On Health Care Costs

We've known since for at least forty years that supply rather than demand is the primary determinant of healthcare utilization (and here again we are discussing healthcare rather than health, which I bring up here only to emphasize the distinction).  Studies surrounding the spate of hospital construction following Hill-Burton demonstrated this perfectly well, as has decades of excellent research from the Dartmouth Atlas.

But, as any medical humanities interlocutor understands, stories can be persuasive in ways that an army of facts and data cannot.  Thus, I want to particularly recommend Atul Gawande's current article in the New Yorker entitled The Cost Conundrum.  No summary would do it justice, as it is a tour de force, even while it simply highlights phenomena that we have known about for decades.  Gawande has been on a particular roll of late, in my view, and this latest article continues his outstanding work.  Here I excerpt a paragraph that Brad F. found revealing:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. 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.

Read Gawande.

(h/t Health Beat Blog)

Comments

[Roy M. Poses MD]

We have been heading in this direction for some time. I learned from Arnold Relman's article in JAMA (Relman AS. Medical professionalism in a commercialized health care market. JAMA 2007; 298: 2668-2670. Also see also my blog post here: http://hcrenewal.blogspot.com/2007/12/relman-in-jama-on-threats-to-physicians.html) that a US Supreme Court decision that seemed to make physicians especially vulnerable to anti-trust laws resulted in the AMA and other professional societies acquiescing to the commercialization of medical practice.

It seems that physicians are no longer legally able to hold themselves to standards that eschew commercialization, and hence standards that require physicians to put the interests of patients ahead of profits.

I don't think many physicians were aware of this history before Relman wrote his article.

It seems we need some sort of legal way to restore our professionalism, or all of us will end up like the doctors of McAllen.

[Daniel S. Goldberg]

Roy,

Thanks for your comments. A couple of points: first, for a variety of reasons, I am decidedly dubious of the discourse on professionalism. Erde has a particularly trenchant critique:

http://jmp.oxfordjournals.org/cgi/content/full/33/1/6

Second, and related, I tend to think that exhorting physicians to behave "professionally" as opposed to "commercially" will not do much to change culture. As I've suggested on this blog several times, changing culture is just about the hardest thing in the world to do.

So while I agree with Gawande that cultural change is needed, I am extremely cynical that the desired changes will happen any time soon, in no small part because they would, in my view, require radical reformation of a number of powerful structures and institutions in American health care and medicine.

In any case, it is, I hope, possible to parallel process by agitating both for culture change and for behavior change, so long as we do not placate ourselves with the fallacy that changing the latter is equivalent to changing the former.

And if we want to change behavior, we can certainly construct a more sane set of reimbursement policies which will not incentivize the behavior Gawande identifies. Whatever its flaws, that objective seems to me to be a prime mover of P4P.

No?

[David Block MD, PhD]

Doctors are people who went to Doctor School. They are not, and never have been, doctors who went to People School, and failed some of the classes. And so when Gawande, in his effective if not-quite-complete study, writes that we are witnessing a battle for "the soul of American medicine," he is right in that jeremiad tradition which often mistakes us for our other selves; we are afraid to say, “our real selves”. While we physicians here in America have had some thoughtful critics, few have come with Gawande's credentials. Or his knowledge of the realities of both health care and clinical care. Yes, he might have looked at actual chart documentation rather than just diagnoses a little more closely: physicians are notorious for not knowing how to establish (or, indeed, refusing to know how to establish - which brings Erde's critique to mind) "medical necessity", which might make some procedures appear to be just padding in some of these offices or hospitals. Yes, he assumes a "doctor as manager as well as role model" scenario (as a non-surgeon, I kind of expect this in a surgeon), which might inflate the importance of the physician some, and overlook the characters and responsibilities of hospital administrators, attorneys (threat moves many more than execution, as chess players know, and there is more to lose than 'just' money in a lawsuit - which even a once-bit doctor never forgets), and even consumers themselves (who, in the guise of "patient", have their own expectations and agendas). He might also ask why, if payers look at doctors as cost centers, if everybody (except doctors) discusses "health care" as if it were a commodity, if patients no longer come to physicians in a microcommunity and culture of mutual fealty but rather as "consumers and providers", well... then why should the people-who-are-doctors NOT see themselves as "revenue centers"? If you prick us, do we not bleed...?

But, it's a great piece. Where do we go from here?

If we truly do get the behavior we reward rather than NOT getting the behavior we punish, then audits, the False Claims Act, fear and cynicism and despair must not be the way to go. Indeed, Gawande's point is: go forth, Doctor, and do what is right and not what is fiscally responsible. He trusts that the same social contract which protects the academician will protect the physician. But "trust" is the operative word. Surveys may say you trust your doctor more than your used car salesman, but do you? Do you really? Or is it easier merely to assume that your doctor is right , for example, rather than to trust the person who is your doctor?

So, none of us rewards the behavior he wants. (I never called up Anthem or Donna Shalala, for example, to compliment them, nor did I ever FEEL, or even conclude, that I should since they were paying me only 60-80% of my 'just' reward). And none of us trusts the other, whether in the Doctors' Lounge or the Faculty Lounge, in the 'hood or maybe even at home. So where do we begin to rescue the soul of American medicine?

The educated part of me says, "Oh, won't it be so very interesting to see how this plays out?" The person part of me says, "Bullshit - I'm scared as hell for me, my kids, my grandchildren, and for you and yours. Unless, of course, YOU deserve what you got! I never did! " I like the ambiguity.

David Block MD, PhD