Healthcare costs and quality of care
May 28, 2009 8:11 AM   Subscribe

How many New Yorker articles is it going to take before the US finally gets smart, visits all the other Western nations, looks at all the different systems, and simply steals copies every bit that actually works? I'm sure most health care administrators in other western countries would be very happy to see that happen, and would invite whoever is assigned the copying over for dinner as well.
posted by DreamerFi at 8:47 AM on May 28, 2009 [1 favorite]

I've seen that bouncing around the internet. State laws come into play quite a bit in terms of health insurance and Texas is (not surprisingly) one of the worst.

One thing you have to remember about Healthcare. While high Healthcare costs seem like a problem to you and me, they're not a problem for everyone. The more healthcare costs, the more money healtchare companies make. That's the key point, and it's why they are so adamant about lobbying against any sort of universal Healthcare other then "force everyone to buy our policies".

If overall healthcare spending goes down, their revenue goes down, their profits go down, and their stock prices come down.
posted by delmoi at 9:03 AM on May 28, 2009 [4 favorites]

Great article, definitely describes much of why the US healthcare system is broken. In a related vein the October issue of The New England Journal of Medicine had an editorial criticizing one particular wasteful practice: the "executive physical". It doesn't look like the article is available for free, but the gist of it was that these extended batteries of physical exams and tests are a bad deal. They have not been shown to make patients any healthier, they subject patients to unnecessary tests which can lead to spurious abnormal results and further tests (for an explanation of why this is, look here), and perhaps worst of all that sort of special treatment for VIP patients reinforces the notions that more (and more expensive) medicine is better medicine and that the wealthy and important deserve better health care than the rest of us. I would guess executive physicals are pretty popular in McAllen.
posted by TedW at 9:09 AM on May 28, 2009

Wonderful article! I recently came to a similar conclusion after spending the last month reading up on the history of medicine and the role of iatrogenesis, which the article touches on but does not use that phrase. My doctor is very cost conscious and will often prescribe things over the phone when I give him symptoms and is very hesitant to order any kind of additional test unless the needs are obvious. I have a friend who goes to what we termed a "Vale doctor" (because we assume they have a house in Vale, in joke, probably not that funny). He has a super sleek office with flat screens and all kinds of technology, at considerable cost and dubious long term value. It does, however, make my skittish friend feel as if he's getting better health care. He is well educated, smart, but there was a mental barrier there where if there's a .01% chance that the new $100k machine will catch something, he'll take it. A similar scene took place in "W" with Dick Cheney asking Bush if there was even a 1% chance he could die from that sandwich would he still eat it.

Medicine is not immune to this problem as the financial markets have demonstrated. A blind use of technology without empirical studies backing its usefulness is not entrepreneurial, it is a gamble. If doctors want to gamble on spec houses and condos in Arizona, let them, but not on fancy gadgets with marginal medical value on a marginal number of cases.

Oh, and I do wonder how an atmosphere of smart, qualified doctors at Mayo influences their reliance on solid medical science and not on high tech tests. I am not saying the doctors elsewhere are less qualified, but it must be a great boost of confidence to see storied doctors taking the less is more approach and showing faith in their own medical knowledge. Requesting tests and unnecessary procedures seems more to, "I don't really know, so let's see what the tests come up with."
posted by geoff. at 9:13 AM on May 28, 2009

Fascinating article. Reminds me of an old story I read once about car mechanics.

A magazine wanted to find out the quality of car mechanics across the country. So they got a car, tinkered with it slightly, and went from one mechanic to another.
Most younger mechanics would run a battery of tests and a lot of them would not be able to pinpoint what the problem was.

A lot of the older ones walked over to the car, popped open the hood, and spotted the issue after a quick scan.
posted by 7life at 9:19 AM on May 28, 2009 [3 favorites]

American doctors are little money grubbing businessmen? I would never have guessed! Remember back in the day when the cops were the good guys, the doctors there to help fix you up, and the bankers weren't destroying society?

Remember how awful everyone thought lawyers were? Remember all those lawyer jokes? My favorite was: what is a thousand dead lawyers at the bottom of the sea called? A good start! HAW!
posted by zenon at 9:28 AM on May 28, 2009

Is this a re-post? I'm sure I read this article a few days ago. Hello for the first time by the way.
posted by dearsina at 9:35 AM on May 28, 2009

My dad is a doctor who teaches now. He told me something interesting about young vs. old doctors.

