Cost Consciousness in Patient Care — What Is Medical Education’s Responsibility?

Molly Cooke, M.D., N Engl J Med 2010

It is old news that the cost of medical care in the United States is unsupportable, yet we seem unable to grapple with the issue effectively. As current ideas for health care reform have percolated through Congress, cost-control mechanisms have generally been recognized as the weak component. Our country is remarkably generative in the development of new diagnostic tests, drugs, and procedures — and remarkably undisciplined in their deployment. New diagnostic and therapeutic procedures and the broadened application of established ones account for two thirds of the growth in health care expenditures.  Since the importance of this problem has been recognized for nearly 40 years, one might imagine that medical educators have attempted to incorporate cost consciousness into their teaching, but such efforts have been remarkably few, and curricula remain largely silent on the role of cost in the planning of diagnostic and treatment strategies.

The reasons for this silence are historical, philosophical, structural, and cultural. In the 1970s, Jerry Avorn, Wayne Ray, and others attempted to engage physicians in cost control by using a variety of educational approaches, such as “academic detailing” — having trained individuals, often clinical pharmacists, rather than salespeople, provide physicians with information about appropriate prescribing and diagnostic testing. This campaign produced only modest improvements in prescribing patterns and other costly physician practices, and with the rise of managed care, cost-control efforts moved on to administrative control tactics and financial incentives for physicians to provide less costly care — strategies that soured both physicians and the public on approaches that rendered the doctor a “double agent.”

Philosophically, we physicians have conceived of ourselves as, and taught students that we are, advocates for each patient, obligated to eschew all considerations other than benefit to that patient and his or her preferences. Intensifying the challenges posed by this conception are the increased emphasis on patient-centered care and the expanded access of nonprofessionals to sophisticated medical information, which have transformed patients from dependent and acquiescent recipients of the physician’s care plan to activated, informed, and sometimes insistent consumers of health care services.

The structural factor contributing to the evasion of cost consciousness is the inpatient setting in which most medical education occurs. A predominant driver of the cost of hospital care is the length of stay, so a high priority is readying patients for discharge — which serves as a rationale for preemptively ordering any test and consultation that might be called for, to avoid delaying discharge. Consequently, students and residents have scarce opportunity to practice devising cost-effective diagnostic strategies and explaining their rationale to patients and families.

Finally, cultural values powerfully influence the selection of teaching topics. Academia celebrates the “high knowledge” of medicine: pathophysiology, molecular biology, genomics. Even evidence-based medicine, although it deemphasizes fundamental mechanisms, is regarded as acceptably intellectual in comparison with “low,” real-world concerns such as cost.

Combating such forces is a tall order, but I believe that medical educators have an obligation to address cost. This obligation derives from our responsibility to individual patients and from our role as informed physician-citizens in the larger society. Being a physician is not just about finding benefit for patients; it is also about helping them to understand value. The informed-consent conversation about the risks and benefits of a procedure is such a value-finding discussion. Of course, the patient usually stands to both bear those risks and gain those benefits. But some familiar situations require talking to patients about interventions that have benefits that they would, or think they would, experience and major risks that lie elsewhere; negotiating the use of antibiotics in outpatient settings is an example. I would argue that patients depend on us to help them understand both the likelihood that they will experience benefit and the cost, broadly construed, at which that benefit might be won.

Our position as professionals with a sophisticated understanding of the implications of medical overconsumption is the second source of our obligation to consider cost. We are advocates for individual patients; we are also stewards of what Hiatt referred to as “the medical commons.”

How should we deal with these forces that have resulted in a failure of medical education to address the urgent issue of costs? First, we must acknowledge the lesson of recent history: creating financial incentives for physicians to behave in ways that are not, or are not perceived to be, in patients’ interest creates distrust and antagonism. We physicians should not gain from doing too little for patients any more than we should prosper from doing too much.

Second, we must abandon the myth of the physician as single-minded advocate for any amount of benefit for every patient. We make all kinds of choices in caring for patients; some involve denying care that patients perceive as — and that might actually be — beneficial. Given that we make value-based decisions about the deployment of other finite resources, such as our time and the use of beds in the intensive care unit, why not about costly treatments? In fact, numerous studies in the United States and Europe confirm that bedside rationing of care is common practice. Problematically, it is done in an occult and unpredictable manner. If we teach that cost should not be a consideration in the care of patients, then we delegitimize the topic for discussion; the ensuing silence allows marked interphysician variation in practice.

We must also educate medical students and residents in settings where they have opportunities to develop and use cost-conscious strategies in caring for patients — generally, outpatient settings, where costs are predominantly influenced by decisions about diagnostic testing and treatment choices. In addition, training physicians to be cost aware will require knowledgeable, skilled faculty members who — since cost is not an inherently scintillating topic — are innovative and engaging teachers.

In 1975, Hiatt exhorted physicians to collaborate with other experts and the public to protect the medical commons.5 Not only have we failed to rise to his challenge, but our overconsumption and waste are now compromising our ability to address other pressing social needs and national priorities. Educating physicians to be cost aware is a critical responsibility of medical schools and residency programs. Like all medical education, it is fundamentally a moral undertaking, but it also requires that learners acquire the requisite knowledge and be afforded the opportunity to develop relevant skills.

First, we must be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit. Second, we must prepare every physician to assess not only the benefit or effectiveness of diagnostic tests, treatments, and strategies but also their value. Value can be increased through cost-conscious diagnostic and management strategies and by the engineering of better and less wasteful processes of care. Evidence-based medicine and comparative-effectiveness research help us understand the relative effectiveness of management strategies; appreciation of cost and metrics such as “number needed to treat” help us approach value.

Of course, negotiating with patients or families who insist on a low-value course of action is difficult. Doctors must be provided with the skills to discuss value with patients honestly, effectively, and compassionately. We have devoted much effort to teaching about other difficult conversations; we must rise to the challenge of this one. Like the limitation of interventions at the end of life, consideration of cost must be explicit, transparent, and consistent. We need to present cost consciousness to our students as a positive professional value, clarify its contribution as we discuss diagnostic and therapeutic strategies, and teach skills that support open discussion with patients and families.

Third, we must broaden our programs so that all trainees receive a foundation of exposure to health care management and health services delivery, enabling them to participate as informed citizens in the systems in which they work and learn. Medical school and residency programs should encourage interested learners to pursue these areas in depth through dual-degree and certificate programs and should provide sufficient flexibility and individualization of clinical education to make it feasible to do so. Similarly, we must ensure that all students acquire a basic understanding of how medical care is financed, where national health care policies come from, and the politics that shape financing and workforce choices. Hiatt correctly noted that physicians would not be making the nation’s critical health care choices alone; today’s question is whether medical education will prepare the next generation to participate in this decision making at all.

Squandering Medicare’s Money

By RITA F. REDBERGMAY 25, 2011, The New York Times

Medicare has suddenly taken center stage in American politics, with Democrats now trying to score an advantage from the unpopularity of the Republican plan to overhaul the government health insurance program. Apart from the politics, though, Medicare’s financing challenges are worsening: this month, Medicare’s trustees projected that the insurance program would become insolvent by 2024, five years earlier than previously estimated.

Much has been said about the growing gap between the program’s spending and revenues — a gap that will widen as baby boomers retire — but little attention has been focused on a problem staring us in the face: Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:

• Medicare pays for routine screening colonoscopies in patients over 75 even though the United States Preventive Services Task Force, an independent panel of experts financed by the Department of Health and Human Services, advises against them (and against any colonoscopies for patients over 85), because it takes at least eight years to realize any benefits from the procedure. Moreover, colonoscopies carry risks of serious complications (like perforations) and often lead to further unnecessary procedures (like biopsies). In 2009, Medicare paid doctors more than $100 million for nearly 550,000 screening colonoscopies; around 40 percent were for patients over 75.

• The task force recommends against screening for prostate cancer in men 75 and older, and screening for cervical cancer in women 65 and older who have had a previous normal Pap smear, but Medicare spent more than $50 million in 2008 on such screenings, as well as additional money on unnecessary procedures that often follow.

Two recent randomized trials found that patients receiving two popular procedures for vertebral fractures, kyphoplasty and vertebroplasty, experienced no more relief than those receiving a sham procedure. Besides being ineffective, these procedures carry considerable risks. Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.

Multiple clinical trials have shown that cardiac stents are no more effective than drugs or lifestyle changes in preventing heart attacks or death. Although some studies have shown that stents provide short-term relief of chest pain, up to 30 percent of patients receiving stents have no chest pain to begin with, and thus derive no more benefit from this invasive procedure than from equally effective and far less expensive medicines. Risks associated with stent implantation, meanwhile, include exposure to radiation and to dyes that can damage the kidneys, and in rare cases, death from the stent itself. Yet one study estimated that Medicare spends $1.6 billion on drug-coated stents (the most common type of cardiac stents) annually.

• A recent study found that one-fifth of all implantable cardiac defibrillators were placed in patients who, according to clinical guidelines, will not benefit from them. But Medicare pays for them anyway, at a cost of $50,000 to $100,000 per device implantation.

The full extent of Medicare payments for procedures with no known benefit needs to be quantified. But the estimates are substantial. The chief actuary for Medicare estimates that 15 percent to 30 percent of health care expenditures are wasteful. Medicare spending exceeded $500 billion in 2010, suggesting that $75 billion to $150 billion could be cut without reducing needed services.

Why does Medicare spend so much for procedures and devices on patients who get no benefit and incur risks from them?

One reason is that Medicare’s reimbursement procedures are not sophisticated enough to track the appropriateness of the care provided. Medicare delegates its claims administration to private local contractors based on how quickly and cheaply they can process claims.

These contractors have few incentives to audit the taxpayer dollars they are paying out, and even if they wanted to, they would need information often not available on the claim form. For example, a claims administrator, processing a claim for a screening colonoscopy, does not know when the patient’s last colonoscopy was, or whether there was a new clinical reason for repeating it. While this information is available, finding it would require extra steps, and there are no incentives to do so.

Moreover, denying payment after a procedure is performed invites the wrath of both patient and physician. Medicare and private insurers are also keen to avoid situations that could be viewed as telling doctors how to practice medicine — even if such advice is in the patient’s best interest. The political sensitivity of limiting services based on age, for example, was illustrated by the uproar over the Preventive Services Task Force’s finding two years ago that women in their 40s do not benefit from routine mammography.

Another factor is the shocking chasm between Medicare coverage and clinical evidence. Our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test. So while Medicare is obligated to follow the task force’s recommendations to cover new preventive services, it has no similar mandate to deny coverage for services for which the task force has found no benefit.

Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view.

Of course, doctors, with the consent of their patients, should be free to provide whatever care they agree is appropriate. But when the procedure arising from that judgment, however well intentioned, is not supported by evidence, the nation’s taxpayers should have no obligation to pay for it.

Rita F. Redberg, a cardiologist, is a professor of medicine at the University of California, San Francisco, and the editor of Archives of Internal Medicine.

The Cost Conundrum

What a Texas town can teach us about health care.

By Atul Gawande, The New Yorker, June 1, 2009

See the Original Article here.

It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.

McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. “The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”

The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.

From the moment I arrived, I asked almost everyone I encountered about McAllen’s health costs—a businessman I met at the five-gate McAllen-Miller International Airport, the desk clerks at the Embassy Suites Hotel, a police-academy cadet at McDonald’s. Most weren’t surprised to hear that McAllen was an outlier. “Just look around,” the cadet said. “People are not healthy here.” McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.

One day, I went on rounds with Lester Dyke, a weather-beaten, ranch-owning fifty-three-year-old cardiac surgeon who grew up in Austin, did his surgical training with the Army all over the country, and settled into practice in Hidalgo County. He has not lacked for business: in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it. I walked around with him as he checked in on ten or so of his patients who were recuperating at the three hospitals where he operates. It was easy to see what had landed them under his knife. They were nearly all obese or diabetic or both. Many had a family history of heart disease. Few were taking preventive measures, such as cholesterol-lowering drugs, which, studies indicate, would have obviated surgery for up to half of them.

Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both 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 (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)

Was the explanation, then, that McAllen was providing unusually good health care? I took a walk through Doctors Hospital at Renaissance, in Edinburg, one of the towns in the McAllen metropolitan area, with Robert Alleyn, a Houston-trained general surgeon who had grown up here and returned home to practice. The hospital campus sprawled across two city blocks, with a series of three- and four-story stucco buildings separated by golfing-green lawns and black asphalt parking lots. He pointed out the sights—the cancer center is over here, the heart center is over there, now we’re coming to the imaging center. We went inside the surgery building. It was sleek and modern, with recessed lighting, classical music piped into the waiting areas, and nurses moving from patient to patient behind rolling black computer pods. We changed into scrubs and Alleyn took me through the sixteen operating rooms to show me the laparoscopy suite, with its flat-screen video monitors, the hybrid operating room with built-in imaging equipment, the surgical robot for minimally invasive robotic surgery.

