The Cost Conundrum

The Cost Conundrum is a New Yorker piece by Dr. Atul Gawande published at the beginning of this month. It's a good article. The piece, which has been covered on Fresh Air this week, has purportedly become mandatory reading for White House staffers.

In it, Dr. Gawande discusses the peculiarities of our health care system, contrasting areas with high cost, poor-quality health care (such McAllen, TX) versus areas that have low cost, high quality care (Mayo, Grand Junction). The difference is in part cultural, and in part that there is someone at the helm working toward that goal. What's interesting about the article is that so far, the debate has largely been about single-payer insurance versus multiple, private versus government--but Atul states these arguments are neglecting the most important point--we need a contractor, a person actively working to lower costs while increasing quality:

"Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. 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. Nor will changing the person who writes him the check.

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. 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. You get McAllen."

...

The way I read this article, Atul seems to be asking for a Health Care Czar, a contractor in charge of lowering costs, increasing quality, and managing the totality of health care for the country:

"Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world."

...

"As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future."

PS: I like that little nod to Malcolm Gladwell at the end. And that diaeresis over the ö in coordination tickles me... it's just New Yorker whimsical. 

PPS: Kottke points to a follow-up from Atul's address to the University of Chicago, Pritzker School of Medicine.

(From Margaret, that New Yorker I bought at the airport, the SF Bay Area's 88.5FM)