McAllen's Medical Care Pig Trough

A front page article in today's NY Times exposes the anti-reform campaign by Doctors Hospital at Renaissance in McAllen, Texas. The Democratic Senatorial Campaign Committee collected nearly $500 thousand, mostly from doctors and others affiliated from the big for-profit hospital in Edinburgh, adjacent to McAllen. Another event sponsored in 2007 by prominent McAllen developer, Alonzo Cantu raised $800,000 for the Democratic House Campaign Committee. House Speaker, Nancy Pelosi attended this fund raiser and cut the ribbon at at the hospital's new women's center at the hospital. Cantu is an investor in the for-profit hospital and a member of its board of directors.

I was inspired to create this Hub by an article in this week's New Yorker by Dr. Atul Gawande, a professor of surgery at Harvard Medical School, and by his appearance today on NPR's "On Point." Dr. Gawande is one of the brightest and most articulate authorities on health care issues in this country.

Dr. Gawande went to McAllen, Texas, where Medicare costs are $15,000 per year per person which is double the national average and triple the cost in other communities and at places like the Mayo Clinic in Minnesota where, in contrast to McCallen where the profit-seeking medicine is the rule, physicians are on salary.

In McAllen doctors own some of the hospitals and profit handsomely from unnecessary surgery, tests and procedures. Other doctors brazenly demand payments from hospitals for referring their patients. These demands for payments reportedly ranged from $100,000 to $500,000 per year. Other physicians own imaging centers and other test facilities which give them an incentive to order unnecessary and costly tests. One medical student called in to On Point with an anecdote about a doctor who ordered that a colonoscopy be performed on a terminally ill patient. This examination served no purpose other than to increase medical facility's revenue.

According to Dr. Gawande there is currently a battle in health between profit seeking medicine which emphasizes quantity of care over quality of care and traditional patient centered medicine. According to Dr. Gawande, profit centered medicine does not produce better results for patients because of complications resulting from unnecessary diagnostic examinations and surgery. He cited gall bladder attacks which routinely result in unnecessary surgery in some medical venues in contrast to other hospitals surgery is deemed necessary in only 8 percent of gall bladder attacks.

A caller to On Point argued that medical malpractice lawsuits are partly responsible for the excessive costs in McAllen. Dr. Gawande replied that the doctors with whom he spoke told him that malpractice lawsuits had declined greatly as a result of a Texas law capping medical malpractice judgments at $250,000. Gawande didn't deny that malpractice judgments are a factor. However, in his opinion, for profit medicine is the major driver of excessive health care costs in McAllen and other communities, not malpractice judgments and insurance costs.

Dr. Gawande recounted a conversation over dinner with six McAllen doctors. Some of them expressed surprise when Gawande pointed out that in 1992, the average cost per individual in McAllen was $4,891, almost exactly the same as the national average, but by 2008 costs had increased by nearly $10,000 to nearly double the national average and double the cost in El Paso, a similar border community. Gawande gave the McAllen doctors the Medicare cost data for McAllen which showed that McAllen patients got more of nearly everything, more diagnostic testing, more hospital treatment, more surgery, more home care as follows:

--almost 50 % more specialist visits;

-two-thirds more likely to ten or more specialists in a six-month period;

-20% more abdominal ultrasounds;

-30% more bone-density studies;

-60 percent more stress tests with echocardiography;

-200% more nerve-conduction studies to diagnose carpal-tunnel syndrome;

-550% more urine-flow studies;

-1/5th to 2/3rds more gall bladder operations, knee replacements, breast biopsies and bladder scopes;

-2-3 times as many pacemakers, implantable defibrillators, cardiac bypass operations, carotid endarterectomies, and coronary artery stents; and

--Medicare paid for five times as many home-nurse visits.

One of the six doctors said, "Maybe the service is better here." Another attributed the disparity to "malpractice." "McAllen is a legal hell," a cardiologist agreed. Everyone thought the lawyers in McAllen were worse than elsewhere. This puzzled Gawande because several years ago Texas passed a law capping pain and suffering awards at $250,000. He asked, "Didn't the lawsuits decrease?" "Practically to zero, " the cardiologist admitted whereupon the general surgeon finally said, "We all know these arguments are bullshit. There is overutilization here, pure and simple." Doctors, he said were racking up charges with extra tests, services and procedures.

According to Dr. Gawande, there is currently a battle going on between what he calls traditional patient-centered medical care and profit-centered health care as he found to be the case in McAllen where doctors own for profit hospitals, imaging centers and other medical facilities and base their decisions too often on their own financial interest rather than what's best for the patients. In one sense his conclusion provides hope because there is plenty of room to reduce or stem the increase in health care costs. This will require action to reduce over-utilization costs whatever form Obama's health care reform program takes. Curbing over-utilization will not be easy for Medicare, for a universal single-payer system or for private, for-profit health care insurance companies. But the opportunity for huge savings is there and must be tackled without delay.

I URGE EVERYONE TO READ THE ARTICLE BY DR. GAWANDE LINKED BELOW.

Editorial NEW YORK TIMES

Doctors and the Cost of Care

Pubblished: June 13, 2009

As the debate over health care reform unfolds, policy makers and the public need to focus more attention on doctors and the huge role they play in determining the cost of medical care — costs that are rising relentlessly.

Skip to next paragraph

Related

Times Topics: Health Care Reform

Doctors largely decide what medical or surgical treatments are needed, whether it will be delivered in a hospital, what tests will be performed, and what drugs will be prescribed or medical devices implanted.

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.

All Americans are affected. Those with insurance are struggling to pay ever higher premiums, as are their employers. If the government is going to help subsidize coverage for the millions of uninsured, it will need to find significant savings in Medicare spending, at least some of which should come from reducing over-treatment. In the long run, if doctors can’t be induced to rein themselves in, there is little hope of lasting reform.

A glaring example of profligate physician behavior was described by Atul Gawande in the June 1 issue of The New Yorker. (His article has become must reading at the White House.) Dr. Gawande, a Harvard-affiliated surgeon and author, traveled to McAllen, Texas, to find out why Medicare spends more per beneficiary there than in any other city except Miami.

None of the usual rationalizations put forth by doctors held up. The population, though poor, is not sicker than average; the quality of care people get is not superior. Malpractice suits have practically disappeared due to a tough state malpractice law, leaving no rationale for defensive medicine. The reason for McAllen’s soaring costs, some doctors finally admitted, is over-treatment. Doctors perform extra tests, surgeries and other procedures to increase their incomes.

Dr. Gawande’s reporting tracks pioneering studies by researchers at Dartmouth into the reasons for large regional and institutional variations in Medicare costs. Why should medical care in Miami or McAllen be far more expensive than in San Francisco? Why should care provided at the U.C.L.A. medical center be far more costly than care at the renowned Mayo Clinic?

After adjusting for differences in health, income, medical price and other factors, the Dartmouth researchers’ overall conclusion is that the more costly areas and institutions provide a lot more tests, services and intensive hospital-based care than the lower cost centers. Yet their patients fare no better and often fare worse because they suffer from the over-treatment.

The Dartmouth group estimates that up to 30 percent of Medicare spending is wasted on needless care.

Although most experts think the Dartmouth research is essentially right, a few believe that other factors, including the health of individual patients, play a bigger role. Even if the over-treatment is less than the Dartmouth researchers believe, their findings point to areas and institutions where Medicare should be able to coax or push physicians to behave more prudently, for all their patients.

When President Obama speaks at the annual meeting of the American Medical Association on Monday he will need all of his persuasive powers to bring doctors into the campaign for health care reform. Doctors have been complicit in driving up health care costs. They need to become part of the solution.