Prevention Matters

Atul Gawande, the doctor whose recent New Yorker piece piece comparing the medical systems of El Paso and McAllen, Tex. has caused a major stir in health policy circles, says a greater focus on prevention could help reduce costs in McAllen "overnight."

"...We have not been thinking hard enough about how we control costs and make a better system," in an interview with the Washington Post's Ezra Klein. "I think it's achievable in about 10 to15 years, and maybe even faster. I can tell you three things that will transform McAllen overnight. But CBO doesn't score them."

Gawande said McAllen's average $15,000 annual expenditure per Medicare beneficiary could be reduced to $10,000 through a reduction in home visits, an increase in the use of hospice care vs. ambulance rides, and "work on basic cardiac prevention like getting people statin drugs."

"Most studies have shown you'll lower the cardiovascular disease rate by 25 percent and lower the number of procedures ordered," he said. "This was done in by Kaiser of Northern California, and they became the first community I've ever heard of where heart disease stopped being the leading cause of death."

Atul Gawande has an incisive piece in The New Yorker on what accounts for the vast differences in per capita Medicare spending in different parts of the country. He focuses on McAllen, Texas, where the average annual Medicare expenditure per patient exceeds the average annual income and is double that of Medicare spending in El Paso County, Texas - even though the demographics and treatement facilities are roughly equal and the quality of health care is ranked lower in McAllen than in El Paso County.

Basically, Gawande concludes that the situation in McAllen and many areas with extremely high costs is attributable to an "across-the-board overuse of medicine" fueled by a local economic culture that "came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers."

At the same time, he says, "patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed."