BRATTLEBORO — I feel that Jeremy Gorman's essay (“A Pipe Dream,” The Commons, January), correctly identifies drug and insurance companies, malpractice lawyers, and government subsidies as major contributors to the outrageous costs of our health-care system. But he gives short shrift to the elephant in the living room.
I recently read about that elephant in “The Cost Conundrum,” by Dr. Atul Gawande, a practicing surgeon of the Harvard Medical School, in the June 1 issue of The New Yorker. The piece completely changed my views about doctors, hospitals, health care, and money.
Dr. Gawande's goal was to find out why the cost of health care in the USA is higher than any other place on earth. His main finding was that it's not the insurance firms, the drug companies, hospital administrations, or even one type of payer system or another. It's the doctors and the incentive environment in which they operate!
To quote the author: “Health care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor's pen.”
He started his research by asking why per-capita health care costs in the otherwise unremarkable town of McAllen, Texas, are the highest (expect for Miami) of any other place in the country, and therefore the world.
Dr. Gawande concluded that the primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine: more diagnostic testing, more hospital treatment, more surgery, more home care, more use of specialists.
One major cause is the way government and health-insurance companies pay doctors. They are paid for quantity, not quality. Moreover, we pay them as individuals, not as members of a team working for their patients. Thus, the more discrete medical actions they perform, the more money in their pockets.
For example, a doctor may ask a patient to come in to his or her office for an answer to a question rather than discuss the issue over the phone, because insurance does not pay for phone calls.
Dr. Gawande also pondered how some medical communities have controlled their health-care costs, looking closely at the world-renowned Mayo Clinic in Rochester, Minn., which, despite being at the cutting edge of medicine, had lower-than-average costs.
Decades ago, Mayo recognized that it needed to eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so a doctors' goal couldn't be increasing income. No one there actually intends to perform fewer scans and procedures. The aim is to raise quality and help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.
Other medical communities have also managed to rein in costs with different combinations of arrangements and management, and most have in common what Dr. Gawande describes as accountable care organizations. Local system leaders and managers use measures to blunt harmful financial incentives and take collective responsibility for improving the sum total of patient care.
Dr. Gawande tells us that right now we are witnessing a battle for the soul of American medicine. Too many local medical systems have no one who understands the total picture of how well they are serving their patients. No one is in charge. Someone has to be responsible for the totality of care. Otherwise, you have systems that have no brakes. You get McAllen.
I urge everyone (doctors included) to read “The Cost Conundrum” in full at www.newyorker.com.