where they can bill exhorbitantly for something a person with a high school education can do after six months training, wield a colonoscope, cut out a skin lesion, guide a computer blade.
So what is the solution?
Gwande is enthralled with the Mayo Clinic, where he learns, "The patient comes first." Well, didn't we all learn that in medical school, right before we applied to the dermatology or radiology program?
In fact, the salaried docs at the Mayo Clinic and certainly at the Geisenger Clinic are fed by a huge marketing operation.
Gwande tells the story of a Mayo Clinic doctor who called in a cardiologist right when the patient was sitting there. "The cardiologist adjusted a medication and said that no further testing was needed. He cleared the patient for surgery and the operating room gave her a slot the next day.
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital."
Well, that says something about the Brigham.
In my office building in Bethesda, Maryland, about seventy five percent of the offices were occupied by doctors. While the doctor was not the one to move, it was the patient who simply took the elevator up or down a flight and often saw two or three doctors being bounced from one to the other. And that wasn't even an academic institution, not to say a Harvard hospital. But we accomplished the same instant consult as Gwande saw at the Mayo Clinic.
Of course, every doc billed the patient, just as that Mayo cardiologist did. I guarantee even though the cardiologist was on salary, he had to put that patient's name on some billing slip.
The plan President Obama is talking about is probably the best thing he can get out of Congress. Offer a low cost government alternative insurance, an extended Medicare insurance progralm available to everyone and the nation will beat path to your door. Then you'll see some real competition the Republicans and health industry are always talking about; except neither of those groups wants to see real competition.
In England, the citizens have for decades had the choice to bounce between the national health system and a private system which functions side by side for those with champagne tastes. The difference is the English doctor is a government employee when he is in the national health system and Obama would not make American doctors government employees.
Obama's plan would not solve the problem of producing a corps of physicians on salary whose only motivation is supposedly delivering good patient care, not generating income from unnecessary tests.
The problem with those salaried employees, they have little incentive to see lots of patients. They just want to get paid and go home. Mr. Orszag will have to think how to motivate doctors on salary to want to see enough patients to keep the lines from wrapping around the block.
Salaried doctors in almost every setting outside the National Institutes of Health have all sorts of incentives to see more patients and to be more "Productive" at Geisenger and Mayo and any healthcare organization which salaries doctors.
None of these places have ever figured out how to separate the practice of medicine from financial rewards.
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