Atul Gawande feature on unnecessary medical care

There's a really fascinating piece of writing by Atul Gawande (who I've posted about a few times previously) from a recent New Yorker with "Overkill" on unnecessary, expensive and often harmful medical care provided. In terms of the scope of the problem, Gawande writes below...

"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."

The reasons for the waste, or no-value care as Gawande describes it, include tests and treatments both unethical recommended (with providers trying to collect all available insurance and Medicare dollars) and simply not needed, often as a result of there being so many tests and treatment paths available. What occurs is doctors, with patients buy-in, often test for problems that really aren't likely to have a terrible result if the problem found in someone, and then treat the problem because it's been discovered. The issue from this is the care costs money for someone, whether an individual paying out of pocket, an insurer (who as a result may raise rates) or government. Additionally, testing can bring complications for patients, not to mention problems that can result during procedures; and treatment for a given ailment can preclude different, and perhaps more needed, treatment for the same or another ailment.

Just as interesting to me as the problems that Gawande presents is the better path that he provides in the piece, with two examples including one driven from a corporate perspective and one out of a government act. Gawande tells the story of a Walmart employee with back problems who had surgery recommended to him and could have had the procedure done locally, with large out-of-pocket expense incurred, or follow a path Gawande wrote about...

"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. 

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."

Gawande writes of how Taylor went to Virginia Mason in Seattle, and after examination there, was recommended to not have back surgery, and instead focus on recovery through rehabilitation, an approach that Taylor agreed to and as Gawande quotes him saying, "within a couple of weeks, I was literally pain free." It's a fascinating story and not entirely unexpected one as Gawande writes of the Walmart program around spine, heart or transplant procedures...

"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."

As a wrap-up to Taylor's story, Gawande provides the following...

"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."

Another thing Gawande writes of as leading to optimism for care in the future is out of a provision in the Affordable Care that "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." Gawande writes fairly extensively of McAllen, TX and how "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."

It's a fascinating piece from Gawande and as he towards the end writes "waste is not just consuming a third of health-care spending; it’s costing people’s lives." 

Being Mortal by Atul Gawande

Being Mortal by Atul Gawande was a remarkable book with the subtitle “Medicine and What Matters in the End” from a doctor and author I've posted on a number of times in the past. The book covers a lot of ground on the subject of health choices for people aging or with catastrophic medical conditions and seems it can be broken down into three related categories of (1) doctors who treat the elderly, (2) where those in need live and (3) the decisions that are made around care.

Doctors who treat the elderly

Gawande fairly early in the book writes of how when people in the past died of illness it was more frequently a sudden death, but now illness leading to death is often a case of peaks and valleys until there then becomes one calamity after another as the body stops working. With there now being more ways to prevent death, the doctor-patient relationship becomes more important and Gawande notes how the approach of a given doctor to their patient can either be paternalistic, informative or in the best scenario, interpretive based on someone's desires about their care. This is especially the case with the elderly, but the branch of medicine that deals with aging, geriatrics, doesn't get enough attention and doesn't have enough doctors. People are less interested in going into geriatric care in part because patients don't have one discrete and interesting problem to try and fix, rather they have fifteen that are being pushed forward by the aging process. Additionally, care for the elderly is typically not really about the devices or expensive procedures that would be covered by Medicare. Rather it’s about looking for common problems and attempting to head them off in a quest to preserve quality of life for as long as possible. It’s noted in the book that the biggest danger facing many elderly is falling and risk factors for falling are poor balance, taking more than four prescription medications and muscle weakness.

