Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.
-Atul Gawande, MD
In response to my last blog entry, a colleague who returned recently from six months working in hospitals and clinics in Rwanda and Cameroon asked for resources on “different perspectives on the current politics and changes in health-care.” I am a novice in policy; every time I read a new editorial or column that proposes how to best pay for health care yet keep the costs under control, I am swayed. It seems that many commentators say something that seems to make sense to me.
But, what is the heart of the matter? What fundamentally needs to change in order to reform health care?
In a recent article in the The New Yorker, surgeon-writer Atul Gawande, MD helped me understand the issues in a fresh way. Here is an analogy that he uses to describe the current healthcare situation in much of the country:
"Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country's best electrician on the job (he trained at Harvard, somebody tells you) isn't going to solve this problem."
So what does Dr. Gawande seem to suggest?
First, we need to develop a team approach to medical care. He details the differences between market-driven, free-wheeling healthcare communities like McAllen, Texas, integrated systems like the Mayo Clinic and smaller, partially integrated communities like Grand Junction, Colo. Team care is less expensive and built around evidence.
Second, we need to understand culturally that more health care does not translate to better health care. Some communities seem to value quality medical care and some seem to reward "quantity" care — more tests, more bills, more frequent exams, more procedures. The people who control the number and types of tests (the doctors) don't usually see the impact of their prescribing patterns on the bigger picture. For example, McAllen, Texas, has no better and, in many ways, even worse outcomes than much-lower cost towns. Interestingly, the McAllen physicians with whom Dr. Gawande spoke had no idea that that their community’s health care was extraordinarily expensive nor did the physicians know why that was the case.
Third, in many places, no one, neither the government, the insurers, the physicians, nor the patients has any role in overseeing the entire system of care for the community of patients. As he says, "Someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes."
Finally, and potentially most important, Dr. Gawande shows us that HOW we pay for medical care will ultimately be less important than having a "culture of medicine" that is, above all, consistently ethical. If every test or procedure directly benefits the person who orders it, there is too much temptation.
I still don’t know much about policy, but Dr. Gawande’s house-building analogy makes sense to me. I have seen medical care that concentrates on the fancy decorative embellishments and ignores the foundation. We have a lot of work ahead of us
