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." 

Favorite business writing linked to - on health care

One thing I've been thinking about lately in relation to my writing here has been how to best aggregate what I've written... with that output very much including the great writing from others that I've linked to. I've been happy with the consistent work I've done on this site over the past six plus years and to this point the aggregation has been in the form of books I've compiled and published via Amazon for both the Kindle and in print. Those books have been by category (business, sports, writing on writing, book reviews, etc.) and what I decided recently to take a stab at was going back through my past posts to this site and do new writing on a few particular categories of stories.

The area I've started with is business and over the past week or so I've gone through all of my business-related writing to this site and pulled out particular story links that resonated with me. In looking at the best business writing I've posted on, there's been a handful of topics I've found both to be of import as a subject and to have great writing on that subject I've written about previously. The first to post on here is health care (with at least somewhat a business-leaning angle to the story) and below are the health care stories I've seen that resonated the most with me and which are available online without a subscription:

"Illumina's new low-cost genome machine will change health care forever" by Ashlee Vance for Businessweek in Jan 2014 – on people gaining affordable access to information about the genetic traits that they carry.

"Patient Zero" by Tom Junod and Mark Warren for Esquire in Dec 2013 – on cancer patient Stephanie Lee and noted scientist and researcher Eric Schadt.

"States of Health" by Atul Gawande for the New Yorker in Oct 2013 – on the Affordable Care Act by the noted physician and excellent writer.

"Has Carl June Found a Key to Fighting Cancer?" by Jason Fagone for Philadelphia Magazine in July 2013.

"Is Concierge Medicine the Future of Health Care?" by Devin Leonard for Businessweek in Nov 2012 – on doctors taking on patients on a monthly fee basis rather than billing insurance carriers for exams and basic services. It’s an interesting notion with lots of different service derivations and costs ranging from extremely high to quite affordable.

"Craig Venter’s Bugs Might Save the World" by Wil Hylton for the New York Times in May 2012.

"Adventures in Extreme Science" by Tom Junod for Esquire in Mar 2011 – on scientist Eric Schadt and his "emperor has no clothes" approach to conventional wisdom in the field of molecular biology. Schadt makes for an interesting topic with his proselytizing about the vast networks and cause-effect relationships within the body... and how that runs counter to the previous belief that things within ran independently enough that successful mapping of human DNA would start us on the road to disease cure. In terms of this new viewpoint, the book The Structure of Scientific Revolutions is cited as one of Schadt's early influences and which led to him breaking away from conventional belief. Junod details not just the intelligence and contrarian viewpoint of Schadt, but also his propensity to get out in front of his ideas and advocate loudly for him. Lest that statement make him appear a simple self-promoter, also noted in the profile is Schadt's collaborative approach to solving problems and curing disease... regardless of whether it's he or his company getting the credit and subsequent revenue. It was really interesting reading on Schadt and also striking to me from the piece was an anecdote about how he "likes to do his supercomputing on planes" via Amazon servers.

Employer / Employee Relationship BusinessWeek Pieces

Two brief interesting pieces around employees and the companies they work for from the November 16 issue of BusinessWeek.

The longer of the two is titled "The Return of the House Call" and details the Microsoft program that let's employees request an in-home doctor visit. From a financial perspective, it can actually reduce Microsoft expense in helping to bring down company costs for any unneeded emergency room visits by covered employees (should probably be noted that the Microsoft health care plan is apparently noted for being low-cost to it's employees).

The secondary, but still important impact of the program is in showing employees how valued they are by the company.

Very much tied to this latter concept, I thought the point raised in the extremely short "Are Your Employees Just Biding Their Time?" was a solid one. The concept is that there's a number of companies out there taking the current recession as an opportunity to squeeze employees and that could turn out to be counterproductive when the economy turns around. If an employee doesn't feel valued or treated fairly, it could well be a mass exodus of talent once other opportunities present themselves.

I find this whole idea of the employee / employer relationship to be a fascinating one and (keeping in mind things are always as they appear) it's interesting to read about and reflect upon the approaches taken by some large corporations.

I did a blog post in Oct 2008 titled Corporate Workplace Culture: the Good (Not the Bad or Ugly) which featured some positive employee treatment stories from companies such as Costco, Netflix, Google and yep... Microsoft and then another post in March of this year on People Management at IBM.

Just interesting... I think the point is that companies can squeeze employees under certain conditions, but I really question how sustainable the practice is over the long haul.

Time Magazine - Organic Food & Republican Politicians

Couple of really good articles in the latest issue of Time Magazine.

The cover story is titled "Getting Real About the High Price of Cheap Food" and provides an excellent look at the food industry in America. Written by Bryan Walsh, the piece looks at the potential for problem throughout much of the food chain feeding us today. In order to keep down costs, pigs and cattle are typically raised in unhealthy conditions making them vulnerable to disease... which has to be combated with copious amounts of antibiotic drugs.

It's definitely acknowledged in the article to be more expensive (even in the title), but the basic premise is that local organic agriculture and sustainable farming is the way to go. Tough to bring around everyone, but the point made is that it's worth it to try.

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The second piece of note is the commentary by Joe Klein on Republican political opposition to President Obama's health care plan. Just ill-inspiring is the description of how otherwise level-headed Republicans feel compelled to let Sarah Palin prattle on about "death panels"... simply because to refute her would help their political opponent.

Titled "The GOP Has Become a Party of Nihilists", it's a balanced story that points out this is not the way to have political discourse around an important issue.

Health 2.0: Patients as Partners Article from BusinessWeek

Very interesting article titled "Heath 2.0: Patients as Partners" from the Dec 15 2008 issue of BusinessWeek.



This piece relates to the Jeff Jarvis book "What Would Google Do?" (which I reviewed here) in that it looks at how social networking and collaboration could be used to help people with their personal health care.

Interesting ideas...