Sometimes the answer to a puzzle is simple enough, but rejected because it isn’t what the questioner wants to hear. Why are health care costs spiraling out of control? Looking at McAllen, Texas, where the average annual Medicare expense for each person enrolled is twice the national average, the answer is simple, but who wants to hear it?
Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three 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.
The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
Fifteen years ago, the cost per Medicare patient was exactly the national average. What changed?
“Come on,” the general surgeon finally said. “We all know these arguments are [nonsense]. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”
Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.
What the surgeon means by “young doctors don’t think anymore” is that they do not make direct diagnoses anymore, relying instead on the results of extensive testing. I’ve heard exactly the same thing from Roger Murrell, our pastor who is also an emergency room nurse.
Depending on test results allows a doctor to distance himself from responsibility for prescribing a particular treatment; the course of treatment is dictated by the test results, not the doctor’s personal judgment. It also is a lucrative path for a doctor to follow.
The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.
Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.
This approach has become standard operating procedure in McAllen, known thoroughly by all doctors in the vicinity whether or not they follow it themselves. It isn’t difficult for a group of doctors to predict exactly what expensive, unneeded procedures will occur in response to a common situation.
I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?
Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.
And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.
“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.
The journalist repeatedly returns to the question: why do some cities have high medical costs, while others are much lower? There seems to be a divide in how inclined a physician is to order expensive procedures in certain situations.
The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.
The journalist also asks the same question in a different way: why are costs in El Paso, a city very much like McAllen, so much lower?
There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.
“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.
He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.
This, I think, is the key to understanding the situation. Doctoring used to be something else, and some doctors behave as if things were as they used to be. But doctoring has now become business, big business, and there is little or nothing in how we view medicine today that can incline a doctor to stand apart from business pressures and continue to doctor in the old way.
From the modern point of view, the old-fashioned doctor is a fool. More important, the modern system makes it increasingly difficult for the old-fashioned doctor to provide his service in an old-fashioned way. The expectations of patients, the threat of lawsuits, the expense of getting licensed, the business-minded outlook of the hospitals and testing laboratories and specialists he must de
al with, all these exert a tremendous pressure on an old-fashioned doctor to get in step with the new way of doing things.
Is there any possibility of modifying the existing system to re-introduce the old-fashioned attitude towards doctoring while still retaining the benefits of modernity? I doubt it. The journalist thinks otherwise, and presents the Mayo Clinic model as a hopeful possibility.
The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.
I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.
The story of the Mayo Clinic model is an encouraging one, and it’s worth reading what the writer says and weighing the possibility that it might spread. I am skeptical, but that is just an opinion, based on the idea that McAllen seems to more closely exemplify the peculiar brands of wickedness that flourish in this modern world.
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.
Five years ago, when the living was easy and the cotton was high, who would have objected to the idea of doctors becoming businessmen? I think that they would have been admired for their cleverness and upwardly spiraling incomes.
In fact, the exact same businesslike approach that got us into this quagmire is often championed as a possible way out.
The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”
He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing?
Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”
Sheep and wolves. Exactly. Medicine used to work, sort of, because doctors were not wolf-like. Not that they were a nobler strain of human; in fact, I think that because until the 20th century their range of operation was so limited that they were able to imagine their important but marginal role in the community as a noble, selfless pursuit. That imagined nobility had some momentum, and acted as a counter-pressure as medicine became increasingly powerful and invasive. But I think the nobility has largely evaporated at this point, and the rest will be gone shortly.