Doctor Says New Yorker Used Slanted Stats Against McAllen, TX

James Stewart is an internist in McAllen, TX, a rapidly growing city just a few miles from Mexico, far south of where the border lies in most of the rest of the U.S.

But when he woke up one morning a few weeks ago, his life and that of many other health providers with whom he works had changed. Suddenly they were in the national spotlight of the health reform debate, and not in a good way. Even President Barack Obama was pointing to McAllen as an example of how not to provide healthcare.

"We were shocked," Stewart said.

Thousands of miles away, writer and Harvard surgeon Atul Gawande had used the Dartmouth Atlas, a compendium of Medicare statistics, to accuse McAllen of providing too much expensive medicine, implying much of it is unnecessary, at the expense of the federal government. He referred to some of the doctors practicing in McAllen as "entrepreneurial," and echoed that for many, medicine had become like another business run by people interested mainly in profits.

And he did it in The New Yorker magazine, in an article entitled "The Cost Conundrum,"  which the White House has classified has required reading or those in the health reform debate.

"I am not normally a conspiracy theorist," Stewart said in an interview this week.

But in researching and writing his article, Stewart says, Gawande "totally brushed off the poverty we live with here" and the fact that by the time many people get to a health provider, they are diabetic, morbidly obese, have some degree of organ failure, and in some cases have their first medical encounter in an emergency room.

The thought has crossed his mind that Gawande had an agenda from the start, "motivated by reasons I don't pretend to understand."

Stewart characterized the article as being "intellectually dishonest" and says it did not take into consideration the essential fact that makes providing healthcare in McAllen a lot different than it is in Boston.

Gawande, Stewart says, should have run some risk adjustment calculations for that.

"How did we get in there (The New Yorker) this way when we have 30% of our population with no resources, and so many don't even qualify for Medicaid," he said during an interview yesterday.

Stewart and many of his fellow practitioners from McAllen and surrounding towns joined the Texas Medical Association for a visit to Washington, D.C. this week. They're holding meetings with the Border Health Caucus in an effort to persuade policy makers that there is a much more accurate story about what's wrong with healthcare in the U.S., one told with a visit to south Texas.

Gawande neglected to take into account the fact that hospitals in McAllen and many in the larger county of Hidalgo receive a lot of federal disproportionate share money because of the high number of uninsured, many of them undocumented immigrants.

"How many Medicaid patients we have–that's something that can add 35%," Stewart says. "If you start risk adjusting, all of a sudden, we compare very very favorably, about the same as Grand Junction CO or Rochester MN.

"It's amazing, but though the average age of our population is young, somewhere between 26 and 28…it's a cohort that's already obese and diabetic." Stewart estimated that about 30% of the population has very little care and no resources, and 15% have not been diagnosed, although if they saw a physician, they would probably have "the triad: high cholesterol, diabetes, and hypertension."

True, Stewart says, "this is a very very peculiar and unique area that is clearly an outlier, but to say this area should look like a middle American town in Iowa – this area is never going to look like that. And to have someone parading around the White House saying this is required reading. And now, we're getting in all these blogs. Some of them want to blow up McAllen at this point."

McAllen has a lot of new medical buildings, and there are many providers who have come to the area with new technologies in recent years. There is a heart center, new imaging equipment, and a new hospital. "He cited all the high tech equipment that's available, and there has been a huge amount," says Stewart. "But most of those pieces of equipment have been here less than five years."

They could only have a minimal impact on the Dartmouth Atlas' statistics. "If you want to write an article," he says, "at least keep it in the same time period."

But many of these physicians were recruited to an area that still has an acute shortage of physicians, said to be among the lowest in the country per 100,000 people, Stewart and other McAllen physicians said.

However, Stewart says that all the attention has prompted doctors in McAllen to take a closer look at how they provide healthcare. And while Stewart believes that Gawande's piece is wrong in how much it exaggerates healthcare spending in his area, "it has drawn our attention to areas where there are duplications and inefficiencies.

"Home health, for example, we might use that too much. And we have some other issues with communication, in that one doctor who takes care of a patient has no idea what another doctor has done for that patient," says Stewart. Two hospitals in the area now have electronic medial record systems and a third is launching a more extensive one that can be accessed in physicians' offices.

"I hope Mr. Obama listens when we speak because we have some important things to say," Stewart says. "If he's actually forming policy based on this article, without knowing what we really need, I have serious concerns about healthcare reform. There are very logical and obvious reasons why this area deviates from the norm, and it doesn't have that much to do with overutilization, despite Dr. Gawande's claim."