Doctor: We have a correct diagnosis of your problem. We don’t need a CT scan, an MRI or more blood labs. Your illness, though it sounds serious, is like a slow-moving turtle. No procedure we perform, though some are available, will slow it any further. It will never bother you in your lifetime.
Patient: That’s great. Goodbye.
This conversation doesn’t occur, says Atul Gawande, a surgeon and author of best-selling Being Mortal (Henry Holt, 2014). Doctors are “far more concerned about doing too little than doing too much,” he writes in The New Yorker (5/11/15). Plus, they are in a huge system premised on fee-per-service which motors a doctor’s ability to pay her office rent, her staff, her insurance and her children’s college bills. In addition some doctors have a financial interest in a lab or other supporting agency. But patients are in the mix too. We “like to believe that, as with most things, more is better,” says Gawande.
Drawing upon Less Medicine More Health by Gilbert Welch (Beacon Press, 2015), Gawande says that where medicine is concerned more tests and more procedures may actually be worse. In any case, the primary cause of extreme health care delivery costs is, in his argument, simply the across-the-board overuse of medicine.
In 2009 Gawande looked into the situation in McAllen, TX where costs were particularly high. Granted, the insurance system rewards doctors everywhere “for quantity of care.” But a nearby city with the same demographics “had half the per-capita Medicare costs and the same or better results.” In McAllen doctors fell into the expensive habits of “a profit-maximizing medical culture.” Also, a large number of doctors there owned stakes in agencies, centers and hospitals. (The New Yorker, 6/1/09)
Subsequent to his 2009 expose and post-Affordable Care Act, Gawande returns to McAllen.
Crunching the stats Gawande finds that the “cost of a Medicare patient has flattened across the country,” particularly in McAllen. TV and newspapers there followed-up on his 2009 investigation and “federal prosecutions cracked down on outright fraud.” Conscientious doctors, after a staff or small group discussion, changed their routines.
Gawande is now able to identify the most likely reform agent. It is not the government and its unending reporting requirements. It is not insurance companies exactly. Nor, surprisingly, is it chiefly top surgeons and specialists. It is “primary-care doctors who don’t even seem to recognize the impact of what they’ve been doing,” but who are open to collective thought and action on behalf of their calling.
Some McAllen doctors have joined Well Med. It is a San Antonio-based buffer company standing between the primary physician and the insurance entities, Medicaid, Medicare and private. It rewards the doctor for quality care, not simply for ordering lots of tests. A private insurance company, let’s say, negotiates with a business: “This special employee policy will cost less if your workers use a Well Med doctor.” The insurance company sends reimbursement to Well Med—presuming goals are met. Well Med settles up with the doctor, who can even get a bonus.
Now, patients are not happy if a doctor sweeps them out the door. Well Med (and other similar companies) require doctors to teach patients: why this pill is taken in these intervals, why the nurse or assistant wants results of your home testing when she calls tomorrow, and more. In one example the doctor spent 45 minutes with a diabetic patient, followed by another 45 minutes with his certified assistant. And that doctor still makes money. About 20% of Medicare patients now see a doctor who is paid through one or another buffer company. And there are other models by which primary physicians write fewer lab orders and other procedures.
Gawande admits that there is a “point where conservative care becomes inadequate care.” The caution is balanced against “an entire health-care system [that] has been devoted to this game” of running up costs through unnecessary tests and procedures.
There is a vocation crisis among health care professionals. One worker alone can do little to reform institutions. The potential resides in solidarity. Is there a role for church entities, including religiously sponsored hospitals, in convening conversations among doctors and others about their vocation?
Droel edits INITIATIVES (PO Box 291102, Chicago, IL 60629), the National Center for the Laity’s newsletter on faith and work.
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