Tuesday, August 4, 2015

5 things Atul Gawande learned on his return to McAllen, TX

The Brookings Institution is a nonprofit public policy organization based in Washington, DC. Our mission is to conduct high-quality, independent research and, based on that research, to provide innovative, practical recommendations that advance three broad goals: Much of this post is taken from their May 8, 2015 blog report. One of  the 14 Policy groups  is the Center for Health Policy . 

Gawande returned to  McAllen after a five  year hiatus since his original visit to investigate the extreme variation in health costs at McAllen,TX vs.the rest of the United States. In May 2015 Dr Gwande published an article on health overspending in the New Yorker In this article he explains,

As a follow up to his seminal New Yorker articles, “The Cost Conundrum” and “The Cost Conundrum: Redux,” surgeon and author Atul Gawande provides an update on the very interesting town of McAllen, Texas and their health care spending problem. Six years ago Atul Gawande went on a fact finding mission to McAllen-- a community with double the average Medicare spending ($14,000 versus $7,000)-- to explore what the IOM calculated to equal a third of all health expenditures including unnecessary, redundant, and medically and scientifically ineffective tests, procedures, and treatments. He found a system in denial and with high rates of hospital admissions, evasive-expensive surgeries, and outpatient home health care.
Gawande returned to  McAllen recently and was greeted by an entirely new system. Inpatient visits had fallen by 10 percent; home health care spending was down 40 percent; ambulance rides were down 40 percent; and cost per beneficiary dropped almost $3,000 resulting in nearly half a billion dollars saved. What happened in Texas was unprecedented.  
But Why?

Five Lessons from the McAllen Experience:  

Evidence is hard to ignore, especially if it is out in the open.

Physicians also do not have all the right information. 

Local clinical leadership and clinical knowledge are important in promoting health.

More evidence shows payment and delivery reforms may be working.

The biggest opportunities for cost reductions are with complicated patients.

The development of an ACO (accountable care organization) may provide resources, financially, with leadership and coordination of care. This may be unique  in McAllen since PPOs, Managed care and other group practices were not in existence during the initial study by Dr. Gwande.

"An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?"

The one that got Gwande thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.  The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

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