I was impressed. The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don’t. But that rule doesn’t hold for health care.

At McAllen Medical Center, I saw an orthopedic surgeon work under an operating microscope to remove a tumor that had wrapped around the spinal cord of a fourteen-year-old. At a home-health agency, I spoke to a nurse who could provide intravenous-drug therapy for patients with congestive heart failure. At McAllen Heart Hospital, I watched Dyke and a team of six do a coronary-artery bypass using technologies that didn’t exist a few years ago. At Renaissance, I talked with a neonatologist who trained at my hospital, in Boston, and brought McAllen new skills and technologies for premature babies. “I’ve had nurses come up to me and say, ‘I never knew these babies could survive,’ “ he said.

And yet there’s no evidence that the treatments and technologies available at McAllen are 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. Hidalgo County actually has fewer specialists than the national average.

Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.

One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.

Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.

Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.

The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ “

Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.

The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.

Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.

I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?

Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.

And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.

The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare 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 twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent 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. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.

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.

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. “Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated.

Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.

I had what I considered to be a reasonable plan for finding out what was going on in McAllen. I would call on the heads of its hospitals, in their swanky, decorator-designed, churrigueresco offices, and I’d ask them.

The first hospital I visited, McAllen Heart Hospital, is owned by Universal Health Services, a for-profit hospital chain with headquarters in King of Prussia, Pennsylvania, and revenues of five billion dollars last year. I went to see the hospital’s chief operating officer, Gilda Romero. Truth be told, her office seemed less churrigueresco than Office Depot. She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience. And when I inquired, “What is going on in this place?” she looked surprised.

Is McAllen really that expensive? she asked.

I described the data, including the numbers indicating that heart operations and catheter procedures and pacemakers were being performed in McAllen at double the usual rate.

“That is interesting,” she said, by which she did not mean, “Uh-oh, you’ve caught us” but, rather, “That is actually interesting.” The problem of McAllen’s outlandish costs was new to her. She puzzled over the numbers. She was certain that her doctors performed surgery only when it was necessary. It had to be one of the other hospitals. And she had one in mind—Doctors Hospital at Renaissance, the hospital in Edinburg that I had toured.

She wasn’t the only person to mention Renaissance. It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) Romero and others argued that this gives physicians an unholy temptation to overorder.

Such an arrangement can make physician investors rich. But it can’t be the whole explanation. The hospital gets barely a sixth of the patients in the region; its margins are no bigger than the other hospitals’—whether for profit or not for profit—and it didn’t have much of a presence until 2004 at the earliest, a full decade after the cost explosion in McAllen began.

“Those are good points,” Romero said. She couldn’t explain what was going on.

The following afternoon, I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.

So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”

Then why do hospitals in McAllen order so much more surgery and scans and tests than hospitals in El Paso and elsewhere?

In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.

“Do we provide better health care than El Paso?” Gelman asked. “I would bet you two to one that we do.”

It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.

And, I realized, few people in their position do. Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.

Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.

If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.

Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.

Why? Some of it could reflect differences in training. I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I’d been trained. But the doctor in Alexandria was going to send Walker home. That was how he’d been trained. Suppose things change for the worse? I asked him. It’s extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.

There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.

“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.

He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.

No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.

Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.

Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.

Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.

In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ “

“How much?” I asked.

“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.

He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.

Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.

Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.

Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.

“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.

About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.

The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.

“I’ll be there,” the cardiologist said.

Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.

The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.

“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.

Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.

The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.

Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. 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.

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. 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. You get McAllen.

One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.

“Medicine has become a pig trough here,” he muttered.

Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.

We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.

“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.

How about doing the opposite and increasing the role of big insurance companies?

“What good would that do?” Dyke asked.

The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”

He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”

Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.

This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. 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.

Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.

Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ “

As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.

Atul Gawande, a surgeon and public-health researcher, became a New Yorker staff writer in 1998.


An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?

By Atul Gawande, The New Yorker, January 23, 2017

See the Original Article here.

It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.

The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

Could pointless medical care really be that widespread? Six years ago, I wrote an article for this magazine, titled “The Cost Conundrum,” which explored the problem of unnecessary care in McAllen, Texas, a community with some of the highest per-capita costs for Medicare in the nation. But was McAllen an anomaly or did it represent an emerging norm? In 2010, the Institute of Medicine issued a report stating that waste accounted for thirty per cent of health-care spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education. The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.

I decided to do a crude check. I am a general surgeon with a specialty in tumors of the thyroid and other endocrine organs. In my clinic that afternoon, I saw eight new patients with records complete enough that I could review their past medical history in detail. One saw me about a hernia, one about a fatty lump growing in her arm, one about a hormone-secreting mass in her chest, and five about thyroid cancer.

To my surprise, it appeared that seven of those eight had received unnecessary care. Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. (An MRI does not image thyroid cancer nearly as well as the ultrasound the patient had already had.) The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage. (Arthroscopy can repair certain types of acute tears to the cartilage of the knee. But years of research, including randomized trials, have shown that the operation is of no help for chronic arthritis- or age-related damage.)

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

Why does this fact barely seem to register publicly? Well, as a doctor, I am far more concerned about doing too little than doing too much. It’s the scan, the test, the operation that I should have done that sticks with me—sometimes for years. More than a decade ago, I saw a young woman in the emergency room who had severe pelvic pain. A standard X-ray showed nothing. I examined her and found signs of pelvic inflammatory disease, which is most often caused by sexually transmitted diseases. She insisted that she hadn’t been sexually active, but I didn’t listen. If I had, I might have ordered a pelvic CT scan or even recommended exploratory surgery to investigate further. We didn’t do that until later, by which time the real source of her symptoms, a twisted loop of bowel in her pelvis, had turned gangrenous, requiring surgery. By contrast, I can’t remember anyone I sent for an unnecessary CT scan or operated on for questionable reasons a decade ago. There’s nothing less memorable.

It is different, however, when I think about my experience as a patient or a family member. I can readily recall a disturbing number of instances of unnecessary care. My mother once fainted in the Kroger’s grocery store in our Ohio home town. Emergency workers transported her to a hospital eighty miles away, in Columbus, where doctors did an ultrasound of her carotid arteries and a cardiac catheterization, too, neither of which is recommended as part of the diagnostic workup for someone who’s had a fainting episode, and neither of which revealed anything significant. Only then did someone sit down with her and take a proper history; it revealed that she’d had dizziness, likely from dehydration and lack of food, which caused her to pass out.

I began asking people if they or their family had been subject to what they thought was unnecessary testing or treatment. Almost everyone had a story to tell. Some were appalling.

My friend Bruce told me what happened when his eighty-two-year-old father developed fainting episodes. His doctors did a carotid ultrasound and a cardiac catheterization. The tests showed severe atherosclerotic blockages in three coronary arteries and both carotid arteries. The news didn’t come as a shock. He had smoked two packs of cigarettes a day since the age of seventeen, and in his retirement years was paying the price, with chronic lung disease, an aortic-aneurysm repair at sixty-five, a pacemaker at seventy-four, and kidney failure at seventy-nine, requiring dialysis three days a week. The doctors recommended doing a three-vessel cardiac-bypass operation as soon as possible, followed, a week or two later, by surgery to open up one of his carotid arteries. The father deferred the decision-making to the son, who researched hospitals and found a team with a great reputation and lots of experience. The team told him that the combined procedures posed clear risks to his father—for instance, his chance of a stroke would be around fifteen per cent—but that the procedures had become very routine, and the doctors were confident that they were far more likely to be successful than not.

It didn’t occur to Bruce until later to question what the doctors meant by “successful.” The blockages weren’t causing his father’s fainting episodes or any other impairments to his life. The operation would not make him feel better. Instead, “success” to the doctors meant reducing his future risk of a stroke. How long would it take for the future benefit to outweigh the immediate risk of surgery? The doctors didn’t say, but carotid surgery in a patient like Bruce’s father reduces stroke risk by about one percentage point per year. Therefore, it would take fifteen years before the benefit of the operation would exceed the fifteen-per-cent risk of the operation. And he had a life expectancy far shorter than that—very likely just two or three years. The potential benefits of the procedures were dwarfed by their risks.

Bruce’s father had a stroke during the cardiac surgery. “For me, I’m kicking myself,” Bruce now says. “Because I remember who he was before he went into the operating room, and I’m thinking, Why did I green-light an eighty-something-year-old, very diseased man to have a major operation like this? I’m looking in his eyes and they’re like stones. There’s no life in his eyes. There’s no recognition. He’s like the living dead.”

A week later, Bruce’s father recovered his ability to talk, although much of what he said didn’t make sense. But he had at least survived. “We’re going to put this one in the win column,” Bruce recalls the surgeon saying.

“I said, ‘Are you fucking kidding me?’ ”

His dad had to move into a nursing home. “He was only half there mentally,” Bruce said. Nine months later, his father died. That is what low-value health care can be like.

I’m a fan of the radio show “Car Talk” (which ceased taping in 2012 but still airs in reruns), and a regular concern of callers who sought the comic but genuine advice of its repair-shop-owning hosts, Tom and Ray Magliozzi, was whether they were getting snookered by car mechanics into repairs they didn’t need.

“There’s no question we have considerable up-selling in the industry,” Ray told me when I reached him by phone. “Quickie-lube places are the worst for this. I won’t name names, but they tend to have the word ‘lube’ in them.” He let out that nyuk-nyuk-nyuk laugh he has. “You can’t make money on a $29.95 oil change. So they try to sell you on a lot of stuff. First level, they sell you something you don’t need but at least doesn’t hurt. Second level, they do some real damage mucking around.”

Even reputable professionals with the best intentions tend toward overkill, he said. To illustrate the point, he, too, had a medical story to tell. Eight months earlier, he’d torn a meniscus in his knee doing lunges. “Doing lunges is probably something a sixty-five-year-old should not be doing to begin with,” he admitted. He was referred to an orthopedic surgeon to discuss whether to do physical therapy or surgery. “Very good guy. Very unassuming. I had no reason not to trust the guy. But I also know he’s a surgeon. So he’s going to present surgery to me.”

Sure enough, the surgeon recommended arthroscopic knee surgery. “This is going to fix it,” Ray recalled him saying. “In by nine, out by noon.”

Ray went for a second opinion, to a physical therapist, who, of course, favored physical therapy, just as the surgeon favored surgery. Ray chose physical therapy.

“How’d it turn out?” I asked.

“Amazingly well,” he said. “I feel pretty darn good right now.”

“What did the surgeon say when you told him you weren’t going to do the surgery?”

“He said, ‘No problem, go to P.T., and when that doesn’t work we can schedule the surgery,’ ” Ray recalled. “Who knows? Maybe I will end up having to go back. He wasn’t trying to pull the wool over my eyes. But he believed.”

What Ray recommended to his car-owning listeners was the approach that he adopted as a patient—caveat emptor. He did his research. He made informed choices. He tried to be a virtuous patient.

The virtuous patient is up against long odds, however. One major problem is what economists call information asymmetry. In 1963, Kenneth Arrow, who went on to win the Nobel Prize in Economics, demonstrated the severe disadvantages that buyers have when they know less about a good than the seller does. His prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.

Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body. It has been hard for patients and doctors to recognize that tests and scans can be harmful. Why not take a look and see if anything is abnormal? People are discovering why not. The United States is a country of three hundred million people who annually undergo around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests. Often, these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little nodule that can’t be completely explained, a lab result that is a bit off, a heart tracing that doesn’t look quite right.

Excessive testing is a problem for a number of reasons. For one thing, some diagnostic studies are harmful in themselves—we’re doing so many CT scans and other forms of imaging that rely on radiation that they are believed to be increasing the population’s cancer rates. These direct risks are often greater than we account for.

What’s more, the value of any test depends on how likely you are to be having a significant problem in the first place. If you have crushing chest pain and shortness of breath, you start with a high likelihood of having a serious heart condition, and an electrocardiogram has significant value. A heart tracing that doesn’t look quite right usually means trouble. But, if you have no signs or symptoms of heart trouble, an electrocardiogram adds no useful information; a heart tracing that doesn’t look quite right is mostly noise. Experts recommend against doing electrocardiograms on healthy people, but millions are done each year, anyway.

Resolving the uncertainty of non-normal results can lead to procedures that have costs of their own. You get an EKG. The heart tracing is not completely normal, and a follow-up procedure is recommended. Perhaps it’s a twenty-four-hour heart-rhythm monitor or an echocardiogram or a stress test or a cardiac catheterization; perhaps you end up with all of them before everyone is assured that everything is all right. Meanwhile, we’ve added thousands of dollars in costs and, sometimes, physical risks, not to mention worry and days of missed work.

Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.

My last patient in clinic that day, Mrs. E., a woman in her fifties, had been found to have a thyroid lump. A surgeon removed it, and a biopsy was done. The lump was benign. But, under the microscope, the pathologist found a pinpoint “microcarcinoma” next to it, just five millimetres in size. Anything with the term “carcinoma” in it is bound to be alarming—“carcinoma” means cancer, however “micro” it might be. So when the surgeon told Mrs. E. that a cancer had been found in her thyroid, which was not exactly wrong, she believed he’d saved her life, which was not exactly right. More than a third of the population turns out to have these tiny cancers in their thyroid, but fewer than one in a hundred thousand people die from thyroid cancer a year. Only the rare microcarcinoma develops the capacity to behave like a dangerous, invasive cancer. (Indeed, some experts argue that we should stop calling them “cancers” at all.) That’s why expert guidelines recommend no further treatment when microcarcinomas are found.

Nonetheless, it’s difficult to do nothing. The patient’s surgeon ordered a series of ultrasounds, every few months, to monitor the remainder of her thyroid. When the imaging revealed another five-millimetre nodule, he recommended removing the rest of her thyroid, out of an abundance of caution. The patient was seeing me only because the surgeon had to cancel her operation, owing to his own medical issues. She simply wanted me to fill in for the job—but it was a job, I advised her, that didn’t need doing in the first place. The surgery posed a greater risk of causing harm than any microcarcinoma we might find, I explained. There was a risk of vocal-cord paralysis and life-threatening bleeding. Removing the thyroid would require that she take a daily hormone-replacement pill for the rest of her life. We were better off just checking her nodules in a year and acting only if there was significant enlargement.

H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on overdiagnosis, and in his excellent new book, “Less Medicine, More Health,” he explains the phenomenon this way: we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference.

We’ve learned these lessons the hard way. Over the past two decades, we’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all. In South Korea, widespread ultrasound screening has led to a fifteen-fold increase in detection of small thyroid cancers. Thyroid cancer is now the No. 1 cancer diagnosed and treated in that country. But, as Welch points out, the death rate hasn’t dropped one iota there, either. (Meanwhile, the number of people with permanent complications from thyroid surgery has skyrocketed.) It’s all over-diagnosis. We’re just catching turtles.

Every cancer has a different ratio of rabbits, turtles, and birds, which makes the story enormously complicated. A recent review concludes that, depending on the organ involved, anywhere from fifteen to seventy-five per cent of cancers found are indolent tumors—turtles—that have stopped growing or are growing too slowly to be life-threatening. Cervical and colon cancers are rarely indolent; screening and early treatment have been associated with a notable reduction in deaths from those cancers. Prostate and breast cancers are more like thyroid cancers. Imaging tends to uncover a substantial reservoir of indolent disease and relatively few rabbit-like cancers that are life-threatening but treatable.

We now have a vast and costly health-care industry devoted to finding and responding to turtles. Our ever more sensitive technologies turn up more and more abnormalities—cancers, clogged arteries, damaged-looking knees and backs—that aren’t actually causing problems and never will. And then we doctors try to fix them, even though the result is often more harm than good.

The forces that have led to a global epidemic of overtesting, overdiagnosis, and overtreatment are easy to grasp. Doctors get paid for doing more, not less. We’re more afraid of doing too little than of doing too much. And patients often feel the same way. They’re likely to be grateful for the extra test done in the name of “being thorough”—and then for the procedure to address what’s found. Mrs. E. was such a patient.

Mrs. E. had a turtle. She would have been better off if we’d never monitored her thyroid in the first place. But, now that we’d found something abnormal, she couldn’t imagine just keeping an eye on it. She wanted to take her chances with surgery.

The main way we’ve tried to stop unnecessary treatments has been through policing by insurers: they could refuse to pay for anything that looked like inappropriate care, whether it was an emergency-room visit, an MRI scan, or an operation. And it worked. During the nineteen-nineties, the “Mother, may I?” strategy flattened health-care costs. But it also provoked a backlash. Faceless corporate bureaucrats second-guessing medical decisions from afar created an infuriating amount of hassle for physicians and patients trying to orchestrate necessary care—and sometimes led to outrageous mistakes. Insurance executives were accused of killing people. Facing a public outcry, they backed off, and health-care costs resumed their climb. A decade and a half later, however, more interesting approaches have emerged.

Consider the case of Michael Taylor. A six-foot-tall, fifty-five-year-old optician from Ogden, Utah, Taylor threw his back out a year ago, while pulling weeds from his lawn. When he tried to straighten up, pain bolted from his lower back through his hips and down both thighs. He made his stooped way up his front-porch steps, into his house, and called his wife, Sandy, at work.

“For him to call meant it was really bad,” she said later.

Taylor was a stoic guy who had had back issues for a long time. By his early thirties, he had already undergone two spine operations: the fusion of a vertebra in his neck, which was fractured in a car accident, and the removal of a ruptured disk in his lower back that had damaged a nerve root, causing a foot drop—his left foot slapped when he walked. He’d had periodic trouble with back spasms ever since. For the most part, he managed them through stretches and exercise. He had been a martial artist since the age of thirteen—he’d earned a third-degree black belt—and retained tremendous flexibility. He could still do splits. Occasionally, if an attack was bad, he saw a pain specialist and got a spinal injection of steroids, which usually worked for a while. This episode, however, was worse than any before.

“He could hardly walk,” Sandy said. He tried sleeping in a recliner and waiting out the pain. But it didn’t go away. He called his primary-care physician, who ordered an MRI. It showed degenerative disk disease in his lumbar spine—a bulge or narrowing of disk space between two of the vertebrae in his lower back. The doctor prescribed muscle relaxants and pain medications, and said that Taylor might need spinal surgery. She referred him to a local neurosurgeon.

Taylor put off making the appointment. He did his lower-back stretches and range-of-motion exercises, and worked on losing weight. These measures helped a little, but he still couldn’t sleep in his bed or manage more than a shuffling walk. After four weeks with no improvement, he finally went to see the surgeon, who recommended fusing Taylor’s spine where his disk was bulging. Taylor would lose some mobility—his days of spinning kicks were over—and success was not guaranteed, but the doctor thought that it was the best option.

“He said the surgery would be, like, a fifty-fifty thing,” Taylor recalled. “Half of people would see great success. The other half would see little or no difference. And there’d be a few who find it makes the pain worse.” There was also the matter of cost. The vision center he managed was in a Walmart superstore, and the co-payments and deductibles with the company insurance plan were substantial. His bills were likely to run past a thousand dollars.

But Taylor had heard about a program that Walmart had launched for employees undergoing spine, heart, or transplant procedures. Employees would have no out-of-pocket costs at all if they got the procedure at one of six chosen “centers of excellence”: the Cleveland Clinic; the Mayo Clinic; Virginia Mason Medical Center, in Washington; Scott and White Memorial Hospital, in Texas; Geisinger Medical Center, in Pennsylvania; and Mercy Hospital Springfield, in Missouri. Taylor learned that the designated spine center for his region was Virginia Mason, in Seattle. He used to live in Washington, and the back surgery he’d had when he was younger was at the same hospital. He trusted the place, and it had a good reputation. He decided to proceed.

The program connected him to the hospital, and its staff took care of everything from there. They set up his appointments and arranged the travel for him and his wife. All expenses were covered, even their food and hotel costs.

“They flew us from Salt Lake City and picked us up at the airport in a town car,” Taylor said. He said he felt like royalty.

Walmart wasn’t providing this benefit out of the goodness of its corporate heart, of course. It was hoping that employees would get better surgical results, sure, but also that the company would save money. Spine, heart, and transplant procedures are among the most expensive in medicine, running from tens of thousands to hundreds of thousands of dollars. Nationwide, we spend more money on spinal fusions, for instance, than on any other operation—thirteen billion dollars in 2011. And if there are complications the costs of the procedure go up further. The medical and disability costs can be enormous, especially if an employee is left permanently unable to return to work. These six centers had notably low complication rates and provided Walmart a fixed, package price.

Two years into the program, an unexpected pattern is emerging: the biggest savings and improvements in care are coming from avoiding procedures that shouldn’t be done in the first place. Before the participating hospitals operate, their doctors conduct their own evaluation. And, according to Sally Welborn, the senior vice-president for benefits at Walmart, those doctors are finding that around thirty per cent of the spinal procedures that employees were told they needed are inappropriate. Dr. Charles Nussbaum, until recently the head of neurosurgery at Virginia Mason Medical Center, confirmed that large numbers of the patients sent to his hospital for spine surgery do not meet its criteria.

Michael Taylor was one of those patients. Disk disease like the kind seen on his MRI is exceedingly common. Studies of adults with no back pain find that half or more have degenerative disk disease on imaging. Disk disease is a turtle—an abnormality that generally causes no harm. It’s different when a diseased disk compresses the spinal cord or nerve root enough to cause specific symptoms, such as pain or weakness along the affected nerve’s territory, typically the leg or the arm. In those situations, surgery is proved to be more effective than nonsurgical treatment. For someone without such symptoms, though, there is no evidence that surgery helps to reduce pain or to prevent problems. One study found that between 1997 and 2005 national health-care expenditures for back-pain patients increased by nearly two-thirds, yet population surveys revealed no improvement in the level of back pain reported by patients.

There are gray-zone cases, but Taylor’s case was straightforward. Nussbaum said that Taylor’s MRI showed no disk abnormality compressing his spinal cord or nerve root. He had no new leg or foot weakness. His pain went down both legs and not past the knee, which didn’t fit with disk disease. The symptoms were consistent with muscle spasms or chronic nerve sensitivity resulting from his previous injuries. Fusing Taylor’s spine—locking two vertebrae together with bolts and screws—wouldn’t fix these problems. At best, it would stop him from bending where it hurt, but that was like wiring a person’s jaw shut because his tooth hurts when he chews. Fusing the spine also increases the load on the disks above and below the level of fusion, making future back problems significantly more likely. And that’s if things go well. Nussbaum recommended against the surgery.

This was not what Taylor’s wife wanted to hear. Had they come all this way for nothing? “I got kind of angry,” Sandy told me later. She wanted his back problem solved.

He did, too. But he was relieved to hear that he wouldn’t have to undergo another back operation. Nussbaum’s explanations made sense to him, and he had never liked the idea of having his spine fused. Moreover, unlike most places, the Virginia Mason spine center had him seen not only by a surgeon but also by a rehabilitation-medicine specialist, who suggested a nonsurgical approach: a spinal injection that afternoon, continued back exercises, and a medication specifically for neuropathic pain—chronic nerve sensitivity.

“Within a couple of weeks, I was literally pain free,” Taylor said. It was six months after his visit to Seattle, and he could do things he hadn’t been able to do in decades.

“I was just amazed,” Sandy said. “The longer it’s been, the better he is.”

If an insurer had simply decreed Taylor’s back surgery to be unnecessary, and denied coverage, the Taylors would have been outraged. But the worst part is that he would not have got better. It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care. And that is the hidden harm: unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative. Walmart, of all places, is showing one way to take action against no-value care—rewarding the doctors and systems that do a better job and the patients who seek them out.

Six years ago, in “The Cost Conundrum,” I compared McAllen with another Texas border town, El Paso. They had the same demographics—the same levels of severe poverty, poor health, illegal immigration—but El Paso had half the per-capita Medicare costs and the same or better results. The difference was that McAllen’s doctors were ordering more of almost everything—diagnostic testing, hospital admissions, procedures. Medicare patients in McAllen received forty per cent more surgery, almost twice as many bladder scopes and heart studies, and two to three times as many pacemakers, cardiac bypass operations, carotid endarterectomies, and coronary stents. Per-capita spending on home-health services was five times higher than in El Paso and more than half of what many American communities spent on all health care. The amount of unnecessary care appeared to be huge.

What explained this? Our piecework payment system—rewarding doctors for the quantity of care provided, regardless of the results—was a key factor. The system gives ample reward for overtreatment and no reward for eliminating it. But these inducements applied everywhere. Why did McAllen succumb to them more than other medical communities did? Doctors there described a profit-maximizing medical culture. Specialists not only made money from the services they provided; many also owned stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital, which brought them even bigger returns from health-care overuse.