Where those in need live 

Gawande also writes extensively about how and where the elderly live, often in their homes for as long as they can, then with younger family members, in assisted living facilities or communities and nursing homes. In relation to assisted living facilities and nursing homes, Gawande notes how many hate living there as in the quest to provide a safe environment, caregivers can take away from the elderly their basic rights to privacy and making their own decisions, even if those decisions not always the healthiest. The result can be a dehumanizing with the elderly finding themselves in situations they simply don't want to live, safe or not. Gawande does note there’s another path that can be sought out and gives examples. There’s services like Athens Village in Ohio that people can join and which help them stay in their homes, "living centers with assistance" that were started by Keren Brown Wilson who then created the Jessie F. Richardson Foundation, New Bridge on the Charles in Boston, Peter Sanborn Place and the Green House concept, with one of its facilities the Leonard Florence Center for Living that all about not forcing the elderly to sacrifice autonomy to live in some form of assisted living facility. In some cases the facility will also include pets and frequent visitors, something to help the people living there both feel empowered and have a purpose. There might be a slight drop off in safety from more regimented facilities, but studies have shown that people are happier, require less emergency care and tend to live longer.

Decisions about care

Related to this idea of people being empowered to make decisions about their lives is the notion of people having frank discussions with doctors and especially family members about what choices they want made on their behalf, including what level of risk they want taken and what amount of pain and infirmity they're willing to suffer in order to have a shot at getting better. For some people they’re willing to take huge risks to have better health, but for others, they’d rather not take as large of a chance that they could get worse as the result of treatment, especially if that treatment may not buy that much more healthy time. The choice is all about one’s life and what it could potentially be like, for better or worse, and having the patient set the direction based on guidance from the doctor, with the alternative medical professionals or family members having to make the decisions on behalf of someone incapacitated. If left to doctors and family members, the natural inclination is going to be to press forward for a cure, but too often this may be bullheadedly pursuing a medical fix to a problem that's simply going to result in death. At the same time, it could well be that a patient has given direction that they’re willing to proceed with risky procedures that could make them worse, but as long as they understand, it’s the choice they’re making. This is where the idea of the doctor as someone who provides guidance based on a patient’s wishes, things that matter to them and risk tolerance, becomes so important. The role of medicine is to heal, but also to provide council based on the wishes of patients.

A key part of this discussion and patient decision around their care has to do with hospice care, which is often provided in the home. Covered by Gawande is how hospice care not something that’s simply the last step before death, but something that’s designed to have people feel as good and fulfilled as possible for each day they’re still alive, a concept of living for the best possible day. Additionally, hospice care doesn't have to mean giving up curative treatment as it could be done concurrently with treatment for the illness at the same time there’s palliative care designed to make someone as comfortable, fulfilled and happy as possible. Studies have shown many cases of patients receiving hospice care actually living longer than those without it.

The big take-away from this discussion of hospice care is that patients should hopefully be making the decisions themselves on their care after discussions with medical professionals willing to advise on the best options based on people’s wishes for how they want to pursue treatment. People need medical help, they need council and they need to live their lives in a way that they've got as much control as possible over what happens in it. It’s fascinating reading from Gawande that definitely goes way beyond the idea of a doctor and the medical community as simply being there to try to fix a health problem. Great book, highly recommended.

Atul Gawande essays - on Ebola & end-of-life care

Noted surgeon and author Atul Gawande had two solid pieces of writing publish recently in The New Yorker and New York Times, respectively.

I've read three of Gawande's books and posted on his writing a number of times and was particularly interested to see the Times piece as noted a new book Gawande has coming out. "The Best Possible Day" is excerpted from Being Mortal: Medicine and What Matters in the End and a fascinating personal story of an end-of-life care approach that came out of taking the time to understand what a patient really wants.

The other recent piece to note here was "The Ebola Epidemic is Stoppable" out of The New Yorker that Gawande is a staff writer for and it's a very measured telling of how the dangerous disease not easily transmitted from person to person.

Writing by Saslow, Gawande & Cowen - on the Navy Yard shooting, food stamps, health care & Texas

There's been a few pieces of writing I've come across lately that were all linked together in a fairly circuitous route.

A writer I find to be one of the best working today is Eli Saslow as his pieces so frequently use great detail to tell an emotional and often heart-wrenching story and two recent Washington Post works of his very much fit that description. Published last month after the gun deaths of 12 people in Washington D.C. was "At Navy Yard, the ‘Cube Farm’ had settled into its reassuring Monday routine. Then, a jolt." and just yesterday was "Too much of too little", a piece with the subtitle "A diet fueled by food stamps is making South Texans obese but leaving them hungry."

