Thursday, June 11, 2009

Cost conundrum, or, setting norms?

The June 1, 2009 issue of the New Yorker contains a really fascinating and well-written article by Atul Gawande, MD, author of Better and Complications, called "The Cost Conundrum." Gawande studies the practice of medicine in McAllen, Texas, "the most expensive town in the most expensive country for health care in the world".

Comparing McAllen's runaway costs with national models such as the Mayo Clinic, and even just moderately less expensive places like El Paso, Gawande looks for explanations: better quality health care? Sicker patients? More technologically advanced facilities? No, the smoking gun seems to be peer pressure, or a lack thereof:
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. [emphasis added]
Greed has been a human vice since Moses came down from the mountain (and probably before that, too). Socialization into group ethics and norms should allow communities to maintain the desired standards of conduct.

Take, for example, this week's pet group, the Third Judicial District Medical Society of Oregon. In the summer of 1871, shortly after organizing, the society appointed a five-member committee to develop a fee bill. The fees would need to represent the "different points of practice in the several counties represented," and would (theoretically) be enforced by the group as a whole. Physicians charging more than the standard rate would be censured. Doctors were expected to police themselves, and they considered it a right and an obligation of professional practice.

Have patients, in their insistence on "shopping around" for doctors, contributed to this problem? Have physicians abdicated their professional responsibilities to police themselves? Or has the almighty Market overwhelmed both physician and patient in its cancerous growth? Whatever the cause, we can seek solutions in history.

[Shown here: Umatilla County Medical Society fee bill, 1891]

1 comment:

Sara Piasecki said...

A post script: I've been reminded that the FTC didn't exist at the turn of the century, and that moves to establish fee schedules such as this are often prosecuted under anti-trust laws. Silly? You make the call.