The test of health-care reform, I wrote, was whether McAllen or El Paso would become the new norm. Would McAllen’s costs come down or El Paso’s go up? Now that it has been five years since the passage of the Affordable Care Act, I thought I’d find out. I returned to the economist Jonathan Skinner, of the Dartmouth Institute for Health Policy and Clinical Practice, who had provided the earlier analysis of the Medicare data, and worked with him to get a sense of what recent data reveal. As it turns out, the cost of a Medicare patient has flattened across the country, El Paso included. U.S. health-care inflation is the lowest it has been in more than fifty years. Most startling of all, McAllen has been changing its ways. Between 2009 and 2012, its costs dropped almost three thousand dollars per Medicare recipient. Skinner projects the total savings to taxpayers to have reached almost half a billion dollars by the end of 2014. The hope of reform had been to simply “bend the curve.” This was savings on an unprecedented scale.

Skinner showed me the details. In-patient hospital visits dropped by about ten per cent—and physicians reduced the mad amounts of home-health-care spending by nearly forty per cent. McAllen’s spending on ambulance rides—previously the highest in the country—dropped by almost forty per cent, too.

I followed up with doctors there to find out how this had happened. I started with Lester Dyke, a cardiac surgeon who was one of many doctors troubled by what they were seeing, but the only one to let me quote him by name in my McAllen piece. (“Medicine has become a pig trough here,” he had told me. “We took a wrong turn when doctors stopped being doctors and became businessmen.”) After it was published, television crews descended on the town. Texas newspapers did follow-up investigations.

“The reaction here was fierce, just a tremendous amount of finger-pointing and yelling and screaming,” Dyke recently told me. The piece infuriated the local medical community, which felt unfairly singled out. And Dyke paid a steep price: “I became persona non grata overnight.” Colleagues said that he would be to blame if they lost money. Cardiologists stopped sending him patients. “My cases went down by ninety per cent,” he told me. He had to give up his practice at Doctors Hospital at Renaissance, the for-profit hospital, after it became clear that he wasn’t welcome there, but he was able to continue doing some surgery at two other hospitals. When I talked to Dyke in the first months afterward, he’d sounded low. The few friends who voiced support didn’t want to be seen in public with him. He thought he might be forced to retire.

Yet he insisted that he had no regrets. Two of his children went into medicine, and in a medical-ethics class his son was assigned the article. The professor asked whether he was related to the Dr. Dyke quoted in it.

“Yes, I am,” he said proudly. “That’s my crazy dad.”

“I don’t think you often get a chance in life to stand up to all the badness,” Dyke told me.

With time, the anger of colleagues subsided. Many of them resumed sending him patients. Within a couple of years, he was back to an annual caseload of three hundred open-heart operations. Meanwhile, it got harder for McAllen physicians to ignore the evidence about unnecessary care. Several federal prosecutions cracked down on outright fraud. Seven doctors agreed to a twenty-eight-million-dollar settlement for taking illegal kickbacks when they referred their patients to specialty medical services. An ambulance-company owner was indicted for reporting six hundred and twenty-one ambulance rides that allegedly never happened. Four clinic operators were sent to jail for billing more than thirteen thousand visits and procedures under the name of a physician with dementia. The prosecutions involved only a tiny fraction of the medical community. But Dyke thought it led doctors to say to themselves, “Hey, we’re under the magnifying glass. We need to make sure we’re doing things strictly by the book.”

Jose Peña, an internist, was a board member at Doctors Hospital at Renaissance in 2009. When we spoke recently, he didn’t hesitate to tell me the immediate reaction his colleagues had to what I’d written. “We hated you,” he said. The story “put us in a spotlight, in a bad way,” but, he added, “in a good way at the same time.” They hadn’t known that they were one of the most expensive communities in the country, he maintained. They knew there were problems, “but we did not know the magnitude.” His hospital did its own analysis of the data and reluctantly came to the same conclusion that the article did: inappropriate and unnecessary care was a serious problem.

The major overuse of home-health-care services proved particularly embarrassing. “We didn’t know that home health was a thousand dollars a month” for each patient, Peña said. People in the medical community had never paid attention to how much of it they were ordering or how little of it was really needed. He led monthly staff meetings with more than four hundred local physicians and began encouraging them to be more mindful about signing home-health-care orders. Within a year, home-health-care agencies started going out of business.

But more interesting was how broad and enduring the cost decline has been. E.R. visits, hospital admissions, tests, and procedures all fell from the Texas stratosphere. And, years after the attention and embarrassment had passed, the costs continued to fall. Bad publicity, a few prosecutions, and some stiffened regulatory requirements here and there couldn’t explain that. I probed for months, talking to local doctors and poring over data. And I’ve come to think that a major reason for the change may be a collection of primary-care doctors who don’t even seem to recognize the impact of what they’ve been doing.

Armando Osio is a sixty-three-year-old family physician in McAllen. In 2009, when the article came out, he did not own part of an imaging center or sleep-testing center or hospital or any other medical money-making venture. He didn’t have any procedures or tests that he made big money from. He was just a primary-care doctor doing what primary-care doctors do—seeing patient after patient every twenty to thirty minutes, for about sixty dollars a visit. That’s what Medicare paid; private insurance paid more, and Medicaid or the uninsured paid less. He earned nothing like the income of the specialists that I’d written about.

Then, later that year, officials at a large medical group called WellMed contacted Osio. They wanted to establish a practice in McAllen, catering to Medicare patients, and asked whether he’d join them. WellMed had contracted with Medicare H.M.O. plans to control their costs. Its pitch to clinicians was that, if a doctor improved the quality of care, this would save on costs, and WellMed would share those savings with the doctor in the form of bonuses. That meant Osio would have to see fewer patients, for longer visits, but WellMed assured him that, if he could show measurable quality improvements, he’d actually make more money.

Osio was skeptical, but he agreed to see some of WellMed’s patients. When he was in training, he’d been interested in geriatrics and preventive medicine. In practice, he hadn’t had time to use those skills. Now he could. With WellMed’s help, Osio brought on a physician assistant and other staff to help with less complex patients. He focussed on the sicker, often poorer patients, and he found that his work became more satisfying. With the bonuses for higher patient satisfaction, reducing hospital admissions, and lowering cardiology costs, his income went up. This was the way he wanted to practice—being rewarded for doing right rather than for the disheartening business of churning through more and more people. Within a year, he’d switched his practice so that he was seeing almost entirely WellMed patients.

He gave me an example of one. That day, he’d seen an elderly man who had taken a bad spill two or three weeks earlier, resulting in a contused kidney and a compression fracture of his lower spine. After a couple of days in the hospital, he’d been sent home. But the pain remained unmanageable. He called Osio’s office seeking help.

If the man had called five years ago, a receptionist would have told him that the schedule was full for days and sent him to an emergency room. There, he would have waited hours, been seen by someone who didn’t know his story, been given a repeat CT or MRI, and then likely have been kept for another hospital stay. Once the doctors were sure that the situation wasn’t dangerous, he would finally have been sent home, with pain medicine and instructions to see his primary-care doctor. Cost: a few thousand dollars.

Now when the man called, the receptionist slotted him to see Osio that afternoon. The doctor examined him and, being familiar with his case, determined that he had no worsening signs requiring imaging. He counselled patience and offered reassurance, gave him pain medication, and sent him home, with a plan for his nurse to check on him the next day. Cost: at most, a hundred dollars. And the patient got swifter, better care.

I spoke to Carlos Hernandez, an internist and the president of WellMed. He explained that the medical group was founded twenty-five years ago, in San Antonio, by a geriatrician who believed that what the oldest and sickest most needed in our hyper-specialized medical system was slower, more dedicated primary care. “Our philosophy is that the primary-care physician and patient should become the hub of the entire health-care-delivery system,” Hernandez said. He viewed the primary-care doctor as a kind of contractor for patients, reining in pointless testing, procedures, and emergency-room visits, coördinating treatment, and helping to find specialists who practice thoughtfully and effectively. Our technology- and specialty-intensive health system has resisted this kind of role, but countries that have higher proportions of general practitioners have better medical outcomes, better patient experiences, and, according to a European study, lower cost growth. WellMed found insurers who saw these advantages and were willing to pay for this model of care. Today, WellMed has more than a hundred clinics, fifteen hundred primary-care doctors, and around a quarter of a million patients across Texas and Florida.

There’s a reason that WellMed focussed on these two states. They are among the nation’s most expensive states for Medicare and are less well-supplied with primary care. An independent 2011 analysis of the company’s Texas clinics found that, although the patient population they drew from tended to be less healthy than the over-all Medicare population (being older and having higher rates of diabetes and chronic lung disease, for instance), their death rates were half of the Texas average.

This last part puzzled me. I had started to recognize how unnecessary care could crowd out necessary care—but enough that dedicated primary care could cut death rates in half? That seemed hard to believe. As I learned more about how Dr. Osio’s practice had changed, though, I began to grasp how it could happen.

He told me, for instance, about a new patient he’d seen, a sixty-five-year-old man with diabetes. His blood-sugar level was dangerously high, at a level that can signify a full-blown diabetic crisis, with severe dehydration, rising acid levels in the blood, and a risk of death. The man didn’t look ill, though. His vital signs were normal. Osio ordered a urine test, which confirmed that the man was not in crisis. That was, in a way, a bad sign. It meant that his diabetes was so out of control that his body had developed a tolerance to big spikes in blood sugar. Unchecked, his diabetes would eventually cause something terrible—kidney failure, a heart attack, blindness, or the kind of wound-healing problem that leads to amputation.

Previously, Osio would not have had the time or the resources to do much for the man. So he would have sent him to the hospital. The staff there would have done a battery of tests to confirm what Osio already knew—that his blood sugar was way too high. They would have admitted him, given him insulin, and brought his blood sugar down to normal. And that would have been about it. The thousands of dollars spent on the hospital admission would have masked a galling reality: no one was addressing the man’s core medical problem, which was that he had a chronic and deadly disease that remained dangerously out of control.

But now WellMed gave Osio bonuses if his patients’ diabetes was under better control, and helped him to develop a system for achieving this. Osio spent three-quarters of an hour with the man, going over his pill bottles and getting him to explain what he understood about his condition and how to treat it. The man was a blue-collar worker with limited schooling, and Osio discovered that he had some critical misunderstandings. For instance, although he checked his blood-sugar level every day, he wrongly believed that if the level was normal he didn’t need to take his medicine. No, Osio told him; his diabetes medication was like his blood-pressure medication—he should never skip a dose unless the home measurements were too low.

Osio explained what diabetes is, how dangerous it can be, how insulin works. Then he turned the man over to an office nurse who had taken classes to become certified as a diabetes educator. She spent another forty-five minutes having him practice how to draw up and take his insulin, and how to track his sugar levels in a logbook. She set a plan to call him every other day for a week and then, if necessary, bring him back for another review. This would continue until his disease was demonstrably under control. After that, she’d check on him once a month by phone, and Osio would see him every three to four months. The nurse gave him her direct phone number. If he had any problems or questions, she told him, “Llámame”—call me.

Step by deliberate step, Osio and his team were replacing unnecessary care with the care that people needed. Since 2009, in Hidalgo County, where McAllen is situated, WellMed has contracted with physicians taking care of around fourteen thousand Medicare patients. According to its data, the local WellMed practices have achieved the same results as WellMed has elsewhere: large reductions in overuse of care and better outcomes for patients. Indeed, for the past two years, the top-ranked primary-care doctor out of WellMed’s fifteen hundred—according to a wide range of quality measures, such as the percentage of patients with well-controlled blood pressure and diabetes, rates of emergency-room visits and hospital readmissions, and levels of patient satisfaction—has been a McAllen physician.

I spoke to that doctor, Omar Gomez. He said that he’d set about building a strong team around his patients, and that team included specialists such as cardiologists and surgeons. He encouraged his patients to shift to the ones who, he noticed, didn’t subject them to no-value care. He sat with the specialists, and, he said, “I told them, ‘If my patient needs a cardiac cath—by all means, do it. But if they don’t, then don’t do it. That’s the only thing I ask.’”

The passage of the Affordable Care Act, in 2010, created opportunities for physicians to practice this kind of dedicated care. The law allows any group of physicians with five thousand or more Medicare patients to contract directly with the government as an “accountable-care organization,” and to receive up to sixty per cent of any savings they produce. In McAllen, two primary-care groups, with a total of nearly thirteen thousand patients, formed to take advantage of the deal. One, as it happens, was led by Jose Peña, the Doctors Hospital at Renaissance internist. Two years later, Medicare reported that Peña’s team had markedly improved control of its patients’ diabetes; patients also had dramatically lower emergency-room visits and hospital admissions. And the two McAllen accountable-care organizations together managed to save Medicare a total of twenty-six million dollars. About sixty per cent of that went back to the groups. It wasn’t all profit—achieving the results had meant installing expensive data-tracking systems and hiring extra staff. But even after overhead doctors in one group took home almost eight hundred thousand dollars each (some of which they shared with their mid-level staff). It was proving to be a very attractive way to practice.

