Health care reform

My take from both articles is that there is a very large concern that doctors are ordering too many tests [or operations]. But being the naive optimist that I am, I am inclined to think they are ordering the tests to protect themselves from the threat of malpractice, rather than ordering tests purely for profit. The mindset would be that ordering an extra test may reveal the 1% of cases where there exists a problem and not ordering the test increases the odds of malpractice by 1%, so a doctor will play it safe and order the test. These additional tests/procedures/operations may be easier and more expensive than a more difficult but less expensive recommendation. (Gastric bypass surgery is easier and more expensive than trying to get a fat person to go on a diet and lose 50 pounds, the harder/cheaper option)

I think this is a huge challenge, because it requires changing the mindset of all doctors out there. The examples presented make it seem that collaboration among doctors may be the single best way for doctors to be comfortable ordering fewer tests. (Both at the Mayo Clinic and the community in Colorado).

So the big question is: How do you make doctors want to collaborate and share information/training/
experience/knowledge? I think that is the way to keep costs down. An individual doctor will never see every situation, but if he can ask 100 other doctors about a case and whether he should order a test, he may get enough responses from other doctors who have seen the same symptoms and be able to provide a clue or indicator as to why he shouldn't order the test.

Electronic records is a big step in the right direction.


  1. Where to start...accountable care is what we should be striving for. This includes openness, teamwork and collaboration, electronic records, better doctor-patient relationships - all with some sort of measurable record to track cases. I'm a fan of Universal Health Care because I think it will ultimately lead to this openness as patients are able to choose the best doctor's out there for any procedure they choose (although, just thinking about it now, this scares me because it forces doctor's to focus on cost again).

  2. I agree that accountable care is needed, but I doubt there exists any metric to measure "quality of care." You probably can't ask the nursing staff or the doctors, and you certainly can't ask the patients. There is no way they can objectively judge or rate their care. I feel that collaboration and teamwork can be enforced though.

    I am starting to think this would work within a universal health care system or within the current system.

  3. Look the Gawande article is absolutely huge. I have re-read it 3 times and haven't absorbed it all. But in the example of McAllen, TX, he makes it clear that malpractice isn't a big factor - there is apparently a tough anti-malpractice law, which the doctors say brought lawsuits "practically to zero." So I don't think your malpractice point holds water in that case.

    What this highlights for me, however, is that you really need an expert to sort through all the BS. Read the article again and count the number of times someone gives him a red herring or an insufficient explanation for high medical costs. It is packed with either misinformed or intentionally misleading "causes" for the problem. Gawande is able to sort through it all because he's an expert with a lot of background research on the subject.

    I'm not sure we'll be able to piece together an answer by reading a bunch of Newsweek articles. But dag nabbit we can try! (After all, look at the name of this blog)

    I want to start by asking what do you guys consider the major takeaway points to be from that article, that you think are good foundations to begin healthcare improvement discussions on? For me, it's two things:

    1. Collaboration and team effort are integral to better and cheaper care

    2. As we move towards healthcare reform, a cornerstone of that reform should be an institute full of people like Gawande who can compare what works and what doesn't work using the best data we have available

  4. Unfortunately, I think it's a fundamental change in how doctors go about solving a problem, and it is very difficult to change how they think. You are asking individuals to stop doing all they can to solve a problem and basically ask for help as step #1. I know that when I am trying to solve a problem, I do as much as I can to figure it out on my own before I start calling other professionals and resources available to me and if I was a doctor, I would be doing the same thing. I would order the tests to try and come up with a solution on my own before asking for help. It is the fundamental change in the way doctors seek solutions that will be very difficult. Do you try to force collaboration on them, or work around their current methodologies?

  5. Aaron, I don't mean this is as a way to shut the conversation down, BUT - I don't think you or I are best positioned to determine what is the best problem-solving method for doctors. I defer to Gawande, or guys like Dr. Dan Corman who we know, to tell me what they think is the best way to go. This works at the Mayo Clinic and in Grand Junction and comes down to solving the problem "how can I give the best care possible to this patient?"

    But I think you've also missed a major point of Gawande's rationale. This isn't about forcing doctors to think another way. It's about providing alternative methods of problem-solving, about guiding them into a framework where they CAN collaborate and harness a team to make better and cheaper decisions.

    There is a lot more to say but let me grab a few links from some other articles so I can bring those into the fold.

  6. I think this will take a generation or 2 of new doctor's entering the fold. I agree with Aaron a lot in the whole "I want to find a solution on my own" concept, and it's a fine line between not wanting to bother others and being inefficient. I think with proper training in med school, a collaborative mindset can become the norm in our nation's hospitals.

