Cash, Culture, and Health Care Delivery
You really have to go read Atul Gawande’s article on health care in the new New Yorker. Not only does it make some vital policy points, but it’s a real masterpiece of a craft of long-format feature magazine writing on a public affairs topic. To try to excerpt or reproduce it would be pointless. You should read it.
But instead of rehashing Gawande’s points, we can pick up where he leaves off. Basically, providing effective health care and thinking of health care provision as a commercial enterprise don’t seem to mix very well. I’m not sure this should strike us as all that surprising. Lots of important things—the police department, universities, art museums—can’t be provided well on a commercial basis. The role of a doctor and the role of a salesman are just too different.
Which isn’t to say that it would be realistic to start health care reform by totally overhauling the premises underlying the system. But it is to say that I suspect the kind of reforms currently being contemplated by congress are really only going to be the first steps in a substantially longer journey that we’ll have to take as a country. In addition to things being totally screwed up in terms of who gets health insurance and how and from whom, the actual delivery of health care happens in a very screwed-up way. But the common view is that it actually isn’t screwed up, and so short-term politics dictates spending a lot of time reassuring people that no terrible change for the worse is on the way in terms of delivery. Which is fine as far as it goes, since the insurance mess really does need to be cleaned up. But then there’s this other problem, where the actual practice of medicine in America, though perceived to be good, is actually extremely hit-or-miss and in some respects getting worse.
22 Responses to “Cash, Culture, and Health Care Delivery”
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May 28th, 2009 at 12:32 pm
I read the article last night when you linked to it.
I think the author at times tries to couch a very leftist message (markets are teh suck w/r/t health care) in the trappings of high Broderism: conservatives will argue for private insurance, liberals will argue for public insurance, but both will miss the innovation that’s being made by ngo’s and the genius of late-capitalist civil society.
You know, if anything effective will get done about health care delivery and cost reform, it’s going to take loud political organizing and battles. The deference to existing power structures, which the framing of this article suggests, ain’t gonna do it.
Hope that points not to meta to be relevant.
May 28th, 2009 at 12:33 pm
too meta…
damn, first post fail.
May 28th, 2009 at 12:43 pm
Maybe something in my coffee is making me knee-jerkily contrarian today, but when I read Gawande’s piece yesterday, I couldn’t really see what he was getting at. It seemed like Gawande cherry-picked a few cases to show the scope of the problem and then said, “this will all need to be addressed.” Well, thanks for pointing that out, Atul–but it’s not really new information and not really helpful, either.
May 28th, 2009 at 12:51 pm
This is off-topic, but I haven’t seen any commentary from liberal bloggers on General Casey’s statement that the US is going to be in Iraq for ten years. I have a post up with a link to the announcement and a rundown of the blogs that have ignored his announcement.
May 28th, 2009 at 12:52 pm
Doug, the only thing that will surprise most of us is if it’s ONLY 10 years.
May 28th, 2009 at 12:57 pm
James Gary,
cherry picked? wtf?
…
Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between.
…
It’s only cherry picked evidence if you know of several studies that appear to invalidate the low profit, low-cost, high quality hypothesis that you believe the author is hiding.
Either that or your confused about the literary device of using McAllen, Texas as a hook for the actual point the author is making.
May 28th, 2009 at 1:00 pm
Um – “universities”, Matt? The US private university system may not be “commercial” in precisely the same sense as Walmart is, but nor is the US private medical system. But both are equally commercial in a broader sense. Both have a strong interest in getting as many “paying customers” as possible to spend as much as possible, and advertise and run their operations accordingly.
The difference is that the US medical system is obviously a disaster, whereas the US university system has its problems, but isn’t an obvious disaster. And that is presumably related to the fact that even though going to Harvard (or wherever) slants your economic and social prospects dramatically upwards, it is possible to have a fulfilled and enjoyable life without going to university. But affordable medical care is a sine qua non for any decent quality of life for anyone.
May 28th, 2009 at 1:13 pm
While sitting here in Canada (unfortunately) smug about our imperfect but functional health-care system, I am astounded that those in the US with the power to effect change in the delivery of health-care are so obviously in the pay of forces opposed to change in your dysfunctional system.
Witness your Sen. Baucus who has received over $400,000 from the health and pharmaceutical lobbies in the past two years not only block single payer advocates from congressional hearings, but to have them arrested.
http://www.singlepayeraction.org/blog/?p=726
In any other Western democracy, such an obviously bought-and-paid-for politician would be drummed out of office.
How can you hope for change when these circumstances persist?
May 28th, 2009 at 1:22 pm
It’s only cherry picked evidence if you know of several studies that appear to invalidate the low profit, low-cost, high quality hypothesis that you believe the author is hiding.
No, my reaction was more like: “Well, then, that’s concrete evidence that deploying healthcare resources more rationally could substantially reduce the national expense of healthcare.” It seems a reasonable conclusion to draw, but Gawande–in my opinion–barely touches on the business and political realities of implementing such a decision, which I guess is why I found the piece a bit unsatisfying.
Reading your comment at #6 does clarify Gawande’s point for me. As I said above, I sort of glazed over in the details when I first read the piece.
May 28th, 2009 at 1:22 pm
Lots of important things—the police department, universities, art museums—can’t be provided well on a commercial basis.