McAllen, in large part because of changes led by primary-care doctors, has gone from a cautionary tale to something more hopeful. Nationwide, the picture is changing almost as fast. Just five years after the passage of health-care reform, twenty per cent of Medicare payments are being made to physicians who have enrolled in alternative-payment programs, whether through accountable-care organizations like those in McAllen or by accepting Walmart-like packaged-price care—known as bundled payment—for spine surgery, joint surgery, and other high-cost procedures. If government targets are met, these numbers will reach thirty per cent of Medicare payments by 2016. A growing number of businesses are also extending the centers-of-excellence approach to their employees, including Boeing, Kohl’s, Lowe’s, and PepsiCo. And a nonprofit in California, the Pacific Business Group on Health, now offers to provide a similar network to any health-care purchaser in the country.

Could a backlash arrive and halt the trend? It’s a concern. No one has yet invented a payment system that cannot be gamed. If doctors are rewarded for practicing more conservative medicine, some could end up stinting on care. What if Virginia Mason turns away a back-pain patient who should have gone to surgery? What if Dr. Osio fails to send a heart patient to the emergency room when he should have? What if I recommend not operating on a tiny tumor, saying that it is just a turtle, and it turns out to be a rabbit that bounds out of control?

Proponents point out that people can sue if they think they’ve been harmed, and doctors’ groups can lose their contracts for low-quality scores, which are posted on the Web. But not all quality can be measured. It’s possible that we will calibrate things wrongly, and skate past the point where conservative care becomes inadequate care. Then outrage over the billions of dollars in unnecessary stents and surgeries and scans will become outrage over necessary stents and surgeries and scans that were not performed.

Right now, we’re so wildly over the boundary line in the other direction that it’s hard to see how we could accept leaving health care the way it is. Waste is not just consuming a third of health-care spending; it’s costing people’s lives. As long as a more thoughtful, more measured style of medicine keeps improving outcomes, change should be easy to cheer for. Still, when it’s your turn to sit across from a doctor, in the white glare of a clinic, with your back aching, or your head throbbing, or a scan showing some small possible abnormality, what are you going to fear more—the prospect of doing too little or of doing too much?

Mrs. E., my patient with a five-millimetre thyroid nodule that I recommended leaving alone, feared doing too little. So one morning I took her to the operating room, opened her neck, and, in the course of an hour, removed her thyroid gland from its delicate nest of arteries and veins and critical nerves. Given that the surgery posed a greater likelihood of harm than of benefit, some people would argue that I shouldn’t have done it. I took her thyroid out because the idea of tracking a cancer over time filled her with dread, as it does many people. A decade from now, that may change. The idea that we are overdiagnosing and overtreating many diseases, including cancer, will surely become less contentious. That will make it easier to calm people’s worries. But the worries cannot be dismissed. Right now, even doctors are still coming to terms with the evidence.

Other people of a more consumerist bent will be troubled not that I gave her the choice but that she paid virtually none of the expenses incurred by it. The nature of her insurance coverage guaranteed that. Her employer had offered her two options. One was a plan with a high deductible and a medical savings account that would have made her pay a substantial portion of the many-thousand-dollar operation. And this might have made her think harder about proceeding (or, at least, encouraged her to find someone cheaper). But, like many people, she didn’t want to be in that situation. So she chose the second option, which provided full coverage for cases like this one. She found it difficult enough to weigh her fears of the cancer against her fears of the operation—with its risks of life-threatening bleeding and voice damage—without having to put finances into the equation.

Two hours after the surgery, Mrs. E.’s nurse called me urgently to see her in the recovery room. Her neck was swelling rapidly; she was bleeding. We rushed her back to the operating room and reopened her neck before accumulating blood cut off her airway. A small pumping artery had opened up in a thin band of muscle I’d cauterized. I tied the vessel off, washed the blood away, and took her back to the recovery room.

I saw her in my office a few weeks later, and was relieved to see she’d suffered no permanent harm. The black and blue of her neck was fading. Her voice was normal. And she hadn’t needed the pain medication I’d prescribed. I arranged for a blood test to check the level of her thyroid hormone, which she now had to take by pill for the rest of her life. Then I showed her the pathology report. She did have a thyroid cancer, a microcarcinoma about the size of this “O,” with no signs of unusual invasion or spread. I wished we had a better word for this than “cancer”—because what she had was not a danger to her life, and would almost certainly never have bothered her if it had not been caught on a scan.

All the same, she thanked me profusely for relieving her anxiety. I couldn’t help reflect on how that anxiety had been created. The medical system had done what it so often does: performed tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk. Meanwhile, we avoid taking adequate care of the biggest problems that people face—problems like diabetes, high blood pressure, or any number of less technologically intensive conditions. An entire health-care system has been devoted to this game. Yet we’re finally seeing evidence that the system can change—even in the most expensive places for health care in the country.

Atul Gawande, a surgeon and public-health researcher, became a New Yorker staff writer in 1998.

The Heroism of Incremental Care

We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.

By Atul Gawande, The New Yorker, January 23, 2017

See the Original Article here.

By 2010, Bill Haynes had spent almost four decades under attack from the inside of his skull. He was fifty-seven years old, and he suffered from severe migraines that felt as if a drill were working behind his eyes, across his forehead, and down the back of his head and neck. They left him nauseated, causing him to vomit every half hour for up to eighteen hours. He’d spend a day and a half in bed, and then another day stumbling through sentences. The pain would gradually subside, but often not entirely. And after a few days a new attack would begin.

Haynes (I’ve changed his name, at his request) had his first migraine at the age of nineteen. It came on suddenly, while he was driving. He pulled over, opened the door, and threw up in someone’s yard. At first, the attacks were infrequent and lasted only a few hours. But by the time he was thirty, married, and working in construction management in London, where his family was from, they were coming weekly, usually on the weekends. A few years later, he began to get the attacks at work as well.

He saw all kinds of doctors—primary-care physicians, neurologists, psychiatrists—who told him what he already knew: he had chronic migraine headaches. And what little the doctors had to offer didn’t do him much good. Headaches rank among the most common reasons for doctor visits worldwide. A small number are due to secondary causes, such as a brain tumor, cerebral aneurysm, head injury, or infection. Most are tension headaches—diffuse, muscle-related head pain with a tightening, non-pulsating quality—that generally respond to analgesics, sleep, neck exercises, and time. Migraines afflict about ten per cent of people with headaches, but a much larger percentage of those who see doctors, because migraines are difficult to control.

Migraines are typically characterized by severe, disabling, recurrent attacks of pain confined to one side of the head, pulsating in quality and aggravated by routine physical activities. They can last for hours or days. Nausea and sensitivity to light or sound are common. They can be associated with an aura—visual distortions, sensory changes, or even speech and language disturbances that herald the onset of head pain.

Although the cause of migraines remains unknown, a number of treatments have been discovered that can either reduce their occurrence or alleviate them once they occur. Haynes tried them all. His wife also took him to a dentist who fitted him with a mouth guard. After seeing an advertisement, she got him an electrical device that he applied to his face for half an hour every day. She bought him hypnotism tapes, high-dosage vitamins, magnesium tablets, and herbal treatments. He tried everything enthusiastically, and occasionally a remedy would help for a brief period, but nothing made a lasting difference.

Finally, desperate for a change, he and his wife quit their jobs, rented out their house in London, and moved to a cottage in a rural village. The attacks eased for a few months. A local doctor who had migraines himself suggested that Haynes try the cocktail of medicines he used. That helped some, but the attacks continued. Haynes seesawed between good periods and bad. And without work he and his wife began to feel that they were vegetating.

On a trip to New York City, when he turned fifty, they decided they needed to make another big change. They sold everything and bought a bed-and-breakfast on Cape Cod. Their business thrived, but by the summer of 2010, when Haynes was in his late fifties, the headaches were, he said, “knocking me down like they never had before.” Doctors had told him that migraines diminish with age, but his stubbornly refused to do so. “During one of these attacks, I worked out that I’d spent two years in bed with a hot-water bottle around my head, and I began thinking about how to take my life,” he said. He had a new internist, though, and she recommended that he go to a Boston clinic that was dedicated to the treatment of headaches. He was willing to give it a try. But he wasn’t hopeful. How would a doctor there do anything different from all the others he’d seen?

That question interested me, too. I work at the hospital where the clinic is based. The John Graham Headache Center, as it’s called, has long had a reputation for helping people with especially difficult cases. Founded in the nineteen-fifties, it now delivers more than eight thousand consultations a year at several locations across eastern Massachusetts. Two years ago, I asked Elizabeth Loder, who’s in charge of the program, if I could join her at the clinic to see how she and her colleagues helped people whose problems had stumped so many others. I accompanied her for a day of patient visits, and that was when I met Haynes, who had been her patient for five years. I asked her whether he was the worst case she’d seen. He wasn’t even the worst case she’d seen that week, she said. She estimated that sixty per cent of the clinic’s patients suffer from daily, persistent headaches, and usually have for years.

In her examination room, with its white vinyl floor and sanitary-paper-covered examination table against the wall, the fluorescent overhead lights were turned off to avoid triggering migraines. The sole illumination came from a low-wattage table lamp and a desktop-computer screen. Sitting across from her first patient of the day, Loder, who is fifty-eight, was attentive and unhurried, dressed in plain black slacks and a freshly pressed white doctor’s coat, her auburn hair tucked into a bun. She projected both professional confidence and maternal concern. She had told me how she begins with new patients: “You ask them to tell the story of their headache and then you stay very quiet for a long time.”

The patient was a reticent twenty-nine-year-old nurse who had come to see Loder about the chronic daily headaches she’d been having since she was twelve. Loder typed as the woman spoke, like a journalist taking notes. She did not interrupt or comment, except to say, “Tell me more,” until the full story emerged. The nurse said that she enjoyed only three or four days a month without a throbbing headache. She’d tried a long list of medications, without success. The headaches had interfered with college, relationships, her job. She dreaded night shifts, since the headaches that came afterward were particularly awful.

Loder gave a sympathetic shake of her head, and that was enough to win the woman’s confidence. The patient knew that she’d been heard by someone who understood the seriousness of her problem—a problem invisible to the naked eye, to blood tests, to biopsies, and to scans, and often not even believed by co-workers, family members, or, indeed, doctors.

She reviewed the woman’s records—all the medications she’d taken, all the tests she’d undergone—and did a brief examination. Then we came to the moment I’d been waiting for, the moment when I would see what made the clinic so effective. Would Loder diagnose a condition that had never been suspected? Would she suggest a treatment I’d never heard of? Would she have some special microvascular procedure she could perform that others couldn’t?

The answer was no. This was, I later came to realize, the key fact about Loder’s capabilities. But I didn’t see it that day, and I was never going to see it in any single visit.

She started, disappointingly, by lowering expectations. For some ninety-five per cent of patients who see her, including this woman, the diagnosis is chronic migraines. And for chronic migraines, she explained, a complete cure was unlikely. Success meant that the headaches became less frequent and less intense, and that the patients grew more confident in handling them. Even that progress would take time. There is rarely a single, immediate remedy, she said, whether it was a drug or a change in diet or an exercise regimen. Nonetheless, she wanted her patients to trust her. Things would take a while—months, sometimes longer. Success would be incremental.

She asked the woman to keep a headache diary using a form she gave her to rate the peak level and hours of headache each day. She explained that together they would make small changes in treatments and review the diary every few months. If a regimen produced a greater than fifty-per-cent reduction in the number and severity of the headaches, they’d call that a victory.

Haynes told me that Loder gave him the same speech when he first saw her, in 2010, and he decided to stick with her. He liked how methodical she was. He kept his headache diary faithfully. They began by formulating a “rescue plan” for managing his attacks. During an attack, he often vomited pills, so she gave him a supply of non-narcotic rectal suppositories for fast-acting pain relief and an injectable medicine if they didn’t work. Neither was pleasant to take, but they helped. The peak level and duration of his attacks diminished slightly. She then tried changing the medications he used for prevention. When one medicine caused side effects he couldn’t tolerate, she switched to another, but that one didn’t produce any reduction in headaches. He saw her every three months, and they kept on measuring and adjusting.

The most exotic thing they tried was Botox—botulinum-toxin injections—which the F.D.A. had approved for chronic migraines in 2010. She thought he might benefit from injections along the muscles of his forehead. Haynes’s insurer refused to cover the cost, however, and, at upwards of twelve hundred dollars a vial, the treatment was beyond what he could afford. So Loder took on the insurer, and after numerous calls and almost a year of delays Haynes won coverage.

After the first few rounds of injections—each treatment lasts three months and is intended to relax but not paralyze the muscles—Haynes noticed no dramatic change. He was on four medications for prevention, including the Botox, and had four escalating rescue treatments that he could resort to whenever a bad headache began to mount. Three years had passed, and progress had been minimal, but Loder was hopeful.