Very much related to the Saslow piece on food stamps both because of the topic and with it being by a writer whose byline I'm always interested to see was "States of Health" by Atul Gawande for the New Yorker. About the Affordable Care Act (otherwise known as Obamacare) the piece is from a noted physican and excellent writer and just makes me bothered by what seems to be the fervently held opposition by some to more universally provided health care.

The final piece to note here also relates to Saslow's piece set in South Texas as the October 28 issue of Time Magazine featured the interesting cover story "Why Texas Is Our Future" by Tyler Cowen, economics professor and author of Average is Over. Noted up front in the story is that "three of the five fastest-growing cities are in Texas" and what I also found interesting in the story, and also connected it to the pieces by both Saslow and Gawande, was the mention of how stratified Texas is in terms of it's upper, lower and increasingly small middle class. There's been a lot written about the concept of income inequality, a shrinking middle class and an upper class living in a completely different America than the lower class and Cowen's piece (which requires a Time account to read online any of the nine web pages it split into) shows a state that's both emblematic of the dynamic and driving it.

Great writing on Medicine & Money - by Fagone, Gawande & Lewis

There's been a few pieces of writing I've seen recently that struck me as particularly excellent on the subjects of medicine and money... which, sadly are inextricably linked perhaps more now than ever.

For evidence of that linkage, one could simply look at the Tampa Bay Times feature series "Never Let Go" I wrote on last week. Included in the third story from the writer, Kelly Benham, was mention of how over a million dollars in micro-preemie infant care cost she and her husband $400, and of course would have financially ruined other parents with different or no health coverage.

A medical story I haven't previously written about and linked to was "Slow Ideas" from the July 29th issue of The New Yorker. It's written by Atul Gawande, a noted surgeon and bestselling author who I've posted about a few times and this latest piece is a fascinating one about how ideas spread and recommendations take hold (in this case recommendations toward reducing infant mortality rates in India).

Another really solid medical piece I've seen lately was "Has Carl June Found a Key to Fighting Cancer?" by Jason Fagone for the August issue of Philadelphia Magazine. It's a piece I previously linked to under a different post topic and is a tremendously interesting look at a doctor doing cutting-edge work. In that regard, the feature reminded me of a couple of other physician profiles I've seen in past years, "Craig Venter’s Bugs Might Save the World" by Wil Hylton for the New York Times and "Adventures in Extreme Science" written on Eric Schadt by Tom Junod for Esquire.

Going to the second side of this medicine and money topic, two other pieces of writing to mention here were both by Michael Lewis. Among other bestselling books, Lewis wrote The Big Short and Boomerang: Travels in the New Third World (which I wrote about in 2011) and an excellent recent feature story of his was "Did Goldman Sachs Overstep in Criminally Charging Its Ex-Programmer?" for the September issue of Vanity Fair. The piece was thoroughly reported and details the length to which Goldman would go seemingly to protect their image as a company worthy of the money they make. It's a compelling story and made me think of another piece of writing by Lewis, his "Princeton University's 2012 Baccalaureate Remarks". Really great stuff from Lewis about life and career choices in this speech with the title "Don't Eat Fortune's Cookie".

Writing on the Boston Marathon Bombing

Not to simply list out great writing (well, actually, exactly to simply list out great writing) since the Boston Marathon bombing, there's been some amazing work done, both poignant and well reported with the pieces below being those that have stood out to me the most.

In the poignant essay category were pieces by Patton Oswalt and Joe Posnanski with Oswalt doing a Facebook post about good people and Posnanski's essay on his personal blog containing the same notion with his last sentence of "There are exponentially more good people than bad."

