The border town of McAllen, Texas wasn't on the tip of anybody's tongue before this month. But a few weeks ago, an article in The New Yorker offered it up as exhibit A of all that is wrong with the country's healthcare system, the ground zero of medicine run amok.
In recent weeks, the president himself reportedly carried the magazine into conference rooms announcing that the article, which was called "The Cost Conundrum", was mandatory reading for anyone who was serious about joining the health reform conversation.
But yesterday, the doctors of McAllen began to fight back. In a news conference in Washington, D.C. directed at President Barack Obama and Congress, they said The New Yorker and the article's author, Atul Gawande, MD, got it all wrong.
Gawande, who visited McAllen some months ago, attributed his statistics on McAllen to the Dartmouth Atlas of Healthcare's compendium of Medicare spending costs throughout the country. It showed, he wrote, that McAllen has the second highest per capita spending of Medicare dollars in the nation, next to Miami where the costs of practicing are much greater. In McAllen, the $15,000 annual spending on medical expenses is twice that of the national average, Gawande said.
A surgeon at Harvard Medical School's Brigham and Women's Hospital in Boston, Gawande blamed McAllen's expensive tab on an assortment of McAllen's physician entrepreneurs who have set up large medical practices that perform a lot of imaging and other tests, and formed hospital companies that keep patients longer than average. In effect, Gawande accused McAllen's medical system of over-utilizing and overcharging the federal government.
But yesterday, at the start of a Border Health Caucus in Washington, officials from the Texas Medical Association and the Hidalgo-Starr County Medical Society, explained that is hardly the case.
And they asked that the president come to McAllen to see for himself.
McAllen is different than any other place in the U.S. It provides healthcare to an extremely needy and poor population, they said, and is just more expensive because the healthcare needs are so great.
In effect, they said, Gawande used statistics that were not risk-adjusted for the severity of health problems in McAllen.
For starters, said society president James Stewart, MD, a McAllen internist, Hidalgo County has the lowest average income of any county in the nation, which means it is the poorest. Because of that, as well as its proximity to the border, it is beset with more than its share of health challenges. It has high numbers of uninsured, high numbers of undocumented immigrants, and a high percentages of people who, when they are diagnosed with an illness, their providers learn they have never seen a physician.
Four out of five patients are eligible for Medicare or Medicaid. It has a higher share of diabetes, obesity, heart disease, kidney disease, and kidney failure.
"There's a feeling here that coming to a hospital means the end of your life, which is a cultural thing," said Carlos Cardenas, MD, a McAllen gastroenterologist and chairman of the board of Doctors Hospital at Renaissance. That keeps many people from seeking healthcare earlier, before the disease process has marched too far along to be easily managed, he added.
"Many of our patients believe that if they were to go on insulin, it's something they don't want to do because they feel that people who go on insulin lose their eyesight, or lose their limbs," he said.
Bottom line, healthcare is expensive in McAllen not because doctors or hospitals are charging more, but because they are providing more of the most expensive kind of care, for patients whose health issues went ignored for decades, until they became acute.
All of that racks up the spending bill for healthcare.
"We have the sickest population in the United States," said E. Linda Villareal, MD., an internist in nearby Edinburgh. She said that for most physicians, the bulk of their practices consists of patients on Medicaid or Medicare.
And there's a shortage of physicians too, she added, saying the McAllen area has the lowest rate of physicians, 116 per 100,000 population, in the entire country and 43% fewer physicians than the U.S. average.
And that means the physicians that are there "see more and more patients in less and less time."
The physicians showed photographs of how many of their patients live, in meager buildings in the colonias where drinking water supplies can easily become contaminated with sewage, and where housing often lacks basic plumbing or air conditioning. Instead of bathrooms, residents use latrines.
Because of that, Stewart acknowledged, hospitals may keep patients in the hospital for a few days longer than they need to be there, because they know if they discharge them to a home that is not clean, their wounds will soon become infected and they may come right back into the hospital with hard-to-treat infections.