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The Cost Conundrum: What a Texas town can teach us about healthcare

Atul Gawande explains the complexity providing healthcare with the analogy of building a house. You need experts, raw materials, and expensive equipment and materials. More importantly you need a large amount of coordination.

But imagine a world where you didn’t pay the contractor on the job but rather one where you paid the electrician for every outlet he recommended. Or a plumber for every toilet.

You wouldn’t be surprised to walk into your house and find electrical outlets every few feet.

Under this system, getting the best electrician won’t solve the problem.

…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.