In the June 1st issue of The New Yorker, Atul Gawande writes about the practice of medicine in McAllen Texas. Why McAllen? It is one of the most expensive health care markets in the country; only Miami is costlier. McAllen is a much poorer community. His measure, and it is a standard one, is medicare dollars per enrollee. In this post I will repeat several of Gawande’s points, but I urge my readers to read the whole article.
One reason the people of McAllen suggest for this anomaly is that theirs is an unhealthy community. Despite its high obesity rate, its high rate of heavy drinking, and its poverty, it has lower than average cardiovascular disease rates, and low incidents of asthma, H.I.V., infant mortality, cancer, and injury. In short if one judges by the statistics McAllen is a realitively heathy place.
Gawande develops his argument carefully through a series of interviews, references to statistics and and his own experience as a doctor. In a short post I need to skip to his conclusions. He finds that in McAllen and other high cost areas order more tests, operate more frequently, refer to other specialist more often. He also finds that doctors there are entrepreneurs; they own imaging centers, ultrasound machines, or serve as medical directors at nursing homes.
Gawande contrasts these practices to low cost areas. One of them Rochester Minnesota is dominated by the Mayo clinic which pays it’s doctors a good salary, but does not allow them to participate in the ownership of the auxillary services. As a result fewer tests and scans are ordered and the patients needs predominate. Several other cities are discussed with similar conclusions.
Respect for the common health means that we must pay doctors well, but prevent them from developing multiple streams of medical income. In fairness, we will also have to do something about the cost of medical education. A new doctor may begin practice so far in debt that he cannot afford not to be an entrepreneur. As Bernard Shaw says, ” That any sane nation having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.”