in mcallen texas, it's hunting season on scoundrels. dr. atul gawande investigates america's 2nd costliest city for health care (miami is #1, but somehow lost this opportunity for notoriety) and finds (the new yorker, june 1, 2009) that doctors are raking in profits by referring to labs and hospitals they own. america of course has so-called "stark laws" against kickbacks and self-referral, but why texas doesn't enforce these laws as strictly as boston, where dr. gawande lives, or the bay area, where i live, isn't a question that interests dr. gawande.
instead he compares the greediest private practitioners in mcallen to salaried staff docs at the best institutional practice he can find, the mayo clinic, and - by golly - the mayo docs are nobler! then dr. gawande concludes that private practice and what he calls fee-for-service billing (a mis-nomer as the mcallen docs apparently are actually gouging ppo's and medicare, not billing patients directly) are to blame for rising health care costs in america. one infers we'd do better forcing all docs to work in institutions.
hmmm...something's wrong with pitting the best clinic against the worst private practitioner...an unfair fight? non-matching study cohorts? shooting dick cheney in a barrel? apparently dr. gawande's mom was a private practitioner who saw lots of indigent patients for free. how about comparing her costs of service to the costs at the mayo clinic? then we'd have the best against the best; the solo practitioner would look pretty good. or let's put a mcallen surgeon in the ring against an institutional scoundrel - say richard scrushy of healthsouth. we'd have to hold the fight in shelby county jail, but both fighters would be equally dirty. i'll take scrushy by tko (head-butt) in the fifth round.
so i question dr. gawande's conclusion, now apparently championed by president obama, that "fragmented health care" - read: the private practitioner billing fee-for-service - is to blame. i agree, instead, with kaiser, one of dr gawande's favored institutional practices. "state-of-the-art drugs and technological services fuel health care spending...because they generate consumer demand for more intense, costly services." and these days it takes a flexible doc to forgo ordering a $1000 ct scan just because the machine is there. clinics are rigid; they have "best practice" protocols that often mandate expensive tests a docs must order for a given illness. it's the "fragmented" solo practitioner who can be flexible, forgo the fancy test, and "watch and wait."
meanwhile, dr. gawande can hunt closer to home: he can save america some money by returning the cost of the unnecessary second ct scan that, he writes, he demanded the er doc order on his son. oh, and he can convince his fellow surgeons to reduce their fees, so their average income of $390,000 drops to the average income of a pediatrician, $190,000.
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