THE SETTING
It would not surprise me if you’ve never heard of the town of McAllen in Texas, USA. Neither had I until a week ago. McAllen is located in Hidalgo County which has the lowest household income of any county in the US. McAllen is the largest city in what may be the poorest county in the United States.
Here’s what makes McAllen special. It may have the most dysfunctional group of medical professionals in the first world.
ABOUT US MEDICARE?
Let me explain. In broad terms, US Medicare funds healthcare for people over 65 or people under 65 who are disabled. Almost every American over age 65 is enrolled in some sort of Medicare plan.
Medicare “‘Part A” covers hospital stays. Medicare “Part B” covers almost everything else except for drugs.
THE COST OF US MEDICARE
How expensive is Medicare? To put it another way, how much does Medicare disburse per enrolee?
According to the Dartmouth Atlas of Health Care the 2006 cost per enrolee for Medicare Parts A and B was $8,300. Since over 42 million Americans are covered by Medicare the total cost is of the order of $350 billion.
The average of $8,300 hides wide variations. In Texas the 2006 average per enrolee is $7,900 in El Paso and a whopping $14,800 in McAllen.
WHY DO MEDICARE COSTS DIFFER BETWEEN REGIONS?
The demographics of El Paso and McAllen are similar. Why is there such a wide disparity between two towns in the same state? Why is the El Paso average slightly below the national average while the McAllen average is nearly 80% above the national average?
DOCTOR ATUL GAWANDE’S NEW YORKER ESSAY
That is the subject of a New Yorker essay, “THE COST CONUNDRUM”, by Atul Gawande. If you want to know what Barack Obama and his advisers are reading about health care, read Dr. Gawande’s essay.
SOME SALIENT FACTS
• McAllen was not always the most expensive Medicare city in the US. Back in 1992 Medicare disbursements per enrolee in McAllen were close to the national average.
• El Paso and McAllen have similar demographics. There is no obvious reason why McAllen should be almost twice as expensive as El Paso.
• The Medicare enrolled population of McAllen is not noticeably sicker than in El Paso. If anything the rate of cardiovascular disease among Medicare enrolees in McAllen is slightly lower than the comparable rate in El Paso.
• In terms of outcomes it is hard to spot any benefits Medicare enrolees in McAllen enjoy for the additional $7,000 that is spent on their health. If anything Medicare enrolees in lower-cost El Paso may actually be doing better than their counterparts in high cost McAllen.
• Medicare ranks hospitals according to the quality of care they deliver. On average the five largest hospitals in McAllen ranked below El Paso’s.
• The cost difference cannot be attributed to prescribing practices because drugs are not covered by Medicare Parts A and B. Whatever the reason for the cost differences between McAllen and El Paso, it has nothing to do with the pharmaceutical companies.
HIGH MEDICARE COSTS IN MCALLEN HAVE NOTHING TO DO WITH MISLEADING ADVERTISING BY PHARMACEUTICAL COMPANIES
I want to emphasise the last point. High Medicare costs in McAllen have nothing to do with deceptive advertising by the pharmaceutical industry. Whatever differences exist must be due to differences in the needs of patients in McAllen as compared to patients in El Paso, or due to differences in the way doctors in McAllen practise medicine, or both.
DOCTOR GAWANDE ASKS MCALLEN DOCTORS WHY THEIR TOWN IS SO EXPENSIVE
Dr Gawande asked doctors in McAllen why they thought their town was so expensive. Some excerpts from Dr. Gawande’s essay:
“Come on,” the … 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?’ ” (Emphasis added)
Here we have a doctor flatly stating that his colleagues are motivated more by personal financial reward than by doing what is best for their patients. This has more than mere financial consequences, serious as these may be.
TO CATHETERISE OR NOT
From Dr. Gawande’s essay:
I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?
Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.
And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.
“Oh, she’s definitely getting a cath,” the internist said, laughing grimly. (Emphasis added)
WHAT IS “A CATH”?
