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Are We Missing Gawande's Point?

Philip Betbeze, for HealthLeaders Media, July 31, 2009

If you've not heard the buzz surrounding Atul Gawande's recent New Yorker article, "The Cost Conundrum," you've either been out of the country or you've been following the Michael Jackson death soap opera too closely.

Let's just say that the good doctor's efforts have struck a chord. Even the president has mentioned the article in his efforts to get Congress to pass a healthcare reform bill.

Gawande's work to present the healthcare cost disparity in narrative form has caught the attention of many who believe healthcare's costs are out of control and that its growth profile is completely unsustainable. He found that tiny McAllen, TX, boasts higher healthcare costs than any other statistical area in the country, save Miami, which has much higher staffing and living costs. And the outcomes aren't any better.

Not one, not two, but three influential people gave speeches last week at the American Hospital Association's annual Leadership Summit in which they prominently referenced the article as a window into the problem with healthcare costs. I've been to other conferences around the country too this summer, and if the article is not the first topic people bring up in casual conversation about healthcare, it's the second.

But so what?

What amazes me about these speeches and conversations is not the fact that the article has received so much acclaim. It is well-written, and Gawande, a physician himself, does an admirable job of searching for other possible explanations to McAllen's cost problem than the conclusion to which he's ultimately drawn:

Are people there are unhealthier than those in other areas of the country? No.

Do hospitals and physicians in McAllen provide exceptionally better healthcare than anywhere else? No.

Is it malpractice insurance costs? No.

Is there overutilization of medical services? Absolutely.

People are waving this article around like it's some revelation. They're rightly using it as a call to action for healthcare providers, government, and payers to coordinate care and use evidence-based protocols to prevent so many unnecessary tests and surgeries. But where have they been for 20 years?

The Dartmouth Atlas of Health Care has been around for more than that long. It says the essentially same thing as Gawande's article, except it's much more detailed, depending on reams of Medicare cost data to tell essentially the same truth.

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