The roots of medical inflation

The fault, dear Brutus, lies not in our stars but in ourselves.  

In the June 1 New Yorker, Dr. Atul Gawande tackles what he calls the medical “cost conundrum,” to wit: Medicare costs bear no relationship to quality of care outcomes.

He approaches this delicate subject by examining the medical society of Hidalgo County, Texas, which has the lowest household income in the country. It also spent $15,000 per Medicare enrollee in 2006, roughly double the payola in the home counties of the Mayo Clinic and Duke. It is also double the cost of El Paso County, 800 miles up the border, which is demographically identical.

Why? You won’t be surprised.

Hidalgo County physicians are nothing if not entrepreneurial. Dr. Gawande posits a case for a group of them over dinner. A 40-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 they do 15 years ago? Send her home. Maybe an outpatient treadmill. And today? A stress test, an echocardiogram, a mobile Holter monitor and a cardiac catheterization.

“Young doctors don’t think anymore,” the family physician said.

“There is overutilization here, pure and simple,” the general surgeon said.

I see the same thing in my town. Thinking – that is, making a medical judgment that a test or procedure is not cost-effective – is dwindling. And why should that be a surprise? Every procedure earns a fee for some physician. And if you question the rationale? “You’re rationing care!” is the cry.

This is not family medicine’s problem. It is not primary care’s problem. Primary care’s problem is that entrepreneurial specialist colleagues have so padded their wallets over the past 15 years that medical students – no dummies, they – won’t choose our calling.

We are now under the direction of a new administration, which seems to be more serious about the coming bankruptcy of Medicare than the previous administration. “Nearly thirty percent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” says Peter Orszag, President Obama’s budget director.

He’s right, too. That would push back the bankruptcy maybe a decade.

The solution proposed by the primary care societies is the Patient-Centered Medical Home, with pay-for-performance incentives that will jack up our salaries into the procedurist stratosphere. That’s the basket we’re putting all our eggs in.

In which case bankruptcy comes a decade earlier.

If you believe that’s going to happen, I have a house in Colorado I’d like to sell you.

The solution is going to be rationing by a government agency like Britain’s NICE commission, or self-rationing by the market in the form of Medical Savings Accounts. You can take that prediction to the bank.

In the meantime, we honest family physicians need to do what we’ve always done, which is care for patients in a cost-effective manner – informed by the best medical evidence, and with a close eye on their medical expenses and our administrative expenses.

Which is what I’ve been saying all along.

Posted at 02:43PM Jun 01, 2009 by Doug Iliff  |  Comments[4]