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Monday, June 1, 2009

Superb Health Care Article

Atul Gawande, a practicing surgeon, has written a brilliant article about healthcare reform for the New Yorker. Its basic thesis: while there are a host of theories about how to reduce the cost of healthcare in the United States, the greatest problem is over-treatment -- the prescription of medications, treatments, tests and surgeries that are redundant, unnecessary, and sometimes harmful.

To research the article, Gawande flew to MacAllen, a rural Texas county that's the most expensive health care market in the United States, despite having average or below-average patient outcomes, and residents who are, on average, as healthy as anywhere else. There's a sharp moment when he sits down with some physicians at a diner to talk it over:

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“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.

I thought this discussion was fascinating, because it confirmed my little experience discussing the subject with my best friend, a neurosurgeon practicing in Nashville. Back when he was going through medical school, we used to talk about the high cost of medical care, and he always insisted the problem was malpractice suits; insurance against malpractice was bankrupting doctors and forcing them to add extra testing. When I pointed him to studies showing that malpractice awards were dropping even as insurance costs skyrocketed, he shrugged it off. It was the lawyers, plain and simple.

I have a feeling that now, after many more years of practice and experience, he sees things differently (and I'm looking forward to asking him at my bachelor party next week). My guess is that the malpractice canard is a commonly-held but superficial excuse that one would encounter early on in medical education -- especially while interning and doing early rotations. But as doctors gain more experience, they gain a richer, more nuanced understanding that complicates that reassuring but misleading perspective. And that's what is reflected in the exchange above: initially, the doctors offer the comforting excuse that it's the fault of lawyers and court cases -- not their own. But when push comes to shove, they recognize the problem lies closer to home.

Which isn't to say that insurance reform, digitization, universal coverage, prescription cost controls, etc., aren't key to moving forward. But a huge component is getting physicians to recognize that, despite excellent medical skills, their daily decisions contribute incrementally to the national health care problem.

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