Apparently President Obama was just as struck as I was by Atul Gawande's New Yorker article about health care costs, which I posted about yesterday. According to today's New York Times:
President Obama recently summoned aides to the Oval Office to discuss a magazine article investigating why the border town of McAllen, Tex., was the country’s most expensive place for health care. The article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.
“He came into the meeting with that article having affected his thinking dramatically,” said Senator Ron Wyden, Democrat of Oregon. “He, in effect, took that article and put it in front of a big group of senators and said, ‘This is what we’ve got to fix.’ ”
Unfortunately, it sounds like everyone kind of missed the point! If I understand Gawande correctly, he sees the problem as arising from the culture of the doctors in certain areas, which has been influenced by the hospital administration and its compensation structure. Members of Congress are considering capping Medicare payments in high-spending areas, but with the current system in these areas, that would just lead these doctors to do even more unnecessary procedures so they can make up in volume what they're losing in margin.
So how do you solve this problem? Can government pass laws that would require all hospitals to emulate the culture and structure at the Mayo Clinic, where all the doctors and staff are paid from pooled revenues rather than per procedure performed, so decisions can be made on the sole basis of what is right for the patient? The Mayo Clinic is renowned for great care, and their staff physicians seem to make between $200-300,000 in salary, or more as those numbers were for the Minnesota and Wisconsin locations as of 9/06 to 6/08. (Their salaries are supposed to be in line with "marketplace salaries for physicians in comparable large group practices.") That may seem like less when you consider that a doctor may rack up $300,000 in educational loans, as a commenter pointed out on the last post, but it's still quite a lot of money. This comes back to the problem of culture. How many of these doctors are comparing themselves to lawyers and investment bankers who make millions a year-- or at least did until recently. Maybe if the good old days on Wall Street are over, doctors won't have to feel quite so much like they're missing out!
The other thing that has to change for this problem to be fixed is patient expectations. We are all told nowadays to take control of our own health care, to get second opinions and do our own research, to demand the treatments we feel we need, and to ask our doctors if Medicine XYZ we saw on TV is right for us. And that is a tough one. Who wants to be told they can't have something that might work if they've run out of other options, even when a study has shown that that treatment is 99% likely to fail? I mean, if my dad's doctors had said there was a very expensive brain tumor treatment available but that they weren't going to try it because people like him had a 99% chance of not being helped by it anyway, I'd have had a pretty hard time agreeing that it wasn't "worth it" and just letting him die. (He had an experimental treatment and is doing very well now, by the way.) But there are probably plenty of cases that aren't life and death, where doctors provide unnecessary treatment just to shut patients up!
Anyway, greater minds than mine will have to figure out the answers on this one! For more reading on this topic, here's a book that has been on my radar ever since it was called the "best economics book of the year" by David Leonhardt of the New York Times: Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.