Reverb Consulting

Reform of the American health care system is the center of media attention and political debate in our country today.  President Obama recently proclaimed that the greatest threat to the fiscal health of America is the cost of health care.  The aim of health care reform is to extend medical coverage to all and bring costs under control.   With the premium for my family health insurance plan up 58.8% from two years ago when I last raised my deductible, it is the center of my attention as well. I read that around the White House that a “must read” is Atul Gawande’s recent article in the June 1, 2009 issue of The New Yorker:  The Cost Conundrum, What a Texas town can teach us about health care. Not that every “must read” at the White House is a “must read” at my house, I did take the time to read Gawande’s article.

In hopes that it might lead to some clue as to a solution for our national health care crisis, Gawande traveled to McAllen, Texas in search of an answer to why Medicare expenditures there are twice the national average.  He disproves several suggested explanations including that the quality of health care in McAllen is better.  In fact, he sights research that there is no correlation between money spent and the quality of service received.  He does place blame, however, on the fact that in McAllen there is overuse of medical care.

When Gawande asked leaders in the McAllen medical community to explain the high cost and overuse of medical care in their community, they couldn’t.  While they could defend McAllen reflexively, they really didn’t know the big picture of what was happening in the health care arena.  He realized that it wasn’t their responsibility to understand the big picture.  No one had that responsibility.  Health care costs ultimately arise from the accumulation of individual decisions that doctors make.  In cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum.   Where doctors fall on this continuum, according to Gawande, depends on where they came from. Why?  The culture of money.  Different places have a different dominate culture of money.  The culture of money in the McAllen medical community is one where each patient are treated as a profit center.

There is much incentive for every community in America to be like McAllen, Texas.  Why are they not all this way?  Gawande suggests a answer by highlighting Mayo Clinic and a few other situations where highest quality is coupled with low costs.  The core tenet at Mayo is ‘the needs of the patient come first’.  The needs of the patient come before the convenience or the revenue of the doctor.  Mayo has a collaborative way of practicing medicine.  The aim is to raise quality and to help doctors and staff work together as a team.  Doctors take time to interact listen and discuss.  They collaborate on cases.  At Mayo doctors are not silos.  A side effect of this is that costs are lower.

Gawande opines that a war for the soul of American health care is being waged all over the country and it centers on one question:  is the doctor set up to meet the needs of the patient or to maximize profits?  While he believes that there is not an insurance system that makes the two aims match perfectly, one that does so much to mis-align them as our current system is disastrous.  In America, doctors are paid for quantity not quality.  They are paid as individuals rather than as members of a team working together for patients.  There is no one accountable for the totality of care.

To successfully reform our health care system, someone must take responsibility for the totality of care.  There must be collaboration to increase prevention and the quality of the care.

There are a number of themes that are revealed in Gawande’s article.  These themes can be a lesson for anyone without regard to their specific industry:

Money spent and results obtained do not always correlate.

Choose quality not quantity.

Collaborate; silos can be costly.

Teamwork is powerful.

An ounce of prevention is worth a pound of cure.

I challenge you to read Gawande’s article with an eye to what you can glean that can be applied to your own work.