In a procedure known as cardiac catheterisation a thin tube is inserted into an artery or vein, usually the femoral artery in the groin. From there it is advanced under X-ray guidance to the coronary arteries or into the chambers of the heart. It is used to measure blood pressure in the heart as well as the heart’s pumping capacity. Catheterisation may also be used to take real time pictures of the heart and arteries or to perform a heart biopsy.
It is a tribute to the skills of cardiac surgeons and to the progress of surgical techniques that this highly invasive procedure is relatively low risk. Appropriately used it saves lives.
However the key word is “relatively”. It is not risk free. According to Medline the risks of catheterisation include heart attack and stroke. It is definitely not a procedure to be used without carefully considering whether the potential benefits really do outweigh the risks. “She’s definitely getting a cath…” does not bode well for Medicare patients in McAllen.
BROAD COMPARISONS BETWEEN MCALLEN AND EL PASO
Excerpts:
“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. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. 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….”
Remember none of this increased use in medical resources seems to have resulted in improved outcomes for Medicare enrolees in McAllen. If anything the reverse is true.
THE LESS IS MORE RULE
Yet more excerpts:
“…Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. 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.
“In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.”
In other words when it comes to health care the rule seem to be that, up to a point, less is more.
WHY IS LESS MORE?
Obviously “less is more” applies only up to a point. I am not suggesting we can improve health outcomes by reducing medical expenditure to zero!
I am saying that beyond a certain point, and where that point is reached will always remain a matter of clinical judgement that will vary from patient to patient, more becomes self-defeating. No procedure and no medication is risk free and beyond some point the risks start outweighing the benefits to the patient.
Perhaps in McAllen and other regions where Medicare costs are high the local medical communities have passed the point where risks to the patient outweigh the benefits. And perhaps they have been motivated more by the desire to maximise their revenues than by considering what is best for their patients.
THE DOCTORS OF MCALLEN RESPOND
The doctors of McAllen have not taken Dr. Gawande’s assertions lying down. In a media release they assert that McAllen’s Medicare expenditures are high because McAllen doctor’s see patients who are sicker than most and who require longer hospital stays because of their poor living conditions.
That may be. It does not explain why the “less is more” rule seems to apply in other states or why the Mayo clinic, perhaps the world’s finest, seems able to provide top quality care at such relatively low cost.
THE MOST OUTRAGEOUS REVELATION IN DOCTOR GAWANDE’S ESSAY - KICKBACKS
Perhaps the most outrageous revelation in Dr. Gawande’s essay is the fact that some doctor’s demand kickbacks. Another excerpt:
“…I spoke to a marketing rep for a McAllen home-health agency….Her job is to persuade doctors to use her agency rather than others. …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.
“Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.
“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.”
Doctors taking kickbacks should have their licences to practise medicine yanked. For life.
THE MOST DAMNING INDICTMENT OF THE AMERICAN MEDICAL ESTABLISHMENT
A leading journal, Health Affairs, organised a round table discussion on Dr. Gawande’s essay and related topics. Here is what one of the participants, Elliott Fisher, Director of Health Policy Research at Dartmouth’s Center for the Evaluative Clinical Sciences, had to say:
“…he [Gawande] was able to tell plausible stories that are consistent with lots of what we’ve found in our research. He made it easily understandable to a lay audience that the differences in practice aren’t about differences in patient need, and that they can be driven — sometimes quite powerfully — by both the payment system and how local physicians decide to practice.”
And:
“…Gawande appears as the translator of what we’ve all known for a long time.” (Emphasis added)
In other words, according to a distinguished member of the American medical establishment, Dr. Gawande’s essay is old news!
And that may be the most damning indictment of the American medical establishment.
DO THE SAME PROBLEMS EXIST IN AUSTRALIA?
I do not know but I am going to try and find out. I am drafting a letter to send to the minister of health and to the health spokespersons for the Liberal and Green parties.
Tags: ethics, gawande, health care, medicare
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