Young doctors tend to prescribe surgery, not just because it's more expensive, but because it's fun. Surgeons generally love to do surgery.

Older doctors tend to look at it as a last resort.

I experienced this once when I had a salivary gland stone. The young doctor was going to cut open my face and take out the gland. The old doctor looked under my tongue and pulled the stone out using a pair of tweezers...
posted by Lord_Pall at 9:50 AM on May 28, 2009

An excellent article. There are no simple answers to providing quality health care and yet being able to afford it as a nation.

Several years ago the health care problem in the Rio Grande Valley was malpractice lawsuits. Doctors were packing up and fleeing the area because the malpractice situation was out of control. Laws were passed in Texas to limit awards, and now it seems that doctors are flocking to the area.
posted by Midnight Skulker at 9:56 AM on May 28, 2009

holy shit.
posted by shmegegge at 10:00 AM on May 28, 2009

Great article, thanks!

There's so many factors doctors have to consider when making decisions for their patients, I think there's a good argument that cost shouldn't be one of them. And I mean I don't think doctor should be looking to either increase or decrease the cost of car when they are making decisions.

Working in publically-funded mental health care I see huge differences in how doctors approach this issue. The psychiatrist I work with adamantly believes in not treating patients differently based on their financial circumstances. He prescribes the same treatment for indigent patients as for his private, wealthy, self-pay clients. Another doctor working for the public mental health agency was bitter about tax money being used on the poor, so he only prescribed the cheapest psychiatric medications. Similarly, the local jail doctor is the lowest bidder, and he refuses to give inmates any medication over $5, to save the county money.

The best treatment isn't always the most expensive, but it's not always cheap either. The problem is that doctors are human, and many of them have flexible ethics. Or let's say the system offers them rewards that conflict with perfect ethics. But I would feel a lot better if the question of money was removed from the already complex considerations a doctor has to deal with.
posted by threeturtles at 10:06 AM on May 28, 2009

Yea, this is why I, on previous threads, have gotten so annoyed at the HURF DURF INSURANCE COMPANIES SUCK. Check out the McKinsey report on healthcare costs. We spend more than twice as much on "outpatient care," mainly through testing, in the US. That's a third of the entire "additional spending" we have compared to our peers (as defined by the report). Health and admin add'l costs are only 15% of the total add'l costs.

To actually save on healthcare in the US, we'll have to dramatically redefine healthcare treatments. Which wouldn't be a bad thing, what with the wacky incentive everyone above has pointed out.
posted by FuManchu at 10:17 AM on May 28, 2009

You know, the only thing I qualify for with medicare is for my annual.

I desperately need health insurance but cannot afford it. Where can I hop on that Medicare bandwagon that everyone seems to be on? Do I have to pop out five children first?
posted by Malice at 10:17 AM on May 28, 2009

Medicare? Medicaid?
posted by Malice at 10:17 AM on May 28, 2009

I desperately need health insurance but cannot afford it.

Currently your only solution is to emigrate.
posted by DreamerFi at 10:26 AM on May 28, 2009 [1 favorite]

Malice, you have to be over 65 to qualify for Medicare. Medicaid is for low-income folks, but it's pretty hard to quality for.
posted by echo target at 10:27 AM on May 28, 2009

Malice, I suggest you start with Wikipedia if you are interested in learning about Medicaid eligibility. HHS also has a good overview. It is important to note that Medicaid is administered by the states, so there are a lot of variations.

I am not particularly knowledgeable but there are various income restrictions within qualifying categories (age, pregnancy, disability, blindness, etc) that must be met before you can receive benefits. Having five children is not a prerequisite.
posted by ChrisHartley at 10:29 AM on May 28, 2009

Nit-picking where I don't have time to delve further: how does "the Tex-Mex diet [contribute] to a thirty-eight-per-cent obesity rate."? Is it because the fast-food variations aren't healthy? Wouldn't it be more accurate to say "the fast-food diet contributed to the obesity rate"?
posted by filthy light thief at 10:37 AM on May 28, 2009 [1 favorite]

Great article, thanks for the link!
posted by jasper411 at 10:48 AM on May 28, 2009

filthy light thief: The main ingredients of Tex-Mex cuisine, from my 18 years of growing up there, are cheese, lard, and ground beef. Plates of enchiladas float in pools of bright red grease. This is not fast food, this is sit-down restaurant fare. It's really terrible for you. But so delicious.
posted by vilthuril at 11:24 AM on May 28, 2009 [1 favorite]

I desperately need health insurance but cannot afford it.

