Two weeks later Atul Gawande’s New Yorker article has multiple interpretations. This NY Times editorial provides another example – Doctors and the Cost of Care
There is disturbing evidence that many do a lot more than is medically useful — and often reap financial benefits from over-treating their patients. No doubt a vast majority of doctors strive to do the best for their patients. But many are influenced by fee-for-service financial incentives and some are unabashed profiteers.
This editorial blames the doctors. As I read the article, the doctors in McAllen lived in a culture of excessive technology and service. Others have focused on the examples of lower cost care, like the Mayo Clinic.
How should we interpret Gawande’s article? Those who do not practice medicine might miss the nuances in this article. As I read the article, I see differing cultures of medical practice. Now I am biased, but I believe that we are getting the care that we reward. Our current public plan – Medicare – has the wrong incentives. We do not reward thinking; we reward doing.
We live in a culture and respond to that culture. Patients often want another test. Patients often "demand" a subspecialist in situations where tincture of time trumps further exploration.
Physicians desire money. That does not make us bad people. We delay gratification until our 30s, and enter practice with significant debt. We work hard during training, and usually in practice.
If our payment system rewards excess practice, then we should look carefully at our payment system. If ordering technology makes profits, then we should revalue the payment for those technologies to minimize the rewards.
I often write that we should pay physicians an hourly rate – understanding that surgeons should receive a higher rate than me. The main objection that I see is that physicians might cheat.
If we paid by time, then we could and would audit the time spent practicing. Auditing would actually become more simple. Paying by time would allow thinking. You would be paid to spend time with patients rather than being paid per patient. You would be paid for communicating with patients – email and phone calls.
Gawande’s article is wonderful, and requires study. We should not let politicians use this article as their justification for the wrong reforms. We should ask that reform reward the Mayo Clinics and disincent technology use.
{ 3 comments… read them below or add one }
I loved his article. I think it goes to the heart of medical costs. All of us are paid to do things, the more we do, the more we make. And it gets worse as clinics add services, usually XR,CT or lab that generate the income lost by decreasing reimbursement. It is much easier to order a CT scan if the machine is down the hall and you will receive the revenue said scan will generate.
A patient of mine was seen during 09 at the Mayo Clinic, which simply requested all my records and the various local specialists, ordered tones of CTs, MRIs, and labs, and simply listed all the diagnoses that all of us had already made in about 20 pages of typed records. The patient was charged almost $50,000 for this outpatient workup in rapid speed that took less than a week.
I feel like Gawande’s article gave health care consumers a free pass on their role in escalating health care costs. They are a significant part of this “over-utilization culture.” Sure, ultimately, physicians are the ones who do the procedures or order the tests, but we all get bombarded by patient demands to order a certain test or prescribe the more expensive drug or choose the surgical rather than medical management option. And, if we don’t order the test, someone else will or if something happens where the patient actually has a problem, we get sued because we didn’t order the test they demanded. The article was well-written with very good points about overutilization of the health care system, but it lay too much of the blame on physicians.