“I am actually quite optimistic about his long-term outlook for improvement,” she wrote in her notes that spring. “I detect slow but steady progress. In particular, the extremes of headache at the upper end have come down nicely and vomiting is much less of a problem. That, in my experience, is a clear sign of regression.” Haynes wasn’t so sure. But after another year or so of adjustments he, too, began to notice a difference. The interval between bad attacks had lengthened to a week. Later, it stretched to a month. Then even longer.

When I met Haynes, in 2015, he’d gone more than a year without a severe migraine. “I haven’t had a dreadful attack since March 13, 2014,” he said, triumphantly. It had taken four years of effort. But Loder’s systematic incrementalism had done what nothing else had.

I later went to visit Haynes and his wife at their lovely nine-room inn on the Cape. He was tall and lanky, with a John Cleese mustache and the kind of wary astonishment I imagine that men released after years in prison have. At sixty-two, he was savoring experiences he feared he’d never get to have in his life.

“I’m a changed person,” he said. “I’ve a bubbliness in my life now. I don’t feel at threat. We can arrange dinner parties. I’m not the social cripple that I was. I’m not going to let anyone down anymore. I’m not going to let my wife down anymore. I was a terrible person to live with. That’s gone from my life.”

Migraines had ruled his life for more than four decades. For the first time, he could read a book all the way through. He could take jet flights without fear of what the air pressure might do to his head. His wife couldn’t say enough about the difference.

“It’s almost a miracle,” she said. “It has been life-changing for me. It makes me so happy that he’s not ill. I feel good about my future. We can look forward together.”

Recently, I checked in again, and he hadn’t had another headache. Haynes doesn’t like to think about what would have happened if he hadn’t found the headache clinic. He wished he’d found it decades earlier. “Dr. Loder saved my life,” he said.

We have a certain heroic expectation of how medicine works. Following the Second World War, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases that it had been thought only God could touch. New vaccines routed polio, diphtheria, rubella, and measles. Surgeons opened the heart, transplanted organs, and removed once inoperable tumors. Heart attacks could be stopped; cancers could be cured. A single generation experienced a transformation in the treatment of human illness as no generation had before. It was like discovering that water could put out fire. We built our health-care system, accordingly, to deploy firefighters. Doctors became saviors.

But the model wasn’t quite right. If an illness is a fire, many of them require months or years to extinguish, or can be reduced only to a low-level smolder. The treatments may have side effects and complications that require yet more attention. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.

I was drawn to medicine by the aura of heroism—by the chance to charge in and solve a dangerous problem. I loved learning how to unravel diagnostic mysteries on the general-medicine ward, and how to deliver babies in the obstetrics unit, and how to stop heart attacks in the cardiology unit. I worked in a DNA virus lab for a time and considered going into infectious diseases. But it was the operating room that really drew me in.

I remember seeing a college student with infectious mononucleosis, caused by the very virus I was studying in the lab—the Epstein-Barr virus. The infection causes the spleen to enlarge, and in rare cases it grows so big that it spontaneously ruptures, producing major internal bleeding. This is what happened to the student. He arrived in our emergency department in hemorrhagic shock. His pulse was rapid and thready. The team could barely detect a blood pressure. We rushed him to the operating room. By the time we got him on the table and under anesthesia, he was on the verge of cardiac arrest.

The resident opened the young man’s belly in two moves: with a knife he made a swift, decisive slash down the middle, through the skin, from the rib cage to below his umbilicus, then with open-jawed scissors pushed upward through the linea alba—the tough fibrous tendon that runs between the abdominal muscles—as if it were wrapping paper. A pool of blood burst out of him. The resident thrust a gloved hand into the opening. The attending surgeon stood across from him, asking, in a weirdly calm, quiet voice, almost under his breath, “Have you got it?”




“You have thirty more seconds.”

Suddenly, the resident had freed the spleen and lifted it to the surface. The organ was fleshy and heavy, like a sodden loaf of bread. A torrent of blood poured out of a fissure on its surface. The attending surgeon put a clamp across its tether of blood vessels. The bleeding stopped instantly. The patient was saved.

How can anyone not love that? I knew there was a place for prevention and maintenance and incremental progress against difficult problems. But this seemed like the real work of saving lives. Surgery was a definitive intervention at a critical moment in a person’s life, with a clear, calculable, frequently transformative outcome.

Fields like primary-care medicine seemed, by comparison, squishy and uncertain. How often could you really achieve victories by inveigling patients to take their medicines when less than half really do; to lose weight when only a small fraction can keep it off; to quit smoking; to deal with their alcohol problem; to show up for their annual physical, which doesn’t seem to make that much difference anyway? I wanted to know I was doing work that would matter. I decided to go into surgery.

Not long ago, I was talking to Asaf Bitton, a thirty-nine-year-old internist I work with, about the contrast between his work and mine, and I made the mistake of saying that I had more opportunities to make a clear difference in people’s lives. He was having none of it. Primary care, he countered, is the medical profession that has the greatest over-all impact, including lower mortality and better health, not to mention lower medical costs. Asaf is a recognized expert on the delivery of primary health care around the world, and, over the next few days, he sent me evidence for his claims.

He showed me studies demonstrating that states with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke. Other studies found that people with a primary-care physician as their usual source of care had lower subsequent five-year mortality rates than others, regardless of their initial health. In the United Kingdom, where family physicians are paid to practice in deprived areas, a ten-per-cent increase in the primary-care supply was shown to improve people’s health so much that you could add ten years to everyone’s life and still not match the benefit. Another study examined health-care reforms in Spain that focussed on strengthening primary care in various regions—by, for instance, building more clinics, extending their hours, and paying for home visits. After ten years, mortality fell in the areas where the reforms were made, and it fell more in those areas which received the reforms earlier. Likewise, reforms in California that provided all Medicaid recipients with primary-care physicians resulted in lower hospitalization rates. By contrast, private Medicare plans that increased co-payments for primary-care visits—and thereby reduced such visits—saw increased hospitalization rates. Further, the more complex a person’s medical needs are the greater the benefit of primary care.

I finally had to submit. Primary care, it seemed, does a lot of good for people—maybe even more good, in the long run, than I will as a surgeon. But I still wondered how. What, exactly, is the primary-care physician’s skill? I visited Asaf’s clinic to see.

The clinic is in the Boston neighborhood of Jamaica Plain, and it has three full-time physicians, several part-timers, three physician assistants, three social workers, a nurse, a pharmacist, and a nutritionist. Together, they get some fourteen thousand patient visits a year in fifteen clinic rooms, which were going pretty much non-stop on the day I dropped by.

People came in with leg pains, arm pains, belly pains, joint pains, head pains, or just for a checkup. I met an eighty-eight-year-old man who had survived a cardiac arrest in a parking lot. I talked to a physician assistant who, in the previous few hours, had administered vaccinations, cleaned wax out of the ears of an elderly woman with hearing trouble, adjusted the medications of a man whose home blood-pressure readings were far too high, and followed up on a patient with diabetes.

The clinic had a teeming variousness. It didn’t matter if patients had psoriasis or psychosis, the clinic had to have something useful to offer them. At any given moment, someone there might be suturing a laceration, lancing an abscess, aspirating a gouty joint, biopsying a suspicious skin lesion, managing a bipolar-disorder crisis, assessing a geriatric patient who had taken a fall, placing an intrauterine contraceptive device, or stabilizing a patient who’d had an asthma attack. The clinic was licensed to dispense thirty-five medicines on the premises, including steroids and epinephrine, for an anaphylactic allergic reaction; a shot of ceftriaxone, for newly diagnosed gonorrhea; a dose of doxycycline, for acute Lyme disease; or a one-gram dose of azithromycin for chlamydia, so that someone can directly observe that the patient swallows it, reducing the danger that he or she will infect someone else.

“We do the things you really don’t need specialists for,” a physician assistant said. And I saw what a formidably comprehensive range that could be. Asaf—Israeli-born and Minnesota-raised, which means that he’s both more talkative and happier than the average Bostonian—told me about one of his favorite maneuvers. Three or four times a year, a patient comes in with disabling episodes of dizziness because of a condition called benign positional vertigo. It’s caused by loose particles of calcified debris rattling around in the semicircular canal of the inner ear. Sometimes patients are barely able to stand. They are nauseated. They vomit. Just turning their head the wrong way, or rolling over in bed, can bring on a bout of dizziness. It’s like the worst seasickness you can imagine.

“I have just the trick,” he tells them.

First, to be sure he has the correct diagnosis, he does the Dix-Hallpike test. He has the patient sit on the examination table, turns his head forty-five degrees to one side with both hands, and then quickly lays him down flat with his head hanging off the end of the table. If Asaf’s diagnosis is right, the patient’s eyes will shake for ten seconds or so, like dice in a cup.

To fix the problem, he performs what’s known as the Epley maneuver. With the patient still lying with his head turned to one side and hanging off the table, Asaf rotates his head rapidly the other way until his ear is pointed toward the ceiling. He holds the patient’s head still for thirty seconds. He then has him roll onto his side while turning his head downward. Thirty seconds later, he lifts the patient rapidly to a sitting position. If he’s done everything right, the calcified particles are flung through the semicircular canal like marbles out a chute. In most cases, the patient feels better instantly.

“They walk out the door thinking you’re a shaman,” Asaf said, grinning. Everyone loves to be the hero. Asaf and his colleagues can deliver on-the-spot care for hundreds of conditions and guidance for thousands more. They run a medical general store. But, Asaf insisted, that’s not really how primary-care clinicians save lives. After all, for any given situation specialists are likely to have more skill and experience, and more apt to follow the evidence of what works. Generalists have no advantage over specialists in any particular case. Yet, somehow, having a primary-care clinician as your main source of care is better for you.

Asaf tried to explain. “It’s no one thing we do. It’s all of it,” he said. I found this unsatisfying. I pushed everyone I met at the clinic. How could seeing one of them for my—insert problem here—be better than going straight to a specialist? Invariably, the clinicians would circle around to the same conclusion.

“It’s the relationship,” they’d say. I began to understand only after I noticed that the doctors, the nurses, and the front-desk staff knew by name almost every patient who came through the door. Often, they had known the patient for years and would know him for years to come. In a single, isolated moment of care for, say, a man who came in with abdominal pain, Asaf looked like nothing special. But once I took in the fact that patient and doctor really knew each other—that the man had visited three months earlier, for back pain, and six months before that, for a flu—I started to realize the significance of their familiarity.

For one thing, it made the man willing to seek medical attention for potentially serious symptoms far sooner, instead of putting it off until it was too late. There is solid evidence behind this. Studies have established that having a regular source of medical care, from a doctor who knows you, has a powerful effect on your willingness to seek care for severe symptoms. This alone appears to be a significant contributor to lower death rates.

Observing the care, I began to grasp how the commitment to seeing people over time leads primary-care clinicians to take an approach to problem-solving that is very different from that of doctors, like me, who provide mainly episodic care. One patient was a Spanish-speaking woman, younger-looking than her fifty-nine years, with a history of depression and migraines. She had developed an odd set of symptoms. For more than a month, she’d had facial swelling. Her face would puff up for a day, then go back to normal. Several days later, it would happen again. She pulled up pictures on her phone to show us: her face was swollen almost beyond recognition. There had been no pain, no itching, no rash. More recently, however, her hands and feet had started swelling as well, sometimes painfully. She had to stop wearing rings. Then the pain and numbness extended up her arms and into her chest, and that was what had prompted her to come in. She was having chest pain as she sat before us. “It feels like a cramp,” she said. “My heart feels like it is coming out of my mouth. . . . The whole body feels like it’s vibrating.”

Doctors in other settings—say, an emergency room or an urgent-care clinic—would use a “rule out” strategy, running tests to rule out possible conditions, especially dangerous ones, as rapidly as possible. We would focus first on the chest pain—women often have less classic symptoms of a heart attack than men do—and order an EKG, a cardiac stress test, and the like to detect coronary-artery disease. Once that was ruled out, we might give her an antihistamine and watch her for a couple of hours to see if the symptoms went away. And, when that didn’t work, we would send her home and figure, Oh, well, it’s probably nothing.

This was not, however, the way the woman’s primary-care physician approached her condition. Dr. Katherine Rose was a young, freckle-faced physician two years out of training, with a precise and methodical air. “I’m not sure I know what’s going on,” she admitted to the woman.

The symptoms did not fit together in an obvious way. But, rather than proceed directly to an arsenal of tests, Rose took a different, more cautious, more empirical approach, letting the answer emerge over time. It wasn’t that she did no tests—she did an electrocardiogram, to make sure the woman really wasn’t in the midst of a heart attack, and ordered a couple of basic blood tests. But she didn’t expect that they’d show anything meaningful. (They didn’t.) Instead, she asked the patient to take allergy medicine and to return to see her in two weeks. She’d monitor her over time to see how the symptoms evolved.

