It seems to be the accepted wisdom that the prime problem with our health services is a lack of resources and therefore all will be well if we can find enough money to meet all the demands. However we have only to look at the USA to appreciate that this view is nonsense. The Americans spend more than twice the amount on health care per capita as other developed nations, but ranks 49th in life expectancy worldwide. I have just been listening to the Reith Lectures by Dr Atul Gawande who is a surgeon and commentator on health policy issues (1). In 2010 he was named as by Time magazine as one of the world’s influential thinkers.
In an article in the New Yorker in 2009 he compared the medical facilities between 2 communities in Texas. One was McAllen and the other was El Paso County. Both of these counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006, Medicare expenditures which is the best approximation of the costs of health care in El Paso was $7,504 per enrollee—half as much as in McAllen (2). There was no evidence to indicate that the treatments and technologies available at McAllen were any better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. In fact Mc Allen actually has fewer specialists than the national average.
Dr Gawande eventually gained access to commercial insurance data which revealed that compared with patients in El Paso and the country as a whole, patients in McAllen were given more diagnostic testing, more hospital treatment, more surgery and more home care. More detailed information was obtained from Medicare payment data. This showed that between 2001 and 2005, critically ill patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received 20% more abdominal ultrasounds, 30% more bone-density studies, 60% more stress tests with echocardiography, 200% cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and 530% more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. So Dr Gawande had absolutely no doubt that the primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
A study conducted at Dartmouth’s Institute for Health Policy and Clinical Practice, analysed the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. It was found that patients in higher-spending regions received 60% more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Despite all this they did no better than other patients, as determined by survival, ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.
In 2006 there were at least 60 million surgical procedures performed on people living in the USA, which is one for every 5 citizens. About 100,000 people die as a result of complications which arise during surgery, which is greater than the number who die in car crashes.
It is evident that where costs of medical treatment are excessively high, many of the treatments are unnecessary and may well do more harm than good. Dr Gawande considered the workings of the Mayo Clinic which has a fundamental philosophy that “The needs of the patient come first”—not the convenience of the doctors, not their revenues. In contrast to some other medical organisations the object is not to get more money out of the patients. Some years ago, it decided that all the income would be pooled and that doctors would be paid a salary, thereby breaking any link between the choice of treatment and remuneration. This was an integral part of a strategy which aimed to raise quality and to help doctors and other staff members work as a team. So it was no great surprise to discover that unnecessary costs are avoided so that The Mayo Clinic is not only very cost-effective but the quality of care extremely good.
Further probing in Texas revealed that in McAllen the growth of profit became accepted as legitimate in the practice of medicine and consequently many doctors
“came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers”.
This goes a long way to explain why there has been so much use of treatments and procedures which are not absolutely essential. So the crux of the issue is the focus of the doctor. Is the over-riding objective to meet the needs of the patient above all else or is it to maximize revenue?
Although Dr Gawande is based in the USA he does have insight into the way medicine operates in Europe. Even so his studies and analyses are particularly valuable because understanding what actually motivates people is critical in the formulation of policy irrespective of where it is applied.
It should certainly serve as a warning to those involved in any re-organisation of the NHS here in the UK. It does not mean that privatisation per se will be detrimental to patients. It will all depend on how the how the contracts are set up. For privatization to be effective it is essential that:
1. Contractors are paid a fixed price, which is agreed at the outset. They must not be given an open cheque book so that they are re-imbursed for costs of all treatments and procedures, which is apparently what happens in the USA.
2. It is essential to incentivize for high quality care and any failure to maintain high standards should be penalized.
My prime concern is that I am not convinced that the authorities have either the will or the competence to devise contracts which will provide the incentives to achieve what is best for the patient and will ensure that procedures are in place to guarantee that the terms and conditions are fulfilled. Those responsible for the commissioning could learn a lot from how the food supermarkets deal with the suppliers of own label products.
Dr Gawande also highlights the widespread usage of unnecessary procedures and treatments that may well be doing more harm than good which is not confined to the USA… a subject I will return to in a later blog.