Wednesday, May 27, 2009

"Why healthcare costs so much"

Andrew Sullivan has a series of blog posts, Why healthcare costs so much, in which various blind men describe their part of the elephant. Atul Gawande, writing in the current New Yorker, has the answer -- beyond a shadow of a doubt:
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of co√∂rdination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.
Gawande focuses on McAllen, Texas, a poor community that is one of the most expensive healthcare markets in the country. In McAllen, he learns, an "entreprenuerial spirit" has become the dominant culture among doctors:

One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.

“Medicine has become a pig trough here,” he muttered.

Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.

The antidote, unfortunately, is not readily apparent. Creating the right incentives -- or unwinding the wrong ones -- is complicated. Some institutions have done so by creating systems in which doctors essentially oversee each other and the institution holds itself collectively responsible for outcomes. Some, like the Mayo clinic, produce excellent outcomes at low cost. But how to replicate their successful cultures is not yet clear:
McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering....

This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities.

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