Taxation without Representation

The health care discussion, if it can be called that, is the closest thing I’ve seen to public hysteria in years. It is a coupling of pure emotion with a remarkable lack of knowledge about medical care in America.

The knowledge deficiency isn’t hard to understand. Health care is a very big elephant. Most of us are like the proverbial blind men. We base passionate opinions on a few experiences with a small part of the elephant, like the amazing cure of Uncle Roy or mom’s unnecessary death.

And, yes, doctors can be found among the blind. Responding to a recent column with a throwaway line suggesting American health care might not be the best in the world--- one doctor wrote to say our health care IS the best in the world. As evidence, he pointed to the people from all over the world who come to get care in America.

People do come from all over, but it’s a two-way street. Americans are flying to Mexico, Europe, and India to get top-quality medical care for a fraction of the price in the U.S. ---“medical tourism” is a fast-growing industry. The doctor, defending rather than thinking, simply failed to use real evidence.

Others avoid actual thinking about the subject by saying everything would be fine if it weren’t for the fraud and abuse from (insert demonized ethnic group or institution here).

If you’re as frustrated as I am about this subject, I’d like to make a suggestion. Read “The Cost Conundrum,” the June 1 New Yorker article that asks how it is that McAllen, Texas, can have Medicare spending that is nearly twice the national average. People don’t flock to McAllen because it is a paragon of high-quality care and good outcomes.

This suggests something very hopeful: More care isn’t always better care. If you read the article, I know you’ll agree with me that it should be required reading for every legislator in Washington, every doctor, every hospital administrator and every insurance executive in America. “The Cost Conundrum” doesn’t require a Ph.D. in statistics or an M.D. degree to read. It has the ease and fluidity of a Malcolm Gladwell article. It may be more compelling than stories by the late John Updike. It’s a good read.

In 2006, the last year for which the Dartmouth Medical Atlas has published data, the national average spending per person on Medicare Parts A and B was $8,304. In McAllen, Texas, the same figure was $14,834--- 79 percent more than the national average.

Spending in Texas tends to be above the national average. It was $10,046 in Houston and Dallas, $9,022 in San Antonio, and $8,744 in Austin. Abilene came in below the national average at $7,594.

Every one of these areas costs more than the $7,092 in Minneapolis, near the much admired Mayo Clinic. At the Mayo Clinic, doctors are salaried. They are not paid on the piecework basis that is the prevailing model for garment workers, windshield installers, and the vast majority of M.D.s in America. The piecework basis of payment, known as “fee for service” in medicine, may be one of the primary drivers of high healthcare costs in America. If your income depends on the number of services you can do and charge for, you’ll do more rather than less. That’s just the way it is.

But more service doesn’t automatically translate into superior health care. A study by the Dartmouth Institute for Health Policy and Clinical practice, for instance, found just the opposite. Comparing higher spending areas to lower spending areas, the Dartmouth researchers found:

  • That the supply of hospital beds and medical specialists was higher in higher-cost areas.
  • That doctors in the high-cost areas were less inclined to follow evidence-based care guidelines.
  • That patient mortality from heart attack, hip fracture, and colorectal cancer was higher in the high-cost areas.
  • That patients reported worse access to care, greater waiting times, and worse inpatient experiences in the high-cost areas.
  • That doctors reported poor communication among doctors and inadequate continuity with patients in high-cost areas.
  • That doctors reported greater difficulty getting specialist referrals in high-cost areas.

This doesn’t mean that less is best. It means that more care isn’t necessarily better care. It also means we have a massive opportunity. Institute “best practices” and we can save this country from a healthcare-driven bankruptcy.

On the web:

The Cost Conundrum

The Dartmouth Institute

Dartmouth Atlas---Healthcare Spending, Quality and Outcomes: More Isn’t Always Better

Dartmouth Atlas---Tracking the Care of Patients with Severe Chronic Illness

August 10, 2003: The $35.5Trillion Medicare Elephant

August 7, 2009: Representation without Taxation