- ‹ previous
- 1010 of 2797
- next ›
Can the Mayo Clinic Save Healthcare?
McAllen and El Paso are very similar places: similar people, similiar diets, similar health profiles, both border towns only a few hundred miles apart from each other. But healthcare costs in McAllen are almost twice what they are in El Paso. What could possibly account for that? Atul Gawande visited McAllen to find out, and ended up getting multiple answers from a group of doctors he went to dinner with one night. Finally he got to the bottom of it:
“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
The surgeon came to McAllen in the mid-nineties,
and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”
....The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period....They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
....“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” [a hospital administrator] said. But in McAllen, the administrator thought, that percentage would be a lot less.
He knew of doctors who owned strip malls, orange groves, apartment complexes — or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said.
....About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. 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 treated home buyers: as profit centers.
This comes via Ezra Klein, who didn't excerpt anything from the piece because he wanted to encourage everyone to click on the link and read the whole thing. Obviously I'm not quite so high-minded myself. Plus there's the fact that I have a dim view of human nature: most of you guys aren't going to click the link no matter how much I tell you to, are you?
But you should! It really is a good piece. "Overutilization" is a boring buzzword that Gawande breathes real life into. If you want to know why American medicine should look more like the Mayo Clinic — and why it would be both better and cheaper if it did — turn off the House reruns and read Gawande instead. And if you want a different perspective on the same issue, try reading Shannon Brownlee's Overtreated. It's good too.
(OK, fine, keep watching House. It's a great show. Just don't use it as your template for what medical care should look like, OK?)
I already fucking read it
I already fucking read it the magazine so I didn't need to click.
Yes, it's a very good piece.
What a surprise!
What a surprise! Physicians are self interested small business people! It's no wonder that outcomes don't correlate with medical spending. One of the many things that needs to change about health care in the U.S. is that medical providers need to own up to what they are: fallible and self interested, just like the rest of us. Markus Welby they ain't.
SunBelt mindset ?
Atul Gawande >"...In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care...."
Hmmm, I wonder what it is about these states that might fuel this behavior. Certainly worth looking into I would think.
"The difference between what we do and what we are capable of doing would suffice to solve most of the world`s problem." - Mohandas Gandhi
Okay, So I Read It
Okay, so I read the article. I must say I disagree that it is that good or persuasive. Other than the higher costs of care in McAllen, and some speculation and hearsay by local doctors, the article does not present any actual evidence of overutilization. It is a bit conclusory--there is quite a difference between finding "there was overutilization" and "there must have been overutilization." I'm not saying that McAllen's costs are not due to in some part to overutilization--but the author sort of presumes it without proving it, order to make a broader policy argument.
Also, who cares if the doctors invest in strip malls and orange groves? If you've been to McAllen, you would know that is pretty much all that is there. What, did the doctors invest in the stock market too? Scandalous.
How do you change the culture?
As a physician, I can tell you that this is a highly accurate description of the economic problems facing the US medical system. Third-party reimbursed fee for service medicine encourages excess utilization which leads to unsustainable cost increases. As the article points out, this unfavorable outcome occurs whether private insurance or Medicare is paying. Changing to single payer would not solve the problem without hard cost limits (rationing). But even limiting the total budget would not eliminate fraud and waste. It might actually encourage abuse as competition for limited healthcare dollars increased.
But using Mayo Clinic as a model is not as simple as it sounds. Mayo is a large group practice with all physicians on salary. The physicians there spend more time with patients, but as a result they are less productive in terms of the number of patients seen or procedures performed. We don't have enought physicians to treat everyone at the Mayo Clinic level of productivity and maintain the current number of procedures and office visits. Of course, you can argue that the current amount of medical care provided is excessive, and we probably have enough physicians to provide necessary care.
But it is not at all clear how you would transition from a high-volume low-quality fee for service environment to a lower volume high-quality medical practice on a nationwide level.
Remember that all of that excess utilization means jobs and income for many people, businesses, hospitals, pharmaceutical and medical supply companies, and they will fight to the death against anything that threatens their income stream.
more healers and less entrepreneurs
The Atlantic magazine had a feature article several years ago (Jan. 2003?) that identified medical specialists as being a primary cause of increasing medical costs. Areas with more specialists spent much more on health care.
Several months ago a plea was made in comments for more healers and less entrepreneurs in the medical community.
The pursuit of wealth by mathematicians and other number crunching specialists has destroyed the economy. The pursuit of wealth by doctors has destroyed health care. The pursuit to dominate society by those lucky enough to have fine minds and the ability to pay for education is destroying America.
