Tuesday, June 09, 2009

Obama Read That Health Care Article Too!

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.


Anonymous said...

I think your observations are right on regarding this article. However, I feel the Mayo Clinic should not be held up as an example that can easily be reproduced. Many large medical centers, especially academic ones, receive funding from their state governments. This funding comes with the stipulation that they must treat all patients, even those who can not pay. I could be wrong, but I believe Mayo is not required to do so and therefore may have a more stable funding stream to work with.

Anonymous said...

I'm always wonder what doctor salaries really are after you subtract the loans, missed earning years, and malpractice insurance. 300K for a staff physician is just outrageous. Health care is not a free market, complex negotiation happen between health care providers, insurance companies and the government to set prices, and then everyone who "needs" the service gets it. Its all going to end when the US runs out of money and we will in the next decade or so, as the boomers start retiring. BTW I have a PhD in engineering from a top 5 school, and me and my friends don't make anywhere near 300K. Most are between 100 and 130K.

Anonymous said...

The problems are 2 folds:

1. The hospital, doctors, medical community had more interest in making money than keeping us healthy. I'm not even sure if they want us healthy, and I said that because we just need to read the Hippocratic Oath to understand the true meaning to be a doctor or any sort of physician. Within it says, "NEVER do harm to anyone". Then you look at the leading causes of death in America (health care being one of them) and all the side effects of drugs... it really makes you think.
(They deserve to make money but that should be secondary and only if they place the good of the patient first, right?)

2. We ourselves have to learn and realize the true meaning of health, which is definitely NOT not-feeling-sick. Once that is realized, stop delegating our health responsibility to others.

The key is NOT health care.
The key is our health.

Therefore, no policy, no plan can solve our "health care" problem because our problem is not "health care". That is missing the point.

Our health care costs are shooting up exponentially because we are becoming more and more unhealthy. The increase in medical cost does have a role but we also play a part in the increase because we are increasing our demand. Basic supply and demand rule in capitalistic society.

We need to start looking at our health, which again, does not mean non-ill, non-sick, or non-disease. More technology, medicine are not going to make us healthy. They probably can keep us alive longer. But healthy?

Super Saver said...

Sounds to me like more Obama grandstanding to get populist support for a vague health care program that has no basis to deliver the savings results promised. There are already great examples of high quality health care at low costs. (WSJ cited Minnesota, Mayo clinic). What disappoints me is that Obama doesn't say, "This is already working, let's figure out how to get it everywhere."

Amy K. said...

Could the Gov't do an equivalent "salaried" medicaid payment? meaning a patient's primary doctor gets $4,000 per patient, per year, for non-critical care regardless of how many tests or visits the patient has. The doctor then has an incentive to avoid the unnecessary tests (cutting into margin) or booking visits rather than phone/e-mail consults (cutting into time). I'm not sure if critical care should be in that bucket too, I haven't fully fleshed out the idea. Ideally, we would penalize excess while encouraging prevention.

I've been thinking about this lately, because my husband and I go to the same clinic, but different doctors with wildly different styles. My doc sends pages and pages of preventative info home with me, happily chats via e-mail, and is willing to skip tests if I think the cost (time, annoyance) outweighs the benefit. OK, maybe not skip, but she seems to be working in my best interest rather than pushing extra stuff.

My husband, on the other hand, just went in for a physical and his iron was low - borderline anemic - for the first time ever. His doc ordered a fecal occult blood test, which sounded OK on paper. Once we read the instructions though, and saw that there were 6 test cards (twice as many as usual, according to Wikipedia), our hackles were raised. A week or more of dietary changes awkward bathroom sessions, for "borderline"? And no followup/preventative info from the doctor, not much interaction outside the appointment itself. We had no idea what this test would prove if it came back positive or negative - just online searches to make us even more nervous. And no idea why twice as many tests were ordered. Hubby is looking for another doctor, it really just seems like tests for the sake of tests.

Anonymous said...

Amy K-
Fecal occult blood tests (FOBT) test for the presence of blood in your stool. An FOBT is a screening tool, not a diagnostic tool. They are meant to be one of the first gates to go through to get to a diagnosis. Then, if the test comes back positive they can move forward for further testing.

FOBTs are used as a first step because they are much much cheaper than having someone undergo a colonoscopy or a scan.
Yes, false positives and false negatives can happen with these tests, but that can happen with any medical test.
I would check with the doctor on the number of cards; there are different types of FOBT tests out there so that may affect the number of cards. (And keep in mind Wikipedia is not written by medical professionals.) Good luck!

Jerry said...

The culture of medicine, insurance, and health care in the US will need to change before any substantive progress can be made. There ARE doctors who are breaking the mold and opening their own "micro-practices" to try to provide better care and minimize the ancillary costs of care for their patients, while still earning a decent living and having a good life away from the office. I hope this movement leads to change in a positive direction...