Wednesday, May 27, 2009

The WHY of medical cost variation

The inescapable Dr Atul Gawande has drilled down on the why of medical cost variation: Annals of Medicine: The Cost Conundrum: Atul Gawande: The New Yorker. He drills down into the town with the world’s (universe’s?) highest health care costs -- McAllen, Texas – a mid-sized city with explosive population growth – and a significant amount of poverty

… The median income for a household in the city was $33,641, and the median income for a family was $36,050. Males had a median income of $30,089 versus $22,480 for females. The per capita income for the city was $14,939. About 20.9% of families and 23.8% of the population were below the poverty line, including 30.5% of those under age 18 and 20.3% of those age 65 or over…

This isn’t another boring (boring) article on health care cost variation. Gawande, who is no amateur, knows the interesting question is “why?”. I loved his description of the body language of an anesthesiologist and hospital entrepreneur during one of his visits. I bet that CEO would prefer a root canal to a Gawande interview…

… I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.

So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”…

Gawande, like me, is interested in the (too few) qualitative studies of health care spending decisions

… Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from

But is it really where doctors trained, or is it something far more concrete?

.. I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.

“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,” he 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

… many physicians are remarkably oblivious to the financial implications of their decisions...

.. Others think of the money as a means of improving what they do…

…Then there are the physicians who see their practice primarily as a revenue stream...

In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme….

When we talk about practice variation we don’t usually think anthropology. That’s probably a mistake …

Woody Powell is a Stanford sociologist who studies the economic culture of cities..

.. Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream…

…The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up…

Culture really, really, matters. Damnit.

And now from my neighborhood (more or less) …

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country…

…The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible…

…Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys…

Gawande tries to come up with ways to replicate the lessons from Mayo et al. It’s not easy. One of lessons, which he quietly skates around, is that superb physicians will deliver superb medical care for much less than they’re paid in Texas. We don’t overpay our specialists as insanely as we overpay our CEOs – but we do pay far more than is needed to fill the jobs. CEOs are paid perhaps 5-20 times what they’d work for, but surgeons and many specialists are probably only paid 3-5 times too much.

Rationalizing reimbursement and incentives would more than pay for high quality universal health care – but it would be a devastating transition.

hat tip: Richard Neill, via Facebook

3 comments:

J. Meezan, MD said...

I read Dr. Gawande's article last night, and I do believe he exposed some very important conditions that are leading to cost increases. However, I definitely disagree with your assertion that doctors are paid much more than is required to fill their position. I would argue that we are on the cusp of a dramatic nationwide shortage of physicians in certain fields, particularly primary care internal medicine and general surgery where physicians earn significantly less than their sub-specialist colleagues. Unfortunately, most experts in medical economics and healthcare agree that primary care medicine needs to be expanded in this country.

Where I practice in Northern California, general internists routinely earn less than nurses and pharmacists with less than half their education. Many are closing their practices and becoming hospitalists in order to reduce their overhead and earn a living. Most general surgeons I know would have to close their practices if their reimbursement was cut even 33%, much less the 67-80% you imply is possible.

Medical students (many of whom will graduate with > $100,000 of school debt), when confronted with a choice of specialties, can't see why they should pursue fields which require the same length and difficulty of training but pay _way_ less. You don't have to be an economist to do the math, especially when considering a ~30 year career ahead.

This shortage is not acute yet, but is on the horizon based on the choices medical students are making now. There is a buffer from the 3-7 year length of residency training, but this also means the shortage will take years to reverse. Yes, it is true that some physicians are "overpaid" compared to the cost of filling the job, but the ludicrous disparity in earning between different specialties needs to be addressed.

John Gordon said...

I absolutely agree with your main point. I blame the confusion on hasty editing. I thought I'd made it clear that I was writing about some medical and surgical specialties, but after you wrote I saw I'd erred.

I have corrected the post.

I haven't seen a patient in 15 years, and I get recruiting letters. There is a relative shortage of primary care physicians.

I suspect that if the reimbursement to highly reimbursed specialties were sharply reduced that the flow to primary care would pick up even without a significant increase in compensation however.

It's also true that if we paid surgeons at Canadian levels that they'd work fewer hours and we'd need more of them -- but that could be a win win.

Alas, I don't agree that the long education of physicians entitles us to more money. Life's not fair that way. If it were then there'd be fewer underpaid PhDs.

If we can fill the physician workforce paying $150-$250K then that's the "fair" price. (OF course we can also "cheat" by importing labor, but that's another story ...)

Clark said...

For Northern California I think there are huge distortions due to the costs of living and high skilled workers demanding higher salaries to make up for this. Increase the rate of housing by lowering regulations for buildings decreasing the cost of living and then more becomes possible there. It's dangerous to extrapolate from high cost regions like the Bay Area, New York, DC, etc. to the whole country.