The piece of writing reported from the scene that I found most memorable was "In Grisly Image, a Father Sees His Son" by Tim Rohan for the New York Times. Recounted is the story of Jeff Bauman, a marathon spectator who lost both his legs at the scene. While the piece certainly contains a graphic image and some difficult to read text, it's also an inspiring depiction of helping others with Rohan's description of Carlos Arredondo (the subject of NYT piece from 2007 that Rohan links to) coming to Bauman's aide. Incredibly, there's a story that's come out just this evening on Bauman with "Boston Bombing Victim in Iconic Photo Helped Identify Attackers" by Asjylyn Loder & Esmé E. Deprez for Bloomberg.

The final pieces to note here contained details about the response of emergency personnel to the bombing and injuries with a New Yorker essay "Why Boston's Hospital's Were Ready" by noted author and Boston area surgeon Atul Gawande and "First responders to Boston bombings get relief, postgame beers from grateful Bruins" by Les Carpenter for Yahoo Sports.

Finally, it's of course not a piece of writing, but here was footage from the Boston Garden two nights after the bombing...

 

100 Most Influential People List from Time

Interesting stuff written about some really interesting people in the Time Magazine "100 Most Influential People in the World" list for 2010... as featured in the May 10 issue.



Linked to below aren't the ones that stood out to me as most influential (note the omission of President Barack Obama), but rather the ones whose story struck me as particularly interesting and/or entertaining.

- President Luiz Inácio Lula da Silva of Brazil profiled by filmmaker Michael Moore. Incredible to me that Brazil will be making the dual splash (hopefully positive) of hosting first the 2014 World Cup and then 2016 Summer Olympics.

- Admiral Mike Mullen Chairman Joint Chiefs profiled by Joe Klein. An important guy that I recently posted about being on the cover of Fast Company.

Performing artist Lady Gaga by Cyndi Lauper. As is written about in great detail in this Esquire piece, someone in the mold of Madonna at the height of her fame who's been able to transcend performance and package themselves as the product.

Actor Neil Patrick Harris by fanboy darling Joss Whedon. A seemingly super cool guy (based on this Joel Klein piece from Time).

Singer/songwriter Prince by not even near Prince's level singer/songwriter Usher. Another artist like Lady Gaga who made themselves a persona. Additionally... the genius behind the song Purple Rain.

Surgeon, writer and policy advisor Atul Gawande by Tom Daschle. The author of three insightful books... last of which I reviewed here.

Apple CEO Steve Jobs by artist Jeff Koons. Piece contains an interesting comparison of consumer product and art.

Pandora founder Tim Westergren by novelist Kurt Andersen. A missive by an excellent writer about a guy who created just an excellent service.
Ivory Coast soccer star Didier Drogba by Eben Harrell. Can't wait for the World Cup to begin next month...

US Military Chief Master Sergeant Tony Travis by Sully Sullenberger. A guy called into post-earthquake Haiti that took control of the wreckage that was the airport and immediately got aid flowing in.

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There was certainly some great and influential people from this issue I didn't include above (and I'm sure are also great and influential people that Time left off the list), but this was quite a cross-section of interesting folk that in many cases had very compelling stuff written about them.

"The Checklist Manifesto" by Atul Gawande

Finished reading "The Checklist Manifesto" by noted surgeon Atul Gawande and found it to be a fairly interesting book.

Gawande is the author of two bestsellers that I enjoyed quite a bit, "Complications" and "Better"... both about his experiences as a doctor. Where "The Checklist Manifesto" diverged is that is covered not just medicine, but the wider-reaching concept of using a checklist in the pursuit of excellence. Fields discussed in the book range from aviation (where the checklist is perhaps most ingrained) to investing, building and yes... surgery.

While I found definite value in the checklist concept, I was more captivated by his prior two books in that they were all about a topic that he's dedicated his time to. Gawande is a good writer (contributes frequently to The New Yorker), though, and I'm interested in his National Magazine Award winning piece "The Cost Conundrum" (on health care expenditures in McAllen, TX) linked to from his website.

I'd recommend "The Checklist Manifesto" to anyone who either enjoyed Gawande's previous two books or is interested in the idea of peak performance and how to attain it in a given effort.