Greater Louisville Medical Society President's eVoice August 2009

An article by Atul Gawande, MD, is all the rage throughout Washington, D.C. It is described as "must reading" by President Obama and it may help shape the discussion on health care reform. Dr. Gawande is a surgeon and a writer, and a staff member of Brigham and Women's Hospital. Many of his works were written during his residency (perhaps with an 80 hour work week, I could have done that, too, yeah, right). I have read many of his works including two books, "Complications: A Surgeon's Notes on an Imperfect Science" and "Better: A Surgeon's Notes on Performance" as well as one of his older articles in The New Yorker, "The Bell Curve" where he talks about how there is a bell curve for everything, even physician performance. He wonders where he is on the curve, which of course makes all of us wonder the same (and everyone cannot be above average). Anyway, I have always found his books and articles fun to read, provocative and usually, right on. His June 1, 2009, article in The New Yorker entitled, "The Cost Conundrum" is certainly making the rounds within the reform debate. In it, he talks about a Texas town, McAllen, which is one of the most expensive healthcare markets in the country. On average, Medicare spending is twice the national average in McAllen, Texas as compared to almost anywhere else in the country. And yet, people are not healthier, the quality isn't better, and the malpractice wasn't worse (actually it was better, as Texas had passed caps on malpractice). However, the folks in this town had more specialist visits, more tests, and more surgeries than patients in other parts of the country. Why? You need to read the entire article, but it comes down to culture and incentives. The information that Dr. Gawande is referring to comes from the Dartmouth Atlas Study (www.dartmouthatlas.com) which looked at Medicare spending in the last two years (and also in the last six months) of a patient's life. With the endpoint being death, it served as a nice risk adjustment (none of the "our patients are sicker than theirs" argument as they all died within those timeframes). You can look at any state or area and compare nationally the rate of Medicare spending, including the number of physician visits in the last two years or 6 months of life, the number of tests, the utilization of ICU beds, and other spending. Not surprisingly, places like Mayo Clinic provide high quality care at some of the lowest costs, even on their Florida campus. Overall, Louisville is just above the national average in most categories, but there is much variation between hospitals throughout the state. President Obama and all the lawmakers in Washington have all read Dr. Gawande's article. While much of the current debate seems to center on expanding coverage, whether or not to offer a public option, create a health insurance exchange, or tax insurance benefits, one thing is for sure...quality will start to take center stage, over quantity.

Sincerely, Lynn Simon, MD GLMS President