In two of the better essays on healthcare, The New Yorker’s Dr. Atul Gawande and David Goldhill,via the Atlantic Monthly, portray a healthcare system dreadfully disorganized and wasteful. While this is no new discovery, each offers a different perspective (Guwande is a M.D., Goldhill a businessman), and solution.

In his trip to McAllen, Texas—a town with the second highest per person health costs in the country—Gawande tells his story through visits to local medical facilities and conversations with healthcare professionals. He recounts a dinner with six local physicians where he presents them with the question of why? Why does McAllen costs so much despite having similiar demographics to that of El Paso and other surrounding areas. After a few half-hearted responses a general surgeon in the group gets real.

“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?”

The problem to Guwande, is the “across-the-board over usage of medicine.” The solution he arrives at is the not-for-profit model, like the Mayo Clinic, or Geisinger Health. At these places doctors are salaried employees, their earnings having nothing to do with the number of tests ordered or patients seen. They are, as Guwande says, collectively responsible for improving the sum total of patient care.

On the other hand, Goldhill concludes the system greatest flaw is payment model that makes the insurance companies the ones who really matter. Through the story of his father landing in the hospital and dying five weeks later due to a hospital-borne infection, Goldhill illustrates a system overrun with inefficiencies and error. He asks the question, why not just set-up a system where the patient is responsible for their own health costs, and have healthcare insurance enter only in catastrophic situations. Goldhill argues that in our current system we have this notion that we aren’t paying for our healthcare, but as he explains we are—and we’re paying a ton for it.

Let’s say you’re a 22-year-old single employee at my company today, starting out at a $30,000 annual salary. Let’s assume you’ll get married in six years, support two children for 20 years, retire at 65, and die at 80. Now let’s make a crazy assumption: insurance premiums, Medicare taxes and premiums, and out-of-pocket costs will grow no faster than your earnings—say, 3 percent a year. By the end of your working days, your annual salary will be up to $107,000. And over your lifetime, you and your employer together will have paid $1.77 million for your family’s health care. $1.77 million! And that’s only after assuming the taming of costs! In recent years, health-care costs have actually grown 2 to 3 percent faster than the economy. If that continues, your 22-year-old self is looking at an additional $2 million or so in expenses over your lifetime—roughly $4 million in total.

Goldhill believes that if the patient was the consumer market forces would drive prices down—to stay afloat doctors would need to focus on the patient, not whether the patient’s insurance is covering the consult.

If you read this blog you probably know I’m in a agreement with both. I know, I know it’s the easy way out. The Goldhill argument is relevant because a lack of transparency is definitely a massive issue, I see with myself and other patients every week. Getting the patient involved is not an incentive currently, perhaps forcing them to be by overtly handing the finances over the patient would help. I’ve also been lucky enough to work in healthcare and observe the way medicine is practiced, and often choices are made in the interest of money rather than the patient. The line is so blurred from the physicians’ angle that they have fooled themselves into thinking their isn’t a difference.

What do you think?

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