Currently your only solution is to emigrate.

posted by CynicalKnight at 11:41 AM on May 28, 2009

Thanks, vilthuril - I thought there might be something like that might be a factor.
posted by filthy light thief at 11:43 AM on May 28, 2009

But, but...Profit drives innovation, leading to greater efficiencies and more value to the consumer through lower costs! Market forces will spur competition leading to even greater cost savings and choices to the consumer! Honest!
posted by Thorzdad at 12:24 PM on May 28, 2009

This is another wonderful article by Gawande; thanks for posting.

I've been thinking for a while about doing a FPP on the Dartmouth research that this article draws pretty heavily on. If you have an hour (or five!) and a nerdy interest in health care delivery, I highly recommend cruising over to the Dartmouth Atlas of Health Care website.

Their Atlases are really a wealth of information, and extremely readable for the layman. My favorite is probably the 1999 Atlas, which has my favorite graphic in the whole world on page 179: the percentage of Medicare deaths that occur in a hospital. I still remember being gobsmacked when I saw that picture, and having to read it three or four times to make sure I wasn't interpreting it wrong. It took me a while to wrap my mind around the fact that there could be such extreme geographic variations in something like how many deaths among the elderly population actually occurred in hospitals. I know there's a lot of talk about making a living will and expressing your wishes to your family if you don't want to end up hooked up to a machine (possibly in pain) when you finally shuffle off this mortal coil, but that figure makes a persuasive argument that you'd probably be better off just moving out of the South or Northeast and living out your retirement years in Oregon if that's your goal.

There's a nifty NY Times graphic based on the Dartmouth research that is lots of fun to play around with, as well.
posted by iminurmefi at 1:31 PM on May 28, 2009 [5 favorites]

I agree, great article. I enjoyed Gawande's books Better and Complications, both of which are worthy reads about the medical profession.

One aspect of the health care profession that several of my medical school friends have lamented is the current and continued dearth of primary care physicians. The reimbursement structures in this country just don't justify going into primary care vs a specialization in say, surgery, if you are acting with an economically rational state of mind. And when you are coming out of school with tens/hundreds of thousands of dollars of debt, it's hard to not think of the financial ramifications in play. Can you blame them?

It's tough for me to comment, but what's clear to me is that the incentive structures are extremely distorted, not just within medicine but in the stairsteps leading to it as well. I've heard from many of my peers (now in their mid 20s) that they previously considered medicine as a career, but that while noble, it just couldn't be justified in today's competitive economy and consumerist culture. High malpractice costs, the poverty of medical school, insurance & gov't red tape, etc... the costs are just too high to favor medicine over more lucrative fields in high finance, big law, etc. My observations are mostly personal rather than empirical, but it's definitely an issue that is being talked about.

Maybe doctors should earn even more money than they do now? Frankly, I want the best and brightest graduates heading into the medical profession, and I want them to be paid enough that they don't need to worry about their finances, or how they are keeping up with their friends in other industries.
posted by gushn at 2:55 PM on May 28, 2009

There were a lot of rumors spreading around in that texas town…. And it wasn’t about health care.
Just let me know if you wanna go to that shack. *wink* You know what I’m talking about.

yes, I read the article. I liked it. No, nothing to add, (other than I’d like a churrigueresco office), plenty of solid comments so I went with this cheap zztop reference.
* waves at dearsina * Hi!
posted by Smedleyman at 3:35 PM on May 28, 2009

I really don't think that the "best and brightest" are attracted by high paychecks - only the greedy. The best and brightest in wall street (with those huge paychecks) were not bright enough, by my measure. I really don't want a greedy doctor, or one worried about their friends in other industries. The article noted the Mayo clinic's approach, which is the opposite of gushn's suggestions and one of the points of the article is that doctor greed is part of the problem, not a solution. And I would challenge your definition that going in to practice medicine in the US for a fat paycheck is noble.
posted by zenon at 3:36 PM on May 28, 2009 [1 favorite]

Please use the single page URL for the article when making a post. Pagination sucks.
posted by Rhomboid at 5:04 PM on May 28, 2009

As long as the incentives aren't structured poorly (which to some extent they are), being motivated by money is fine. Most people work because they need money, not because they love work. If you're a smart person, you have a lot of career options, and many people will chose one over another based on money, because frankly having a lot of money makes life much much easier. I don't see why that is a bad thing, it's just reality. If doctors don't make more money than other professions, fewer people who have other options will become doctors, which will reduce the talent pool.