Very good point. Conservatives talk about an increase in the public sector’s involvement in health care like it’s some radical, unprecedented assault on American values. But the fact is there are lots of areas of life we don’t leave to the market.
But it is to say that I suspect the kind of reforms currently being contemplated by congress are really only going to be the first steps in a substantially longer journey that we’ll have to take as a country.
Word. I wonder if the adoption of a public option (a feature I strongly favor, as it happens) really will lead to a quick slide toward quasi-single payer as some on the right contend, for the simple reason that many employers will find it’s a lot cheaper to to stop providing this benefit — even given the existence of an ObamaCare tax they’ll have to pay — because they’ll no longer have to provide health insurance to retain employees. Anyway, as far as I’m concerned the Canadian and French models are looking increasingly smart, and the quicker we get there the better.
May 28th, 2009 at 1:23 pm
There is no system. That is the point. There is a lot of stuff that looks similar, because it’s all just doctoring, but it works very differently based upon the structure and motivation of the participants. Gawande’s argument is that it’s possible to have a functional system of for-profit medicine, but not one of “medicine for profit”, and McAllen represents medicine for profit.
How is one to know whether the primary care doctor who refers you for a test or to a facility has a stake or a kickback or a referral fee or an exclusivity deal? Or whether having more medical stuff available or done equals better care?
I think the nub of Gawande’s argument is here:
The different ways that doctors deal with money, from the moment they qualify and contemplate their six-figure med-school debt, shapes the American Way of Healthcare.
May 28th, 2009 at 1:25 pm
chet 380:
Exactly, which is why I bristle at the perceived political complacency of this article.
May 28th, 2009 at 1:28 pm
How good a proxy for total health spending is Medicare spending? It seems like that would be pretty highly correlated with poverty in the area, which could muck things up. I know that with some of the examples (Hidalgo County vs. El Paso) they are trying to control for things like that by looking at public health variables, but this was something that was nagging at me as I read the article.
May 28th, 2009 at 1:34 pm
As Tim Armstrong said in “Cash, Culture and Violence”,
“Leave it to the coroner to detect this
And I’m sure the U.S.A. to wreck this”
In fact, that makes more sense in this context than in the song.
May 28th, 2009 at 1:58 pm
Ben:
- “State-Level Poverty Data for the Medicare Population”, The Kaiser Family Foundation, July ‘03
US Census ‘04 says native born poverty rate ~12%.
May 28th, 2009 at 2:19 pm
I thought it was a very interesting and thoughtful synopsis/analysis of Gawande’s visits and conversations across the US medical universe. I hope it gets a lot of play, discussion and consideration in the national debate on the provision and funding of health care.
I had to chuckle (in an older fellow way) at the piece being characterized as a “long-format feature.” I remember when New Yorker long format was really long!
May 28th, 2009 at 2:37 pm
It is beside the point to criticize Gawande’s article for lack of advocacy. he is reporting, not polemicizing.
And anyway, he does make a persuasive case for a very clearly defined (even if not all identical) class of solution: collegial groupings of docs and providers in a salaried system, eliminating incentives to bill or prescribe overmuch, perhaps not-for-profit but not without profit of reasonable scale for the practitioners, but definitely organized so as to make medicine less a dodge for the (one hopes minority of) doctors who are in it to get rich, and more attractive and practicable for those who want to help the hurt and sick. The docs in his exemplars (e.g., Mayo, Permanente, others) certainly make a decent living, and for sure pay back their student loans, they just don’t rival their Wall Street neighbors for granditude. and, we don’t want them to.
May 28th, 2009 at 3:17 pm
the jobs of salesman and doctor may not mix well, but one of the jobs of real professionals is to make their clients’ needs superior to their own interests. This is one of the critical differences between professionals and salespeople.
Doctors who overtreat lack professional ethics. There’s no real way to punish most of them, but that’s too bad.
My own ENT vents right wing rage at those who would “socialize” healthcare. He also constantly overprescribes treatments at facilities he owns.
May 28th, 2009 at 3:17 pm
brendan:
“It is beside the point to criticize Gawande’s article for lack of advocacy. he is reporting, not polemicizing.
…And anyway, he does make a persuasive case…”
It’s an effective, and highly structured argument. It’s advocacy more than journalism, but that’s not to say it’s only advocacy. Advocacy well done is more of a public service than journalism (and more honest).
I admit my point is griping -or “meta”- but this sentence, which attempts to summarize the author’s point and carry all the weight of his advocacy, galls:
When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes.
May 28th, 2009 at 3:59 pm
Steve,
What does that say about Obama and the Democrats? They’re already escalating one warwith the support of liberals, including Yglesias. If they don’t end the Iraq war, they’ll own it. Maybe that will finally convince all the supposed opponents of the invasion that Democrats are nothing more than the other party of imperialist war.
Have we learned nothing from the past?
May 28th, 2009 at 5:16 pm
[...] Excerpt from: Matthew Yglesias » Cash, Culture, and Health Care Delivery [...]
May 28th, 2009 at 9:28 pm
MY is right — this is a really important article. Not because we should forget the things he doesn’t write about, like who pays. But because fixing health care can’t be done with a single thread of analysis, any more than a chair can stand up with one leg. Gawande is showing us a leg that hasn’t been noticed, and one we’d better notice, or the chair will fall over, even if the other legs are beautifully crafted.