What a coincidence, I'm off
What a coincidence, I'm off to take my HIPAA training at Mother Mayo!
I'm a technogeek, not a Doctor, but I've worked at Mayo part time for over twenty years and have kept my mouth shut and ears open, so I have friends and think I've learned a thing or two.
I agree with everything drdr says. It is well known that Mayo physicians and employees are paid okay, but not the top of the scale. Instead they get to work with some super research and their workload is tolerable.
If the US wants to copy Mayo they need to graduate more doctor's every year, and the doctors need to accept a little lower pay but better service. From my limited set of friends Doctor's would go for this. The ones I know don't want the rat race either. They are not in it for the money. They want a decent life, paying off their loans, doing what they love, which is helping people.
It is the 'industry' that keeps the supply of doctors artificially low to raise pay and raise the work pace. The business people want to maximize profit, not the workers nor the customers.
Is it any wonder economics is called the dismal science? Our system requires us to work to death so that a few can become ultrarich and the remainder have no security and work more than they want so they can have a job.
Tripp
Overtreatment is just as dangerous as being undertreated
My mother was admitted to the local Advocate hospital in October 2005 with a pretty severe gut infection. She was in pretty bad health generally, 77 years old, obese, diabetic, bad back, bad knees, she'd been on statin drugs, blood pressure drugs and a whole host of other medications for decades. She wasn't able to walk without a walker and only for short distances, she got around mostly by electric scooter when she got around at all but spent most of her days on the couch.
So within nine days of checking into this hospital and being put on a high dose of wide spectrum antibiotics her doctors (of which there were eventually 17 in on treatment at this one facility) scared her into having a triple bypass which she was in no condition to recover from. They kept her in their brand new Critical Care Unit until the day her Medicare Days ran out and then shipped her off to a rehab hospital, dislocating her shoulder in the process, promising us these folks were wizards at weaning patients off respirators and she'd get the physical therapy there she needed to stand and finally clear the fluids from her lungs. She still hadn't recuperated from the infection she'd been admitted for initially, she'd acquired more infections in the heart surgery mill her weakened immune system with variety of drugs they were giving her couldn't fight off. Only days before her primary care physician told us her vitals were failing, he was sorry, it was only a matter of time, and took her off all the medications they were treating her with. We didn't argue, even though we were all in WTF mode, all we knew was these people were killing her and the sooner we got her out of there the better.
So off to the rehab hospital she went into the cold without so much as a blanket over her on the gurney in the dead of winter. She promptly got a new set of different infections in the rehab hospital where they discovered a shunt they'd inserted into her arm to facilitate her intravenous injections was filthy and making her sick.
None of the promised rehab took place in the 30 days she was there. They were too busy curing infections and trying to keep her cardiovascular system working with a drug regimen that shut down her kidneys. The kidney drugs turned her blood to sludge. It was the same vicious circle that the heart surgery mill couldn't remedy. I begged her new doctors to get her records from the other hospital, I'd already seen the same missteps there. A patient "advocate" who initially assured me my mother wasn't going anywhere until she was better while urging me to go check out nursing homes with respirators told me it'd cost $250 for them to get my mother's records from the other hospital, a move they considered unnecessary.
So after her 30 Medicare days ran out at the rehab hospital they shunted her off to a nursing home with our blessings. At every step of the way, with every promise broken, when informed that they wanted her out our family concurred. Even though we didn't know what stupid greedy bastards we're going to be waiting to manage her "care" next we figured we had to try something, anything other than the reckless bastards who wanted to wash their hands of her, an act I rarely saw them literally perform unless by request when treating her I might add.
So the next stop was the nursing home, a facility built in 1911 as an orphanage, where the attending physician brightened when I told him she'd had a triple bypass at Good Sam. What a wonderful facility he said, they hold the record for getting you under the knife, on average it's only 59 minutes once you enter the doors til they're operating on your heart! I could have punched him.
My mother spent the last six months of her life in a living hell of hospitals, nursing homes, rehab facilities plugged full of tubes with a repsirator down her throat. It was her worst nightmare. She died on April 12, 2006.
The first hospital alone billed Medicare and BCBS over $500,000 for her stay. Doctors I never saw even stop by billed them $100 or $200 daily for her care. The day before she died with her Medicare days running out at the nursing home the administrator was trying to get me to give her not just my parents' financial information (they wanted half of everything my parents owned except for the house) but my and my siblings too to continue her care.
