Atul Gawande: The Cost Conundrum Redux
Gawande answers many of his critics, but I wonder if we really understand the issues. As I look over his many tables – this response is much more academic than the original article – I see that the most expensive community is also the most “under doctored.”
I wonder whether McAllen has many family physicians or general internists. I would bet not.
Adequate primary care (using the IOM definition) decreases unnecessary health care costs. Having less physicians in the community does not necessarily decrease health care costs.
Clearly there are many reasons for high health care costs. The most important health care reform that would help is re-aligning the incentives for physicians, because we do create many health care costs.
Important and interesting read.
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I think that Dr. Centor has it exactly right. There is no primary care and no cognitive infrastructure in Hidalgo County. The tables of Dr. Gawande in the new piece may support that.
I have seen the same syndrome in inner city NY. Patients get little in primary care. The population is not healthy. But once they get diabetes mellitus or HIV/AIDS etc the spigots of care do not stop. This is expensive care with poor results.
Medicaid mills feed the problem since harrassed MDs simply send cases to ERs where specialists find them.
If one looked at population segments in NYC that demographically are similar to the resident of Hidalgo County you would find some of the same kind of patterns.
Maybe not as extreme but there.
Hidalgo County has no institution of higher learning than a high school.
Primary care and health care reform means educating doctors at Harvard to serve such counties in TX, NM, AK, and inner city Detroit. We are very far from that.
Bohdan A. Oryshkevich, MD, MPH
In my area a univeristy-sponsored residency combined with a health care foundation is the only entity willing to see new medicaid patients. They receive grants and the doctors brag that well child visits are reimbursed higher than private insurance plans, once the grants for seeing underserve people in bulk come in.
These same people have doctors assigned for outpatient only and inpatient only medicine and maintain their priviliges at only one local hospital. At least half the Medicaid plans have moved to a capitated rate and trying to assigne a primary care doctor. The problem is the patients use the other hospital, where the residency doctors do not have privileges. The rest of us have to take care of these patients when assigned on call, often for free.
For the private doctors, a Medicaid 15 minute visit pays around $32, with $2 coming from the patient as a copayment. For most doctors, this does not even meet overhead.
The only way a public plan will succeed in the US is with fair fees and incentives for preventive medicine. Medicare is the closest thing to a successful government plan, and Medicare is running out of money.
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