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Debates over health care are heating up. Framed in terms of reforming the payer system, President Obama is putting forth a government-sponsored health plan. Not everyone is pleaed with his proposal, but everyone says that the patient is their #1 concern! We spend over 15% of our economy on health care. In “The Last Conundrum,” Atul Gawande, a surgeon and staff writer for The New Yorker, writes about why we have the most expensive care in the world, and its cost to patients….

I don’t want to go into the details of the debate here (find a good summary in the NYT). Using Gawande’s article, I want to draw attention to our fragmented and comparmentalized approaches to policy-making and three larger lessons I want to draw from the article that I think we can use to deepen discussions of health care and its reform.

  1. The McAllen (TX) model isn’t the only model or the inevitable national system…yet.
  2. The author challenges us to look at the entire system of health care—not just the public or private insurance debate. I might not go so far, but I do agree that we need to look at the whole system: the infrastructure, the culture, and practices in which providers work today.
  3. For those who make the arguments that high tech solutions are always better, we need to challenge them more, and we can start, perhaps as Dr. Lester Dyke (below) does, by asking and answering the questions, for whom does it serve to implement new technologies?

Gawande contrasts health care infrastructure and practices in U.S. locations with the highest healthcare cost per patient (e.g. McAllen, TX) and those with the lowest (e.g. Rochester, MN—home to the Mayo Clinic). Where McAllen spends about $15,000 per patient, Rochester spends about $7,000. Of course, the kicker is that Rochester may be spending less and providing less, but patients and doctors are not losing out.

In visiting McAllen, the author describes state-of-the-art facilities and its doctors and hospital managers tell him that their patients get only the most advanced health care. They also get more of everything: doctor visits and follow-up, surgery, and tests. However, one of the few doctors in McAllen openly critical of the McAllen model for a health care system—Dyke—describes it as turning doctors into businessmen, noting how many of its doctors own bio-imaging centers and even strip malls.

His is surely part of the McAllen story—not too many Rochester doctors are buying strip malls but Gawande frames his story of the battle over the future of the American health care system within a culture of ‘more is better’ that is increasingly dominating our imagination of health care’s future. Another slightly different, but overlapping, way to read his story of the American health care system is within our dominant culture of the techno-euphoria in which high-tech solutions are always the better ones.

Some may be surprised, but Gawande doesn’t find that this means their health outcomes are better. Contrasting the popular McAllen health care system with the less popular Mayo Clinic model, which could be characterized as privileging teamwork, coordination, and less revenue seeking, and perhaps less intentionally, following “appropriate use of technologies” and minimalist intervention, he finds that their patients do just as well—if not better—and doctors are less needlessly busy.

While patients should be top priority, reform won’t happen if provider practices and the conditions of the system that are pivotal in helping to define both patients and providers are not simultaneously addressed.

Posted In: Policy

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