paying more

I'm a big fan if Atul Gawande's writing on medicine (yet another good tip from Patrick Lambe). AG's latest article in the New Yorker is strongly recommended. He visited McAllen, Texas which has the dubious distinction of spending more per person on healthcare than anywhere else in the US (apart from Florida). Is it because healthcare there is better? Apparently not.

And yet there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country... Nor does the care given in McAllen stand out for its quality.

So why is it so expensive to keep people healthy in McAllen?

He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.

In McAllen, there is s tendency for doctors to focus on making money. They are being entrepreneurial, obeying market forces. All the stuff we've been told is good. And is it good?

In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse...

...To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.

Despite our tendency to see price or cost as a reliable surrogate for quality, it ain't necessarily so.

In the Anglophone world, we have spent the last 30 years valorising private enterprise, business, making money as the optimal way of doing things. The generic government plan to fix something involves introducing market forces. Fortunately their success rate so far has been patchy. If they succeed then we're screwed.

I suspect (& I'm hardly original in pointing this out) that in the future, there will be less money around. There'll be fewer natural resources, less farmable land and less cheap energy. We're going to have to ween ourselves off our obsession with growth - and going cold turkey is going to be very painful.