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More medicine does not equal better health: Atul Gawande

The surgeon who everyone loves to read – Atul Gawande – has an article on health care costs in the latest New Yorker that is said to have become required reading for US President Obama’s staff. In lucid and entertaining style, he makes a careful argument that more medicine does not necessarily equate to better health, and may even translate into worse health – but at great cost.

The article contrasts and compares different health systems within the US, and concludes that those which maximise revenue to the medical industry are not only wasteful but tend to provide worse quality care.

Some snippets:

As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems…

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…

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…

But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.

It makes interesting reading at a time when Australia seems to be strengthening its commitment to fee-for-service health care, as evidenced by recent funding developments for psychologists, midwives and nurse practitioners, rather than to funding team-based care.

Meanwhile, still in the US, those with an interest in evidence-based policy may be interested in this blog from the Office of Management and Budget (OMB) Director Peter Orszag, which summarises the Obama Administration’s commitment to evidence-based policy.

The Coalition for Evidence Based Policy is rather excited about the blog: “Peter Orszag’s clear understanding of and commitment to evidence-based reform may represent a major development in evidence-based policy.  As you know, OMB plays a central role in developing the President’s budget and assessing federal program performance; thus his commitment holds the potential to greatly accelerate the pace of evidence-based reform across the federal government.”

Am I imagining it, or do we hear the “evidence-based mantra” less often now from Rudd and his team than in their early, heady days?

Comments 3

  1. EnergyPedant says:

    Long article but its well worth reading.

    Doctors moving from health care into being business owners is a major problem and it has definitely started here in Australia.

    Part of the problem is drastically rising costs. My dad was a GP and from the mid-90s onwards (maybe earlier) his real income decreased every year due to rising costs (insurance was a big one).

    Day procedure clinic that is owned by a gang of anesthetists/surgeons, that only take the simple high-profit cases. There are bulk billing clinics (owned by large companies) that will only see the simple patients that can be churned fast to maximise $/hour. The Medicare gap system having to be changed because some specialists were milking massive profits.

  2. Patrick Bolton says:

    I understand that there is some evidence to support the notion that team based care, but that it is not strong. Before it is promoted we need evidence that it is better than the alternative.

    The common sense of Gawande’s example is not sufficient. If you choose a metaphor of achieving a health outcome as being like driving a car rather than building a house you have one person steering, another on brakes and a third operating the clutch, which one might expect would increase the rate of car crashes. Teams are not the best approach to every endeavor.

    Accepting for the purposes of discussion that teams are better, what would an example of paying for team based care look like? This is important if one is to practically test a funding model supporting teams in order to compare it with the existing model. This is not trivial in the sense that there are probably different models to fund teams which are differently effective, just as there are for health systems now. It would be a pity to abandon team based approaches just because the funding model one tried to use to implement them was not optimal.

    Beyond this though, why fund for individuals or teams. Why not fund for health outcomes? This seems less likely to introduce perverse incentives which Gawande illustrates are an issue with the present model where we pay for practitioners, not outcomes.

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2017 conferences
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#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
#OKtoAskAu
#OTCC2017
#ResearchTranslation17
#TheMHS2017
#VMIACConf17
#WCPH2017
Australian Palliative Care Conference
2018 conferences
#6rrhss
#ACEM18
#AHPA2018
#ATSISPC18
#CPHCE
#MHED18
#NDISMentalHealth
#Nurseforce