Rose told me, “I think the hardest transition from residency, where we are essentially trained in inpatient medicine, to my practice as a primary-care physician was feeling comfortable with waiting. As an outpatient doctor, you don’t have constant data or the security of in-house surveillance. But most of the time people will get better on their own, without intervention or extensive workup. And, if they don’t get better, then usually more clues to the diagnosis will emerge, and the steps will be clearer. For me, as a relatively new primary-care physician, the biggest struggle is trusting that patients will call if they are getting worse.” And they do, she said, because they know her and they know the clinic. “Being able to tolerate the anxiety that accompanies taking care of people who are sick but not dangerously ill is not a skill I was expecting to need when I decided to become a doctor, but it is one of the ones I have worked hardest to develop.”

The woman’s symptoms disappeared after two weeks. A physician assistant figured out why: the patient had run out of naproxen, an analgesic medication she took for her migraine attacks, which in rare instances can produce soft-tissue swelling, through both allergic and nonallergic mechanisms. She would have to stay off all medications in that class. An urgent-care team wouldn’t have figured this out. Now Rose contacted the Graham Headache Center to help identify an alternative medication for the woman’s migraines.

Like the specialists at the Graham Center, the generalists at Jamaica Plain are incrementalists. They focus on the course of a person’s health over time—even through a life. All understanding is provisional and subject to continual adjustment. For Rose, taking the long view meant thinking not just about her patient’s bouts of facial swelling, or her headaches, or her depression, but about all of it—along with her living situation, her family history, her nutrition, her stress levels, and how they interrelated—and what that picture meant a doctor could do to improve her patient’s long-term health and well-being throughout her life.

Success, therefore, is not about the episodic, momentary victories, though they do play a role. It is about the longer view of incremental steps that produce sustained progress. That, such clinicians argue, is what making a difference really looks like. In fact, it is what making a difference looks like in a range of endeavors.

On Friday, December 15, 1967, at 4:55 p.m., the Silver Bridge, which spanned the Ohio River, was funnelling the usual crawl of rush-hour traffic between Gallipolis, Ohio, and Point Pleasant, West Virginia, when a shotgun-like blast rang out. It was the sound of a critical link in the bridge’s chain-suspension system giving way. In less than a minute, 1,750 feet of the 2,235-foot span collapsed, and seventy-five vehicles dropped into the river, eighty feet below. “The bridge just keeled over, starting slowly on the Ohio side then following like a deck of cards to the West Virginia side,” a witness said. Forty-six people died; dozens more were injured.

The newly established National Transportation Safety Board conducted its first major disaster investigation and reconstructed what had happened. Until then, state and federal government officials regarded such catastrophes as largely random and unavoidable. They focussed on building new bridges and highways, and employed mainly reactive strategies for problems with older ones. The investigation determined that corrosion of the four-decade-old bridge, combined with an obsolete design (it was built to handle Model T traffic, not cars and trucks several times heavier), had caused the critical fracture. Inspection could have caught the issue. But the Silver Bridge had had just one complete inspection since its opening, in 1928, and never with such concerns in mind. The collapse signalled the need for a new strategy. Although much of the United States’ highway system was still relatively new, hundreds of bridges were more than forty years old and had been designed, like the Silver Bridge, for Model T traffic. Our system was entering middle age, and we didn’t have a plan for it.

The federal government launched a standard inspection system and an inventory of public bridges—six hundred thousand in all. Almost half were found to be either structurally deficient or functionally obsolete, meaning that critical structural elements were either in “poor condition” or inadequate for current traffic loads. They were at a heightened risk of collapse. The good news was that investments in maintenance and improvement could extend the life of aging bridges by decades, and for a fraction of the cost of reconstruction.

Today, however, we still have almost a hundred and fifty thousand problem bridges. Sixty thousand have traffic restrictions because they aren’t safe for carrying full loads. Where have we gone wrong? The pattern is the same everywhere: despite knowing how much cheaper preservation is, we chronically raid funds intended for incremental maintenance and care, and use them to pay for new construction. It’s obvious why. Construction produces immediate and visible success; maintenance doesn’t. Does anyone reward politicians for a bridge that doesn’t crumble?

Even with serious traffic restrictions, one in a thousand structurally deficient bridges collapses each year. Four per cent of such collapses cause loss of life. Based on the lack of public response, structural engineers have judged this to be “in a tolerable range.”

They also report that bridges are in better condition than many other parts of our aging infrastructure. The tendency to avoid spending on incremental maintenance and improvements has shortened the life span of our dams, levees, roads, sewers, and water systems. This situation isn’t peculiar to the United States. Governments everywhere tend to drastically undervalue incrementalism and overvalue heroism. “Typically, breakdowns—bridge washouts, overpass collapses, dam breaches—must occur before politicians and voters react to need,” one global infrastructure report observes. “Dislocation leads to rushed funding on an emergency basis with dramatically heightened costs.”

None of this is entirely irrational. The only visible part of investment in incremental care is the perennial costs. There is generally little certainty about how much spending will really be needed or how effective it will be. Rescue work delivers much more certainty. There is a beginning and an end to the effort. And you know what all the money and effort is (and is not) accomplishing. We don’t like to address problems until they are well upon us and unavoidable, and we don’t trust solutions that promise benefits only down the road.

Incrementalists nonetheless want us to take a longer view. They want us to believe that they can recognize problems before they happen, and that, with steady, iterative effort over years, they can reduce, delay, or eliminate them. Yet incrementalists also want us to accept that they will never be able to fully anticipate or prevent all problems. This makes for a hard sell. The incrementalists’ contribution is more cryptic than the rescuers’, and yet also more ambitious. They are claiming, in essence, to be able to predict and shape the future. They want us to put our money on it.

For a long time, this would have seemed as foolish as giving your money to a palmist. What will happen to a bridge—or to your body—fifty years from now? We had no more than a vague idea. But the investigation of the 1967 Silver Bridge collapse marked an advance in our ability to shift from reacting to bridge catastrophes to anticipating and averting them.

Around the same time, something similar was happening in medicine. Scientists were discovering the long-term health significance of high blood pressure, diabetes, and other conditions. We’d begun collecting the data, developing the computational capacity to decode the patterns, and discovering the treatments that could change them. Seemingly random events were becoming open to prediction and alteration. Our frame of medical consideration could widen to encompass our entire life spans.

There is a lot about the future that remains unpredictable. Nonetheless, the patterns are becoming more susceptible to empiricism—to a science of surveillance, analysis, and iterative correction. The incrementalists are overtaking the rescuers. But the transformation has itself been incremental. So we’re only just starting to notice.

Our ability to use information to understand and reshape the future is accelerating in multiple ways. We have at least four kinds of information that matter to your health and well-being over time: information about the state of your internal systems (from your imaging and lab-test results, your genome sequencing); the state of your living conditions (your housing, community, economic, and environmental circumstances); the state of the care you receive (what your practitioners have done and how well they did it, what medications and other treatments they have provided); and the state of your behaviors (your patterns of sleep, exercise, stress, eating, sexual activity, adherence to treatments). The potential of this information is so enormous it is almost scary.

Instead of once-a-year checkups, in which people are like bridges undergoing annual inspection, we will increasingly be able to use smartphones and wearables to continuously monitor our heart rhythm, breathing, sleep, and activity, registering signs of illness as well as the effectiveness and the side effects of treatments. Engineers have proposed bathtub scanners that could track your internal organs for minute changes over time. We can decode our entire genome for less than the cost of an iPad and, increasingly, tune our care to the exact makeup we were born with.

Our health-care system is not designed for this future—or, indeed, for this present. We built it at a time when such capabilities were virtually nonexistent. When illness was experienced as a random catastrophe, and medical discoveries focussed on rescue, insurance for unanticipated, episodic needs was what we needed. Hospitals and heroic interventions got the large investments; incrementalists were scanted. After all, in the nineteen-fifties and sixties, they had little to offer that made a major difference in people’s lives. But the more capacity we develop to monitor the body and the brain for signs of future breakdown and to correct course along the way—to deliver “precision medicine,” as the lingo goes—the greater the difference health care can make in people’s lives, as well as in reducing future costs.

This potential for incremental medicine to improve and save lives, however, is dramatically at odds with our system’s allocation of rewards. According to a 2016 compensation survey, the five highest-paid specialties in American medicine are orthopedics, cardiology, dermatology, gastroenterology, and radiology. Practitioners in these fields have an average income of four hundred thousand dollars a year. All are interventionists: they make most of their income on defined, minutes- to hours-long procedures—replacing hips, excising basal-cell carcinomas, doing endoscopies, conducting and reading MRIs—and then move on. (One clear indicator: the starting income for cardiologists who perform invasive procedures is twice that of cardiologists who mainly provide preventive, longitudinal care.)

Here are the lowest-paid specialties: pediatrics, endocrinology, family medicine, H.I.V./infectious disease, allergy/immunology, internal medicine, psychiatry, and rheumatology. The average income for these practitioners is about two hundred thousand dollars a year. Almost certainly at the bottom, too, but not evaluated in the compensation survey: geriatricians, palliative-care physicians, and headache specialists. All are incrementalists—they produce value by improving people’s lives over extended periods of time, typically months to years.

This hundred-per-cent difference in incomes actually understates the degree to which our policies and payment systems have given short shrift to incremental care. As an American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room. Incrementalists are lucky if they can hire a nurse.

Already, we can see the cost of this misalignment. As rates of smoking fall, for instance, the biggest emerging killer is uncontrolled hypertension, which can result in stroke, heart attack, and dementia, among other conditions. Thirty per cent of Americans have high blood pressure. Although most get medical attention, only half are adequately treated. Globally, it’s even worse—a billion people have hypertension, and only fourteen per cent receive adequate treatment. Good treatment for hypertension is like bridge maintenance: it requires active monitoring and incremental fixes and adjustments over time but averts costly disasters. All the same, we routinely skimp on the follow-through. We’ll deploy an army of experts and a mountain of resources to separate conjoined twins—but give Asaf Bitton enough to hire a medical aide or a computerized system to connect electronically with high-blood-pressure patients and help them live longer? Forget about it.

Recently, I called Bill Haynes’s internist, Dr. Mita Gupta, the one who recognized that the John Graham Headache Center might be able help him. She had never intended to pursue a career in primary care, she said. She’d planned to go into gastroenterology—one of the highly paid specialties. But, before embarking on specialty training, she took a temporary position at a general medical clinic in order to start a family. “What it turned into really surprised me,” she said. As she got to know and work with people over time, she saw the depth of the impact she could have on their lives. “Now it’s been ten years, and I see the kids of patients of mine, I see people through crises, and I see some of them through to the end of their lives.” Her main frustration: how little recognized her abilities are, whether by the insurers, who expect her to manage a patient with ten different health problems in a fifteen-minute visit, or by hospitals, which rarely call to notify her, let alone consult her, when a patient of hers is admitted. She could do so much more for her patients with a bit more time and better resources for tracking, planning, and communicating. Instead, she is constantly playing catch-up. “I don’t know a primary-care physician who eats lunch,” she said.

The difference between what’s made available to me as a surgeon and what’s made available to our internists or pediatricians or H.I.V. specialists is not just shortsighted—it’s immoral. More than a quarter of Americans and Europeans who die before the age of seventy-five would not have died so soon if they’d received appropriate medical care for their conditions, most of which were chronic. We routinely countenance inadequate care among the most vulnerable people in our communities—including children, the elderly, and the chronically ill.

I see the stakes in my own family. My son, Walker, was born with a heart condition, and in his first days rescue medicine was what he needed. A cardiology team deployed the arsenal that saved him: the drips that kept his circulation going, the surgery that closed the holes in his heart and gave him a new aortic arch. But incremental medicine is what he has needed ever since.

For twenty-one years, he has had the same cardiologist and nurse practitioner. They saw him through his first months, when weight gain, stimulation, and control of his blood pressure were essential. They saw him through his first decade, when all he turned out to need was someone to keep a cautious eye on how his heart did as he developed and took on sports. They saw him through his growth spurt, when the size of his aorta failed to keep up with his height, and guided us through the difficult choices about what operation he needed, when, and who should do it. Then they saw him through his thankfully smooth recovery.

When he began to struggle in middle school, a psychologist’s evaluation identified deficits that, he warned us, meant that Walker would probably not have the cognitive capacity for college. But the cardiologist recognized that Walker’s difficulties fit with new data showing that kids with his heart condition tend to have a particular pattern of neurological deficits in processing speed and other functions which could potentially be managed. In the ensuing years, she and his pediatrician helped bring in experts to work with him on his learning and coping skills, and school planning. He’s now a junior in college, majoring in philosophy, and emerging as a writer and an artist. Rescue saved my son’s life. But without incremental medicine he would never have the long and full life that he could.