Many of the best and brightest are in fact motivated by money. Not everyone who is called the "best and brightest" are in fact that, so it leads to some of the problems you describe, but many of those who actually are good at stuff still factor money into their decisions.
posted by wildcrdj at 6:51 PM on May 28, 2009

The article was great, but wtf is up with "focussed" instead of focused? Nevermind that; both are correct, sure, but omgwtmf is up with "a huge amount of coördination"?! (page 7 of 8)
More money on spellchecker = lower qualety speeling.
posted by hypersloth at 11:49 PM on May 28, 2009

The New Yorker's house style is what she is.
posted by Bromius at 5:45 AM on May 29, 2009

Bromius is right. The use of the diaeresis for repeating vowels is one of the quirks of The New Yorker's style guide. There's a bit on it here.
posted by shiu mai baby at 11:54 AM on May 29, 2009

wow, thanks shiu mai baby.
posted by hypersloth at 1:28 PM on May 29, 2009

Yeah, a few years back I saw this happen first hand. Fancy ass doctor in lower Manhattan who shared an office with a dermatologist. Lotsa pretty artwork in his office with pricetags on them. Oh yeah, it wasn't just a doctors office, it was a freakin' GALLERY.

Anyway, you know the paperwork they make you fill out when you go to a new doctor? Well, this one featured the question, "Have you had your hearing checked within the last few years?" "Well," I thought, "no, I haven't." Of course the reason for that is that I don't have any problems with my hearing. But whatever, you're just supposed to answer the question, right? So obviously, I checked "no."

I go in and see the doctor about whatever I had to see him about. At the end of the visit, however, he says, "So I see you haven't had your hearing checked... you know, you really should have your hearing checked every so often." And who was I to argue with him? So "Sure," I said, "go ahead and check my hearing." Thinking this wouldn't be a big deal. Boy was I wrong.

His nurse sat me down in front of this big, new, obviously expensive automated computer setup. The nurse said, "now please hold still, this is going to hurt." And she JAMMED these things into my ear. My god did it hurt! There's no way in hell that was necessary. She had to have been doing it wrong. Anyway, they give me this "automated" test which messed up a number of times because it barely worked. I think at least some of the problem was that one of the earphone things kept falling out of my ear despite the best efforts of the incompetent, sadistic nurse. The whole thing took like a half hour of my time that I hadn't planned on giving up. Finally, the doctor gets the results. Everything looked pretty normal, except for the part where the computer messed up, where the graph showed a definite abnormality. "Oh, that was just the computer, we won't worry about that." Which made me wonder how the hell he'd know if I actually *did* have a problem.

Anyway, this was just a regular MD. Not an ENT or anything like that. What the hell was he doing with this computer setup to begin with? Why the hell did he need that? At some point, one of his friends must have clued him in over scotches or golf, "You know, Mike, you know how to make the real money? Get one of these hearing computers. You don't even need to know how to use it! It's automated! And the insurance pays for everything!"

Of course I never saw the bill because it went straight to my insurance, but I can only imagine what that farce of a hearing test tacked on. The sad part is that my insurance at the time was more than happy to cover this joker, while I had been turned down by many other well-recommended doctors because they weren't on my plan.
posted by Afroblanco at 6:11 PM on May 29, 2009

FuManchu, the hurfing and durfing may get annoying, but I've seen some of the waste and fraud that is endemic to the American insurance business. It may not be the root cause of the current mess, but it sure as hell isn't helping, either.
posted by lekvar at 7:09 PM on May 29, 2009

I am confident that the Chinese (nationality) historian who writes "The Fall of America" will describe health care around this time as the first chapter. A Chinese student will read it and shudder that 10% of our GDP was spent completely ineffectually and get angry that his government lent America money to do it......

It's a mess guys and gals. A complete mess.