    Royce - I agree that experts should focus their attention on these topics, but I don't agree with you in saying that we cannot add to the solution. Problem-solving is found all around the world, and, generally speaking, is the same in any industry/discipline. If a hedge fund manager creates a team mindset w/in his group, the same tactics he used could very well apply to hospital managers.

  7. I think Scott emphasized my point a little better. It's not that collaboration in the medical community is too difficult to achieve. It's that I don't think it can be done in Obama's presidency. Which do you think is more likely; Obama sets the groundwork to encourage collaboration, without changing the costs of care or limiting what doctors are allowed to do? OR Obama changes cost and payout structures, forcing doctors ot order fewer tests? (think a nationalized health care program with an oversight level that has the ability to refuse an expensive treatment for an 85 year old, where the treatment will, at best, preserve life for a few months longer)

  8. Let's start with this passage from Gawande's article for further discussion:

    "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.

    That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.

    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."

    Do you grant that his basic premise here is correct? That patients who received significantly more "treatment" did not fare demonstrably better than those who did not? And do you agree that there is a risk to over-use of medicine, especially when it's not strictly needed?

    If so, then do you think this is achievable without gov't-mandated limits on tests, etc, like you suggest Aaron? The next paragraph from Gawande reads:

    "In an odd way, this news is reassuring. Universal coverage won’t be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with. So the idea that there’s plenty of fat in the system is proving deeply attractive."

    He is arguing that his findings dictate exactly the opposite response - we don't need to worry about rationing care, because it is in the interests of patients NOT to over-treat them. Do you think doctors can intuitively understand this, or will they need to be re-educated over 2 generations as Scott suggests?

  9. I completely agree with his premise and that his conclusions are correct. My concern is how we will get doctors to order fewer tests/procedures/operations. I think politicians will have trouble imposing rationing, because it is a PR handicap to have a bureaucrat (even one with an MD) telling the doctors who are actually seeing the patients they can't order a test. That opens a situation where someone is having to make a determination without meeting the patient and that is a road I don't think they should be going down. My wish/dream would be to establish a system where the doctors are voluntarily ordering fewer tests and still feel confident they have done the best for the patient.

  10. OK, here's an example of how to apply my idea. Give every doctor a limit to their average cost per patient (calculated annually). Tell every doctor, they can't order more than $8000 worth of tests and procedures per patient. The doctor can then use his or her judgement to order more tests and go over that average knowing he will have to order fewer tests for the next patient. Doctors will be less inclined to order a test unless they are positive the test is necessary.

  11. But it could still lead to someone who didn't need more than one test getting three, because the doc still didn't even spend half the allotted amount...

    The complication of doctors being asked to incorporate financial factors into healthcare decisions is also discussed in this article:

    In it, the author Dr. Jauhar says he has trouble separating the purely best medical choice from the best choice as weighted by its cost. But most doctors now are asked to weight their choices with cost included, because they can (or have to) make money.

    One prevailing theory is that of paying a set cost per patient enrolled in a group or network... for example, the Grand Junction network. Then doctors would get rewarded based on performance (and if you ask for specifics on what that means, I don't have a solid answer). That would essentially take the doctor's financial decisions out of the equation.

    Would that be sensible? Someone, somewhere, still has to worry about costs. And it's unclear if that's feasible on a national network, or if it has to be delegated to a series of local networks. Even if that type of solution was passed, do you think doctors would be inclined to perform fewer costly and potentially unnecessary treatments and tests?


    I figured this was very appropriate for this post. Another instance of possible over-treatment (this time in Europe). I'm torn on this one as I've seen two instances in which early screening helped save loved ones who were diagnosed with cancer, but I do see how screening can lead to over-treatment.

  13. Great link (by the way, how can we hyperlink things in the comments?)

    Scott I think you've hit on the most difficult part of healthcare policy - how do you balance the best policy for the overall population while not being insensitive to the health of the few?

    This is a corollary of the "Who Will Say No?" article, because you have to separate the best overall care from the best treatment for a specific patient. Maybe it's the job of the doctor to make the moderate treatment decisions, or maybe patients can be educated on both the intense and less intense treatments and choose for themselves (I cannot for the life of me find the Business Week article... sorry).

    But I do come back to Gawande's point that nothing in medicine is without costs, and over-treatment can be as dangerous as under-treatment in a lot of cases. Do you think we fully grasp that danger of healthcare as a society?

  14. Scott, that article was incredibly relevant because I never knew that it was possible to have breast or prostate cancer that never showed any symptoms, never affecting lifestyle or life expectancy. Did either of you know that? I feel like that fact was slightly glossed over in that article.

    From that article it seems that doctors are required to aggressively treat all forms of breast cancer. It seems that an interactive discussion between the doctor and the patient, discussing all possible ramifications of treatment, from no treatment and increased frequency of mammograms, to a mastectomy, would be more effective.