You don't want to get sick in America. They'll kill you for your insurance or let you die if you don't have enough.
markg8: she'd had a triple
markg8: she'd had a triple bypass at Good Sam
Is that the Good Sam on Long Island (West Islip)? I know Good Samaritan is a common hospital name, but I have some issues with the one here on Long Island.
No alex
Downers Grove Illinois
House
Actually, after reading the piece (which seems to be quite a bit different than the piece read by MP as described above), I think House is an excellent model on how to do health care right. Patient's care is paramount, none of the healers make $$ off the tests, precedures, etc. that they order. They all seem to be on salary.
It's hard to argue with that.
Money and medicine just don't seem to mix well.
right
I probably should have been more specific. The author lost a bit of credibility with me when he concluded that McAllen and El Paso so similar. They really aren't. McAllen has a subtropical climate (thus all the orange groves and palm trees), much like parts of Florida. What this means is lots and lots of "snowbirds" and retirees. It is very attractive because of the Florida-like climate (with fewer hurricanes) and it is much, much cheaper than Florida. You can also go right across the border into Reynosa or Matamoras for cheap prescription drugs. And the Rio Grande Valley does, in fact, have a reputation for having good medical care.
But the author either ignored or didn't know about this phenomenon. But it seems critical to the analysis.
Re: similarities between McAllen and El Paso
I had the same reaction you did. But the author specifically mentioned demographic similarity, so we should probably go to the tape:
http://www.city-data.com/city/McAllen-Texas.html
http://www.city-data.com/city/El-Paso-Texas.html
In the following pairs of stats, McAllen is first, El Paso second
Population: 127,245, 606,913
Median age: 30.5, 31.1
Median household income: 39727, 35646
Poverty rate: 27.3, 27.4
Hispanic population %: 80.3, 76,6
Cost of living (100 = US avg): 79.9, 79.3
Unemployment rate: 8.7, 9.2
Other than El Paso's obviously larger population, and a significantly higher household income in McAllen, pretty darned close. You might get a different result using MSAs, but I doubt it would be overwhelming.
doctors sell their patients to the highest bidder
Today's NYT has an essay by Sandeep Jauhar, M.D., regarding how referrals work in the health care industry:
"Logic says that a referral should depend only on a patient’s needs and the reputation and skill of the physician to which the patient is referred. But medicine is a business too, so that isn’t how it always works in practice."
"When I was in training, simple referrals from internists, like patients with only mild hypertension, bothered me as a waste of time. Now that I am in practice, I welcome them. I haven’t changed my mind that these referrals are probably unnecessary, and there is plenty of evidence that wasteful expert consultation is adding to health costs and creating redundant care. But as a full-fledged doctor, I appreciate the business. It is hard not to view a referral as an overture from another physician, and it is equally hard not to return the favor."
"Our health care system needs a different approach, one in which patients are not treated as commodities."
Our health care systems needs to make health providers commodities if it is ever going to deliver adequate health care to everyone. Instead, our economic system makes patients commodities. Most doctors partly finance their retirements by selling their patients, their 'practices,' to the highest bidder.
great
Is that so ?
evidence in support of your hypothesis
My personal case provides some evidence in favor of your dim view of human nature. I read Ezra's post and I didn't click the link.
sorry for double post
how do I delete this thing ?
Read the article finally
tagged as:- solution
Man was that depressing. It shows our health care system to be incredibly screwed up.
I'm still impressed that the financial life of a med student/resident/young-doctor is a mess and that it contributes to their zeal for high pay as soon as they can get it. Close to that is the high pay demanded by med school doctors and med schools which put their students in this incredibly bad situation. Add limited slots for med school students and you have limited # of doctors pushing for high pay. Seems like a fine prescription for a too-small group of doctors who aren't interested in competing with one another on price.
Once into private practice the pressure to push for extremely high pay is obvious and the fee for service system feeds that. Fee for health issue care has to be better, but doctors-on-salary seems far simpler and probably better.
Open med school slots, charge affordable fees, pay doctors salaries, limit the insurance company gouges (like paperwork and ins. co. doctors interfering).
I also liked the idea of more universal standards for how to do medicine. Being told in the workplace that "we don't do it that way here" doesn't make sense.
Tying doctors to those standards by relieving them of some malpractice costs might be the right incentive. Another malpractice idea from the article is group plans and I can't tell whether that's a great improvement, but we should probably experiment with it and find out.
http://www.erreauk.com
..“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” [a hospital administrator] said. But in McAllen, the administrator thought, that percentage would be a lot less.
erreauk