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Friday, May 29, 2009

New Yorker article: what the Square Dance capital can teach us about the business of health care

I found one of those once in a lifetime articles on Bob Lazewski's health care blog. Atul Gawande's piece in the New Yorker truly captures the US health care system, why we are in this position, and even how we can get out of it.

It all takes place in McAllen, TX which bills itself as the "Square Dance Capital of the World." It's also a border town with one of the lowest incomes in the country and the 2nd highest medical costs. Demographically it is very similar to El Paso, TX but health care costs are 50% lower in El Paso. It's not about a sicker population, medical malpractice, cancer-causing abandoned industrial sites, or anything else. It's about the way that health care operates as a business, how physicians practice, and patient expectations. Here are some highlights.

  • Health care providers didn't have any idea that their costs were so high And why would they? As Gawande explain, hospitals know market share and margin and try to get doctors to send them patients. Therefore, it is impossible for a single provider to change the tide of health care costs.
  • Overutilization There is a fascinating section where the Gawande interviews a group of local doctors and after thinking about their high costs, they come to the conclusion that it's "racking up charges with extra tests, services, and procedures." There's an example of how a patient with chest pains and no other symptoms used be given a stress test and sent home. Today, they receive an EKG and cardiac catherization despite only having chest pains.

  • High quality care does not have to be expensive The Mayo Clinic has locations in Minnesota, Arizona, and Florida. Florida has the highest health care costs in the country. However, the Mayo Clinic has some of the best outcomes, highest quality scores, and their costs are in the lowest 15th percent due to their practice model.

  • It doesn't matter who pays for health care The current debate on health care reform centers around insurance. Should the government fix costs and pay for health care or should private insurance companies wheel and deal and pay for health care. However, who cuts the check will not address these fundamental questions about our health care system.

The author's article points out to hope for reform as there is evidence that there is waste in the health care system. We can cut out the waste, such as Overutilization described above, and no one will get hurt. While, the cardiac catherization might locate a heart problem once out of the 100 times its given, that does mean that other services won't be provided. Health care resources are limited. We can pay for extra cardiac screenings or provide more preventive care.

Personally, I think one way to approach this is to reintroduce the stigma and negative stereotypes associated with hospitals and doctor visits. 30 years ago, hospitals were uncomfortable places where people went when they absolutely had to. Today, hospitals have private rooms, cable, room service, and such wonderful extras that it's no wonder that people want to go there.

When I worked psych crisis, some patients I worked with, wanted an inpatient hospitalization despite it not being necessary. It was viewed as a place to escape their current problems. Our clinical guideliness called for inpatient psych hospitalization in cases where the person was at risk for hurting themselves or others not an escape option. 30 years ago no would have requested to be placed in an inpatient psychiatric facility.

I'm not suggesting that health care delivery return to offering poor and sometimes inhume services. However, as a country, we shouldn't like getting invasive time-consuming procedures done to us. Providers shouldn't feel like they will make us happier if we get another test, take some pills, or have another procedure.

This article is a very good example of how our health care system works exactly the way that we have currently designed it. If we want to fix it,we need to change the design.

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