In the next few months, the worry is whether Walker and others like him will be able to have health-care coverage of any kind. His heart condition makes him, essentially, uninsurable. Until he’s twenty-six, he can stay on our family policy. But after that? In the work he’s done in his field, he’s had the status of a freelancer. Without the Affordable Care Act’s protections requiring all insurers to provide coverage to people regardless of their health history and at the same price as others their age, he’d be unable to find health insurance. Republican replacement plans threaten to weaken or drop these requirements, and leave no meaningful solution for people like him. And data indicate that twenty-seven per cent of adults under sixty-five are like him, with past health conditions that make them uninsurable without the protections.

The coming years will present us with a far larger concern, however. In this era of advancing information, it will become evident that, for everyone, life is a preexisting condition waiting to happen. We will all turn out to have—like the Silver Bridge and the growing crack in its critical steel link—a lurking heart condition or a tumor or a depression or some rare disease that needs to be managed. This is a problem for our health-care system. It doesn’t put great value on care that takes time to pay off. But this is also an opportunity. We have the chance to transform the course of our lives.

Doing so will mean discovering the heroism of the incremental. That means not only continuing our work to make sure everyone has health insurance but also accelerating efforts begun under health reform to restructure the way we deliver and pay for health care. Much can be debated about how: there are, for example, many ways to reward clinicians when they work together and devise new methods for improving lives and averting costs. But the basic decision has the stark urgency of right and wrong. We can give up an antiquated set of priorities and shift our focus from rescue medicine to lifelong incremental care. Or we can leave millions of people to suffer and die from conditions that, increasingly, can be predicted and managed. This isn’t a bloodless policy choice; it’s a medical emergency.

Atul Gawande, a surgeon and public-health researcher, became a New Yorker staff writer in 1998.

Republicans can repeal Obamacare. They can’t repeal the logic of health insurance.

Updated by Uwe Reinhardt, Vox, Nov 23, 2016, 9:40am EST

See the Original Article on

President-elect Donald Trump was very explicit during the presidential campaign that one of his first acts in office would be to initiate the complete repeal of the Affordable Care Act — something Republican Congress has been itching to do for years.

Repealing Obamacare, however, will neither eliminate nor bypass the central challenge of health care, which can be gleaned from the chart below. That challenge will persist regardless of whether the Republicans quickly settle on an alternative plan, or if they repeal without a replacement.


Adapted from Julie Schoenman, National Institute for Health Care Management, 2016

Shown on the horizontal axis are deciles of the US population, arrayed from individuals with low per-capita spending on the left to high spending on the right. The vertical axis shows the percentage of total national health spending accounted for by a particular decile on the horizontal axis. In addition to the deciles, the most expensive 5 and 1 percent of the population are shown on the right.

Included in the high-cost segment of this graph will be individuals who may be only temporarily sick — for example, as a result of an accident. For the most part, however, they represent chronically ill people, often with multiple conditions that can be medically treated, albeit at great expense that exceeds these individuals’ capacity to finance their care with their own financial resources.

The fundamental questions in the US, as in other countries, are a) what kind of treatments these very sick members of society should receive, especially end-of-life treatments, and b) how those treatments should be financed, given that these treatments can quickly exhaust the budgets of the afflicted.

In very poor, developing countries the answer to this question may well have to be to leave those sick people to their own fate. That approach is unacceptable in the more developed world, where sick individuals usually do receive needed treatments even if they cannot pay for them. This leaves three alternative outside sources of financing that care, to wit:

  1. public subsidies financed from general taxation,
  2. cross-subsidies baked into health insurance premiums, forcing healthier individuals to subsidize through the premiums they pay the health care of chronically sicker member in the same insurance risk pool, or
  3. cross-subsidies baked into the prices charged paying patients by doctors, hospitals and other providers of health care, which forces paying patients to cover these providers’ so-called “uncompensated care.”  Paying patients include both insured patients and self-paying patients.

All health insurance systems in the developed world use one or the other of these approaches to respond to the plight of very sick members of society.

Canada, for example, uses the first of these approaches, financing its single-payer provincial health plans mainly out of general taxation.

Germany relies on the second approach, using the premium mechanism to trigger the needed cross subsidies. The premiums paid by individual employees or retired persons have long been solely a fraction of the individual’s income. Thus they automatically embody cross subsidies from healthy to sick individuals and from high-income to low-income persons.

The unique US system combines all three ways of subsidizing care

The highly pluralistic health insurance system of the US uses a mixture of all three approaches. Public programs such as Medicare, Medicaid, the VA health system and Tricare (the health insurance programs of families of active military personnel), rely mainly on taxation as a source of financing.

The far flung employment-based private health insurance system, on the other hand, which covers about two-thirds of the population and accounts for one-third of total national health spending, uses mainly the premium mechanism to subsidize the very sick. In that system, the individual employee’s contribution toward the premium for his or her health insurance is divorced from that individual’s health status; it is, in the jargon, community rated, meaning younger or healthier employees cross-subsidize the care of their sicker colleagues.

Finally, the nation has always relied and continues to rely on an informal catastrophic health insurance system operated mainly by hospitals. Under this system, the cost of health care rendered to uninsured patients unable to pay for it is added to the prices charged insured or self-paying patients.

The Affordable Care Act of 2010 (ACA) incorporates a judicious mixture of the first two approaches. Within age belts, health insurance premiums on the ACA market places are community rated; the individual’s premium is completely divorced from that individual’s health status. The law limits the differences among age groups, so that people over 64 pay no more than three times what 21-year-olds pay. (The insurance industry has long pleaded for an age-band ratio of at least five-to-one.).

That feature of the ACA naturally forces relatively healthy individuals to pay premiums in excess of their actuarially projected costs. And the excess is used by insurers to cross-subsidize the health care of sicker members of the risk pool whose premiums are below their actuarially expected costs. But individuals up to 400 percent of poverty also receive direct, tax-financed federal subsidies toward the purchase of health insurance; individuals or families below 250 percent of the federal poverty level get, as well, direct federal subsidies towards out-of-pocket expenditures.

The idea that individuals stricken with illness should not be punished by health-insurance premiums that reflect their dire health status probably appeals to many Americans — perhaps most, including president-elect Trump. It is, after all, the ethical foundation of the bulk of health insurance in the US. But implementing a policy that divorces premiums from the individual’s health status is very tricky when applied to the market for individually purchased insurance policies, as it is on the marketplace exchanges of the ACA. The graph below illustrates the problem.

Some people will inevitably have to pay more than is “fair”

The graph represents an insurer’s risk pool of insured individuals who purchase health insurance individually and who are arrayed, on the horizontal axis, from relatively healthy on the left to relatively sick on the right. The vertical axis exhibits the premium charged individuals for a specified, insured benefit package.

Prior to the onset of the ACA, insurers in this market would have based the premium charged the individual on that individual’s health status, a process called “medical underwriting.” Applicants had to complete very long detailed questionnaires on their own and on family members’ health status. The result was “actuarially fair” premiums — that is, premiums that reflect the projected cost of buying insured benefits for that individual. In the graph, these premiums are depicted by the upward-sloping white line.

img_0139Uwe Reinhardt
A switch from actuarially fair premiums to community-rated premiums that are divorced from the health status of individuals might result in the common premium represented by the light blue line in the graph. Relative to actuarially fair premiums, this switch would raise premiums for relatively healthy people who now are forced to cross-subsidize the health care of relatively sicker people. Those sicker people now pay a premium much below their actuarially fair premium. It is immediately obvious that such a switch presents a difficult political problem, because it redistributes income among the insured based on their health status.

If healthier people are free to decide whether or not to purchase health insurance, many of them might prefer to go uninsured rather than pay the community-rated premium. If so, the remaining risk pool of insured individuals will contain relatively more sick people, which will then raise the community-rated premium over this sicker risk pool from the blue line to, say, the dotted green line. This appears to have happened on the marketplace exchanges of the ACA, and is one major reason why premiums between 2016 and 2017 have risen by an average of 25 percent across the nation, albeit with a wide variance about that average. (In some areas premiums rose only by low single digits, in others by more than 100 percent.)

Americans with insurance from the ACA marketplaces with incomes under 400 percent of the federal poverty level will not be affected by these high premium increases on the ACA exchanges. But the increase will seriously impact individuals with higher incomes and those who for one reason or another procure coverage apart from the ACA exchanges and are therefore not entitled to federal subsidies (a group estimated to be about 7 million.)

The health insurance debate will be driven mostly by actuarial logic, not ideology

Because of this likely outcome of ever riskier insurance pools and the high premiums they trigger, nations that employ private health insurance coupled with community-rated premiums — for example, Germany, the Netherlands, and Switzerland — impose strictly enforced mandates on all individuals to purchase health insurance with a specified benefit package.

In principle, the ACA embodies such a mandate as well, but the penalty of disobeying it (an amount equal to 2.5 percent of income) is generally much lower than the premium for the mandated health insurance. Therefore, many healthier, younger individuals simply prefer to pay the penalty and go uninsured. That action then raises the community-rated premiums of the remaining, sicker insured.

The important point to note is that the process described here is a purely an actuarial problem. If it is desired that:

  1. everyone in society should have access to needed health care;
  2. no individual or family should be in financial distress as a result of medical bills;
  3. the health insurance system employ private health insurers to implement the first two principles; and
  4. sicker people not be confronted with sky-high health insurance premiums or be refused coverage altogether, but instead pay community-rated premiums under guaranteed issue,

then such a system cannot long survive unless either everyone is mandated to buy insurance, or subsidies are provided through tax revenue to keep the premiums paid by individuals to some reasonable percentage of their income.

That brings us to Trump, and his commitment to repeal the ACA. In this aim, the president-elect should be able to count on his Republican Congress, which has long stated a similar goal, and, in fact, has tried to do so, only to have its bill vetoed by President Obama. But there are two obstacles to Trump’s objective.

First, it would be very difficult to repeal the ACA in its entirety. That’s because the Senate, although in Republican hands, is not filibuster proof, which would require 60 Republican votes, which the Republicans don’t now have. The Senate could use a maneuver called “budget reconciliation” to get rid of any provision in the ACA that involves the flow of federal money — for example, the federal subsidies toward the purchase of health insurance on the exchanges. That could be achieved with only 51 votes.

But numerous other provisions, including the mandate to be insured, community rating, guaranteed issue (no denials for preexisting conditions) and many others, do not involve federal money and therefore cannot be eliminated through reconciliation. They are subject to a filibuster by Democrats. The problem for insurance companies is that the regulations on their industry would remain even as the subsidies for the purchasers of insurance disappeared.

Second, Republicans cannot get around the actuarial problem described above. Even if somehow they could eliminate guaranteed issue and community rating, they would face the problem of how to finance health care for the very sick segment of the population whose care exceeds their own resources. Just giving everybody a refundable tax credit as is proposed by Congress member Paul Ryan’s “A Better Way,” would not much help a very sick individual charged sky-high, actuarially fair premiums.

But unless these tax credits were tied closely to the health status of individuals, which is not part of the plan, they would do little to help such individuals. As Vox’s Sarah Kliff points out, Ryan’s proposal “makes insurance better for people who are young and healthy. It makes insurance worse for people who are old and sick.”

At this time, it still remains every expert’s and pundit’s guess how a Trump administration and its Republican Congress would deal with the ethical and technical problems posed by a repeal of Obamacare. By itself, that move would yank affordable health insurance coverage away from about 20 million Americans who by now have gotten used to it. That does not seem a politically wise move. It would also deprive the health insurance industry, hospitals, physicians, and other providers of health care of revenue on which they have come to count.

Chances are, many components of the ACA would actually reappear under a Republican replacement for the ACA, perhaps rechristened as Trumpcare or Freedomcare or something like that. Recall that Obamacare basically rests on a 1990s vintage Republican chassis onto which Democrats fastened some additional policy particulars.

In any event, for observers with secure health insurance, it will be fascinating to watch how health reform will develop in 2017. For the less fortunate, however, it could be painful rather than, as Trump put it, “terrific.”

The unfolding drama may seem to be driven largely by ideology and partisanship. In the end, however, there is no getting around the actuarial mathematics on which health insurance everywhere in the world rests — public as well as private.

Unless, that is, our government is content to leave millions of Americans without the benefits of health insurance, and the access to essential health care it provides.

The presence of millions of citizens lacking health insurance remains a uniquely American problem.

Uwe Reinhardt is the James Madison professor of political economy at Princeton University.