Dr. Atul Gawande provided a chilling description of the problems facing true health reform in his recent article in The New Yorker. In "The Cost Conundrum" he describes how medical care is provided in McAllen, Texas, which is second only to Miami as the most expensive healthcare market in the country. McAllen's expenditures are twice as high per person as in El Paso, Texas, a city with similar demographics.
There are no good reasons for the differences. McAllen's population isn't demonstrably sicker and the care isn't measurably greater. Hospital heads and average citizens weren't able to explain the city's dubious distinction. But it's easy to see how the medical care environment in El Paso will become like McAllen's. If that happens, the nation's cost problems will worsen.
Taking Theories into Practice
In areas like McAllen there seems to be a more than necessary use of tests, procedures and admissions than in towns like El Paso.
One way to reverse this cost increasing tide is to foster a better relationship between primary care physicians and their patients. Research has shown that more access to, and time with, primary care physicians can lead to better management of chronic illness and less interventional work and costs.
We also need to redistribute resources from the well-intentioned, but test-dependent, interventionists to primary care and ambulatory-based clinicians. The overuse of interventional services often occurs because ongoing care by ambulatory physicians is under-compensated. To address that problem, we need to redirect patients toward those physicians who provide high quality care at lower overall cost -- often by spending more of their own time and making more judicious referrals.
Interventionists should collaborate with the facility where they do most of their work. They could create partnerships built from voluntary associations of a facility like a hospital and those physicians whose work depends on access to that facility. It would include not just the radiologists, anesthesiologists and pathologists, but also surgeons, interventional cardiologists, and the hospitalists who provide the daily monitoring of patients.
The team would specifically exclude the office-based physicians who are largely responsible for the ongoing treatment of patients who may need to be admitted. Additionally, it need not include all eligible physicians at the hospital. Bringing the whole medical staff to the table for negotiations will prolong making key decisions. The hospital, however, must allow physicians who opt out of team membership to practice there as long as they meet other established staff requirements.
The key is that the team takes responsibility for an entire episode of care at a fixed price -- whether or not its members provide all of the related services.
A comprehensive realignment of the payment system can accomplish this, but that's something we must work toward. To get there we can use a voluntary major risk pool covering all hospitalizations and chronic illness. This coverage will not be sold to individuals, but to insurers who wish to purchase coverage. This will make them have no need to underwrite insurance policies or design them to be unattractive to people with significant health problems.
McAllen and El Paso are almost 800 miles apart -- a long day's drive. If we truly want to move away from the McAllen model, we need to chart and plan the right course. Building on the self-interest of the players, we can encourage the voluntary changes needed to reform the system. Without reining in costs and restructuring the incentives, we'll never get to where we need to go.
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