An article by Atul Gawande, MD, in a recent issue of The New Yorker magazine caught my eye. In it he was describing his journey through several Texas towns in search of an explanation for the long-appreciated regional variations in Medicare expenditures1. He was specifically interested in why it was that annual per capita Medicare costs in the town of McAllen in Hidalgo County were over $15,000, while those in El Paso county, just 800 miles away, were $7,504. His quest compelled him to speak to many physicians and administrators, as well as to understand regional health statistics. Going through many potential explanations for this disparity, and rejecting each in turn after subjecting it to an intellectually rigorous evaluation, he concluded that in large part these disparities are driven by local healthcare providers’ attitudes towards the practice of medicine. That is, he discovered an inverse relationship between costs and whether the culture in the medical community was more concerned with the patients’ needs rather than with maximizing revenue. With this stroke of his pen, Dr. Gawande opened wide a window on a dirty little secret: the responsibility of individual practitioners in the escalating costs of healthcare in America.
It may be easy to dismiss this idea as an aberration, a few bad apples spoiling everyone’s reputation. It is more difficult to do this in light of the findings by the Dartmouth group, who for years have been reporting vast differences in per capita Medicare spending in different parts of the US, spending that is not commensurate either with worse underlying population health or with better health outcomes. To be sure, Gawande’s theory is not a surprise to anyone who has experienced private practice and has come in contact with the full spectrum of physicians – from those committed to doing what is in the best interest of the patient to ones committed to maximizing their profit. It is neither cynical nor far-fetched to posit that the increasing demands and diminishing returns, both financial and in professional satisfaction, in the race to commodify medicine may drive doctors to prioritize their bottom line above patient care, either implicitly or explicitly. Why not, in a system that financially rewards doing more rather than doing better?
It also becomes more difficult to write off this behavior as an exception when viewing it in the context of the social and political history of our profession. American medicine developed through a series of power struggles and coups worthy of a pulp novel. Early physicians had little political muscle and even less education to distinguish themselves from traditional healers and outright quacks. Yet through formal organizing into exclusive medical societies and by eventually establishing strict licensing rules, they were able to seize enough power to increase their market share of healthcare delivery. During the Industrial Revolution, a heightened emphasis on medical education, better hygiene in hospitals, development of transportation and the change from home- to factory-based business model resulted in moving most of healthcare provision from the home into the office and the hospital. In this way doctors were able to increase their incomes by increasing their daily throughput dramatically: instead of traveling far and wide to visit the ailing, they could see them in the office, an indisputable improvement in efficiency. Over the next century many battles over healthcare financing and access would ensue and persist until today, in which, to use the words of Princeton University Professor Paul Starr from his Pulitzer Prize-winning book The Social Transformation of American Medicine, the “search for efficiency conflicted with the doctors’ defense of their income and autonomy”2.
The conclusion is inevitable: physicians too have had a part in driving up costs of care in the US. While we are willing to admit to our charming penchant for ignoring evidence, and to some misguided inclination among few in our ranks to lie by omission about their support dollars, we rarely see this admission of fiscal guilt in our scholarly journals. What we do see is a massive effort to deflect attention away from our bad behavior to the ills perpetrated by others. The inevitable villains in this formula are the manufacturers of drugs and devices, as well as insurance companies and lawyers. Since I have done a lot of work over the years in partnership with manufacturers, I am well aware of the diverse motivations among their employees. Much like the attitudes of physicians, the ethos within pharmaceutical and device companies ranges from dogged dedication to the well being of the patient to unbridled profit motive. As for the insurance industry, I have traditionally been eager to expose their dirty underbelly. It is in this spirit that I read the recent report from the WellPoint Institute indicating that only 3 cents of every health insurance dollar represents profit3. It is of interest that an average net profit margin for consumer goods (that is all the stuff we as consumers purchase) is 6.57%4, putting the insurance company profits well below this number. At first, I was tempted to discard these data as industry propaganda. But upon dutifully reading the report and then reflecting on it in light of Dr. Gawande’s article, I began to overcome my anti-insurer bias in favor of starting the difficult task of recognition through self-reflection.
What is the over-arching point here? Physicians are human. To admit this does not in any way take away from the selfless dedication of large numbers of doctors to their patients, even, as we were grimly reminded recently by the cold-blooded murder of Dr. Tiller, at the expense of their lives. No one group is innocent; all parties in our healthcare quagmire have been responsible in some way for getting us here. To blame only someone other than self is counterproductive and disingenuous, as is focusing singularly and selfishly on interests of one’s own stakeholder group. We owe it to our patients and the society to come together, all of us, armed with the emotional maturity and political will to listen to each other’s concerns and to promote a culture of cooperation. The conversation, likely to take place in shades of gray, reflecting the topic’s complexity, has to start today and continue until solutions are found whose goal is not merely to appease every participant, but to provide a comprehensive roadmap to developing what may deserve to be called the greatest healthcare system in the world.
1. Atul Gawande. The Cost Conundrum. The New Yorker, June 1, 2009. Available at http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all, accessed June 4, 2009
2. Paul Starr. The Social Transformation of American Medicine. Basic Books, A Member of The Perseus Books Group; 1982:247
3. WellPoint Institute of Healthcare Knowledge. What’s really driving the increase in health care premiums? Available at http://www.wellpoint.com/pdf/Premium%20Cost%20Drivers.pdf, accessed June 4, 2009
4. Yahoo finance. Available at http://biz.yahoo.com/p/3qpmd.html, accessed June 4, 2009