I'm a resident in training and do admit that having 600,000 small business-people (doctors) run medicine is a source of the problem. But the "for profit" motive destroys health care from everywhere.

I'll give you examples of how it's not so black and white what we do.

Other have commented upon this aspect of patient care, but I'll distill it for you again.

The "good" "socially responsible" doctor": 40-something Patient complains of heartburn. Very mild. No blood from his mouth or black stools. He's not anemic. Looks nutrionally ship-shape. Gives him Pepcid (cheap, generic drug) and tells him to refrain from chocolate, spicy foods, or other personal triggers. Patient encounter is about 1 hour -- counseling, education, making sure no history of helicobacter pylori (bacteria known to cause stomach aulcers and cancer) exposure or bleeding problems in him or family in the past. Patient does well.

The "greedy" doctor destroying health care: Same patient. The doctor says "Oh my god, that could be an ulcer and it could be bleeding!" Assigns the patient an intragastric pH monitor. Refers patient to gasterenterology where that specialist gets $500 for a 10 minute anasthesia requiring scope of the stomach. Sends for helicobacter pylori blood tests even though patient has never, EVER been to an endemic country. Tells the patient to take Nexium (basically high dose Pepcid but costs more $$$$) because the 25 year old former cheerleader drug rep visits his office every week, fawns on him, and brings the staff free food. Oh, she has some "science" to back up her Nexium claim -- that drug has 50% fewer platelet related side effects than Pepcid! She does not state that 2 in 500,000 get it on Pepcid versus 1 in 500,000 on Nexium and that's it's reversible once you stop either drug anyways. The patient feels they got brand name, caring medicine. All the doctors and the drug corps got to bill and make more money. The scope shows a pristine stomach, but at least the patient "absolutely sure" no ulcer exists. The primary doctor was able to kick the patient out after 15 minutes, referrals and tests in all, and the patient feels that so much more occurred for them.

In most Western countries, the encounter follows the former. In America, the bottom is so much more routine (especially for insured patients).

Also, for the doctor, sadly, medico-legally, the latter is probably better off. In the absolutely rare event it was an ulcer and the patient bleeds out that night, the latter doctor is at less of a legal risk. Of course, when you have lay-lawyers and lay-juries deciding whether or not physicians who have at the minimum 7-8 years of training are right or wrong, that's the incentive you get.

As doctors, we create need, justifiy that need, and are incentivized by higher and higher salaries to do so. That's fee for service medicine.

In parting another personal example from a month ago.

I'm screening for the Intensive Care Unit and am called to ER to assess a patient in respiratory distress. She's a 62 year old female with Stage IV (metastatic lung cancer) and has never been a candidate for surgery (her best chance at a cure) and has not even started chemotreatments because she has been so emaciated by the cancer. Yet, her oncologists tells her if she can take a nutrition shake a couple times a day for a couple months and is still living, he'll start chemoing her.

She's not able to breath without support of supplemental oxygen and even with that she's tiring out fast. She'll need to be intubated and have a machine breath for her. I've seen this story enough to know that she'll not got off the ventilator and will be in the hospital for many days until an infection probably kills her.

I end up having a 2-3 hour talk with the patient and her daughter about what I feel is the futility of the ICU admission and after lots of emotional exchanges (they just met me and I'm telling them she really has no chance of living much longer) we all agree she go to hospice and die there comfortably and peacefully without the wires, tubes, and artificial support of the ICU. They were thankful and relieved an MD was talking to them straight. The hosptial bill is in the $250,000 range. (It's why like 30% of health care here goes to the last couple months of life prolonging).

As a resident, I'm salaried, and it's a bit more clearly easy to do what's right for the patient.

I think of how I'll act once I graduate from residency and see all the money of my actions instead of the university.

Same patient. But, I'm in the hospital only briefly and gotta make it back to the office. I size up the patient and, state, "Ok, impending respiratory distress. NO ONE faults me for intubating and admitting her. Who knows, she could pull through." In 30 minutes, I admit the patient -- bill at a higher level for an ICU admission and continue to bill throughout a morbid hospital stay. I get in good with her oncologist who praises me for being as aggressive as he is with his patient. He sends me cases and consults later. We both justify our actions because even in Stage IV lung cancer 2-3% of people are living a couple years out from the diagnosis. Who are we to decide that this patient can't be one of them?


