Annals of Medicine: The Cost Conundrum: newyorker.com

Annals of Medicine: The Cost Conundrum: newyorker.com

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Atul Gawande, author of the very popular medical books Better and Complications, has just published an article in the New Yorker that explores the rising costs in US health care. Dr. Gawande suggests that the culture of a local medical community can cause a dramatic difference in the cost of care for each patient per year. This article stated some strong facts supporting an inverse relationship between the money spent per patient and the quality of care one receives. This idea makes sense when considering the risks associated with the medical procedures that cause higher costs.

It was surprising that Dr. Gawande's hosts in the various hospitals he visited were mostly unaware of the per patient expenditure of their hospital as compared to that of the national average. Why is Medicare and Medicaid, two government sponsored agencies, not monitoring this more closely?

The article emphasizes the role of the entrepreneurial spirit that is nurtured in some locations, such as McAllen, Texas and is discouraged in others, such as the Mayo Clinic, Minnesota. It seems that doctors should be salaried, so that in no way do their procedures correlate with total income.

Various clinics in the country show that there is a better model to guide doctors. The leaders need to focus the physicians in the community on patient well being and remove per procedure monetary return. However, this concept of care over finance should start in the formative years of a physicians life: Medical School. The application process for medical school is simply too expensive for a college student ($3000-$5000 per application cycle when considering AMCAS, secondary fees and school visits). Most medical students graduate with $200k in loans. Therefore, it is very difficult for professors to instill a disconnect between clinical care and monetary incentive when the student is burdened severely by their monetary obligations.

The government spends almost $400 billion on Medicare and $275 billion on Medicaid per year. There are about 130 accredited medical schools in the US with on average 140 students in each class (560 total at each school). It would cost the US (130 x 560 x 40,000) just under 3 billion dollars (assuming each school costs 40 thousand per year) to offer every accepted student a free medical school education. This is 0.3% of the cost of government provided health care. If the country wants to make a real investment to have cost conscious physicians in the 21st century, removing the monetary pressure from graduating students is an interesting place to start.

Separately, there are other issues that should be considered when discussing health care. Many private physicians outsource their billing services to private companies that have expertise in diagnostic and billing codes. These billing companies receive payment as a percentage of money received from the insurance companies. They, therefore, have an incentive to encourage billing for the highest possible amounts. Therefore, even a well meaning doctor looses some autonomy over costs when utilizing a service that is so focused on maximizing the profit per patient visit.

Health care dialogue is confusing and often convoluted with biased statistics. Insurance companies tend to be demonized as greedy corporations that often refuse to cover vital services to save costs whenever possible. Yet Dr. Gawande moves the dialogue towards the role physicians have in health care's rising costs. The hardest part for physicians, I think, is connecting the check received from Medicare or Blue Cross Blue Shield with the national economy.

The idea of creating an ethical clinical community is an excellent one. We should address the attitudes of practicing doctors, but maybe an investment in the consciousness of medical students would be the wisest change of all.

A joke at every end:

A guy walks into a doctors office with pain in his leg.
The doctor performs some tests and tells the man that he
has a fracture and will need a cast for three months.
The man freaks out and starts yelling,
"oh no this can't be, I want a second opinion!"
"Ok," says the doctor. "You're ugly too!"