Are We Missing Gawande's Point?

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.

Gawande concludes that local variability is rooted in the overuse of services. But it can be easier to make fun of McAllen than it is to turn the mirror on yourself. You don't have to wait for healthcare reform to take action. Here are a few ideas:

• Do you know where your community stands in the Dartmouth Atlas or other global efficiency metrics?
• Within your hospital or medical group, have you done an analysis of key diagnostic procedures and orders, particularly to identify gross outliers of overuse by procedure or by provider/group?
• Have you fixed those outliers within your control?
• Have you collaborated with other providers in the community to analyze any troubling patterns?
• If there are community health issues (high rate of diabetes, obesity, smoking, etc.) that contribute to overuse of services, have you initiated a critical review of current community wellness programs and explored ideas for future interventions?

Coordinating care is hard. Developing evidence-based medicine protocols is hard. Ordering tests and surgeries is relatively easy, and it pays a heckuva lot better.

It's no surprise that healthcare costs so much. Outside of some commercial plans that pay close attention to such things, what incentive do doctors and hospitals have not to over-test or over-cut their patients? What incentive do they have to tell their patients "no" when "yes" is so much easier, not to mention more lucrative?

Meanwhile, many folks who are against evidence-based medicine or comparative effectiveness research want to raid the national healthcare cash register with one hand while they use the word "rationing" as an obscenity to belittle those who want to do something to fill in the bottomless pit that healthcare spending has become.

We've known about vast waste in healthcare spending for more than 20 years now.

When are we going to actually do something about it?