I'm paid much more handsomely for aggressive for no real return here. I get to pay off my loans faster. I get that European car that much quicker. And, you know, the patient is a consumer and we live in consumer medicine and no one is going to fault me for a giving a rational minded adult what they want.

It's a mess!

It's why smart people who truly care about fixing the system for good reject incremental change and go for single payer. I'm for that and for letting people who want to pay for excessive health care pay for it if they want -- from their own money.

If Obama fixes health care he's a top five President and he gets his mug on the $15 bill they create for him for fixing it also.
posted by skepticallypleased at 8:13 PM on May 29, 2009 [9 favorites]

The sad part is that my insurance at the time was more than happy to cover this joker, while I had been turned down by many other well-recommended doctors because they weren't on my plan.

And then one of the big arguments against socialized medicine seems to be that you can't pick your own doctor in such a system.


I'm glad I'm healthy enough never to have needed it, but I know plenty people who switched doctors (both general care and specialists) when they were unhappy with them.
posted by DreamerFi at 10:31 PM on May 29, 2009

This goes in your mouth, this goes in your ear, and this goes in your butt.

No, wait...

This goes in your mouth, this goes in your ear, and this goes in your butt.
posted by flabdablet at 5:51 AM on May 30, 2009

skepticallypleased, honest question: how do you see single-payer changing the dynamics you laid out above? If you notice, Gawande is talking in his article about the one place in the country with the highest per-beneficiary Medicare costs, and Medicare is pretty much exactly how you'd set up a single payer system. Most of the research, in fact, that has been done on the variation in medical costs looks at Medicare, since the data is available (government-owned and not proprietary, in other words) and it covers virtually every person over the age of 65. So it's a weird argument to me to look at problems in Medicare and assume that moving to a national single-payer system will solve them.

It's interesting, because in the health reform debate there's two camps: those that think that the primary issue is coverage, so fixing the payment system (whether that's reforming the insurance market or regulating insurance companies more stringently or expanding government programs, for example with single payer) will fix things, and those who think the problem is fundamentally a broken delivery system whose incentives have driven costs up so much year after year after year to be unsustainable (in other words, we don't have a coverage problem, we have a cost problem--if health care wasn't so damn expensive people would be able to afford coverage). I have to admit that in the five years I've been studying the issue, I've pretty firmly come around to the second camp, and my take is this article is a pretty good argument for why single-payer isn't a panacea.
posted by iminurmefi at 9:31 AM on May 30, 2009 [1 favorite]

Good question iminurmefi, but I think single payer at least forces costs lower and at least gives doctors and the rest of medico-industrial complex no other place to go. It all assumes that it's run well and it could even screw it to the lawyers since it's the only game in town.

Listen, Canada does more than we do for preventative care and has better aggregate results for much cheaper than we do -- and we're a lot wealthier than them.

Moreover, and I never thought of it in this fashion, but single payer seems to avoid the "moral hazard" (a term I only became familiar to in light of Wall Street collapse) -- as this wikipedia article states.

Medicare has to compete still for doctors, services, etc and will always have to do it as long as private for profit insurance exists. Doctors won't buy in as long as private insurance is a player. As long as private insurance exists, Medicare has to mimic it, and has long as it's tax basis is enough to cover it, it does. (And that's not going to happen much longer). And, remember, Medicare covers a sick, elderly population -- single payer spreads the risk so much more efficiently. I've encountered plenty a patient who has built up enough for Medicare coverage but is out of work around the age of 60 or so (and, so, in this country out of health care coverage). They get sporadic medical care (which is why they are seeing a resident like me in clinic) and not much preventive long term planning. By the time they get to Medicare eligibility, they are a "sicker" more expensive 65 than they might otherwise have been. Remember, single payer works in other places and Medicare in its manifestation is not single payer.

It's America -- profit is good in and of itself, right? And that's what is killing health care. Even in the stimulus and health care reform and electronic records it's amazing how many private corporations are angling to make a profit on this new government directive when simple, cheaper solutions like the VA EMR exist.

Yikes it's such a mess. I agree to Gawande like 90% and I'm not sure why he's so timid upon the possibility we can achieve real, comprehensive, incentive revolutionizing reform.
posted by skepticallypleased at 9:36 PM on May 30, 2009

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