Tuesday, June 09, 2009
McAllen, Texas, spends more per person on health care than any other metropolitan area in America, except for Miami. Why would this poor border town spend $15,000 a year per Medicare enrollee? Rochester, Minn., home to the famed Mayo Clinic, only spends about half as much. Find the answer, and we have the formula for national health-care reform -- that is, controlling costs without cutting quality.
Atul Gawande, a Boston surgeon writing in The New Yorker, has landed on an explanation. It's the different medical cultures, and with them, the incentives for prescribing care. "The most expensive piece of medical equipment, as the saying goes, is a doctor's pen," Gawande notes.
Over-treatment is not necessarily harmless. More Americans die of complications of surgery than in car accidents.
My conservative friends resist this response. They believe that the market provides the best incentive system and that the government should keep its nose out of health care.
Let's first consider other possible reasons for these numbers:
Malpractice suits. The Rio Grande Valley is supposed to be one of those "judicial hellholes," in which doctors order extra tests to protect themselves. Actually, it's home to few medical malpractice suits, thanks to a Texas law that caps pain-and-suffering awards.
Unhealthy people. McAllen has high poverty and obesity rates.
True, but so does nearby El Paso County, where Medicare spending is half that of McAllen. Their populations are similar in size and numbers of non-English speakers, illegal immigrants and the unemployed.
Superior care. McAllen's facilities do offer superb technology.
But on the Medicare rankings for quality of care, El Paso's hospitals outperformed McAllen's on 23 of the 25 criteria.
Dartmouth College's Institute for Health Policy and Clinical Practice compared treatments ordered in McAllen and El Paso. Patients in McAllen received 60 percent more stress tests with echocardiography, 200 percent more tests to diagnose carpal-tunnel syndrome and 550 percent more studies to diagnose prostate problems. They provided two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations and so on.
The Dartmouth researchers found that patients in high-cost areas were less likely to receive inexpensive preventive care, such as flu shots.
They had longer waits in emergency rooms and were less likely to have a primary-care physician.
"They got more of the stuff that costs more," Gawande writes, "but not more of what they needed."
The lower-cost centers had adopted measures to discourage doctors from piling on unnecessary treatment. Doctors at Mayo work on fixed salaries. Well-performing centers where physicians are paid by the procedure had taken other steps. For example, their doctors couldn't cherry-pick patients with good coverage and send them to specialty hospitals that they own.
McAllen is an extreme case of what routinely goes on in American health care. In 2006, U.S. doctors performed one surgical procedure for every five people! Furthermore, it's not true that Americans are especially unhealthy. They may be fatter than others, but they smoke and drink less.
The Obama administration believes that shrinking the expenditure gap between the Mayos and the McAllens will free up resources to insure everyone and curb growing federal deficits. Its critics argue that this is the road to rationing health care.
OK. Suppose you report heartburn symptoms to your doctor. Would you rather be started off with an antacid or have an endoscope shoved down your throat, with the risk of puncturing your upper GI tract? More than 70 percent of doctors in high-cost cities said they would immediately send you to a gastroenterologist and-or order an endoscopy.
The Tums-first route would seem more rational than rationing.
The simpler treatment is also less expensive, but let's not hold that against it.
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