More required reading by Atul Gawande....

Atul Gawande wrote one of the most talked-about stories on health care - his story on the over-use of medicine in McAllen, Texas.

(You can find it here.)

I sent off a bunch of my questions to him and received a thoughtful response from him not long after. His comments on why he selected Medicare costs to develop "the baseline scenario" are instructive:

"We do need broader data than medicare but there are so many fragmented private insurers one cannot gather easily a comprehensive picture of the US practice patterns."

That is a key issue, in my view. A major roadblock to real reform, in fact. We are setting out on a tumultuous journey to control costs in medicine, but because of the fragmented nature of the private sector, it is impossible to gain this "comprehensive picture of the US practice patterns."

There is a problem using Medicare as the example of the cost conundrum. Medicare pays at a lower rate than private insurers pay. There are doctors who will not accept Medicare patients because it is not cost-effective for them to do so. I wonder how much of McAllen's over-use of medicine is common to practices with a high volume of Medicare patients - they order more tests specifically to bring in more money to augment the lower reimbursement rates they get from Medicare.

Would they feel the same economic interest in tests if they were paid at the higher private practice rates? Is medical over-use like that found in McAllen as frequently found in practices with minimal contact with Medicare patients?

We don't know - private insurers are too fragmented to get a handle on their practice patterns.

Or to fully understand why healthcare costs what it costs.

When we start talking about the public option - the price and cost of care is a vital consideration - is the pricing for a public option going to attract the best docs? Or will it repel them, as you see today under Medicare and also under the current HMO model.

(In my experience as an HMO patient, the best docs and hospitals refused many HMOs - it was not worth it to them to see patients who paid significantly lower prices for the visits when they could very successful pack their practices with the higher paying PPO patients.)

Will the exchange plan being hyped by the Obama administration bring relief to the self-insured and uninsurable - or just another layer of admin fees added onto a system already breaking under the weight of administrative fees?

Dr. Gawande also pointed me to a speech he gave this month to the graduates of the University of Chicago medical school.

This should be required reading alongside of his McAllen article.

In this speech, he talks about what we can do right now to start reforming our system.

So what does he talk about in his speech?

Positive Deviants....

In his speech to med students about to enter the world of medicine, he points to the "positive deviants" as examples to follow. The people who somehow have never forgotten the real reasons why they went into medicine in the first place, to heal and treat people.

He opens his speech with a story about a friend, a professor of nutrition who was heavily involved in reducing hunger and starvation in third world communities. And when working for a program that was "starved for money," this professor began to focus on who within a particular village had the best-nourished children. They discovered simple, affordable solutions that were already implemented by some families - the ones with the best nourished children. When other villagers began following the examples of the "positive deviants" within their community, "malnutrition dropped sixty-five to eighty-five percent in every village."

Gawande continues:

"I tell you this story because we are now that village. Our country is in trouble. We are in the midst of an economic meltdown like nothing we’ve seen in more than half a century. The unemployment rate has passed nine per cent. For young people ages twenty-five to thirty-four, the rate is approaching eleven per cent. Our auto industry has filed for bankruptcy. Our housing and finance industries are shadows of their former selves. Our state and local governments are laying off teachers and municipal workers.

It is worth reflecting on how extraordinarily lucky we who are doctors, or doctors-to-momentarily-be, are. Consider the contrast between what every other graduation ceremony taking place today must feel like—the graduation ceremonies for the undergraduates, the business-school students, the law-school students, the architects, the teachers—and what ours does. There are thousands graduating proudly today but fearing for their future. Many have no jobs, no sense of how they’ll make it.

We doctors meanwhile remain with no significant unemployment. Virtually all of us can find gratifying and well-compensated work in our chosen fields, and that is remarkable. It is something to be deeply thankful for.

Yet the idea that we can proceed oblivious to the economic conditions around us is folly. In fact, it is not just folly. It is dangerous.

Job losses and cutbacks have produced an unprecedented increase in the uninsured. Half of hospitals were already operating at a loss before the economy tanked, and the rise in patients who cannot pay their medical bills have since pushed many into insolvency. Hospital closures and layoffs have started, as you know all too well in Chicago. We will be affected by what is going on in our country.

More than that, though, we in medicine have partly contributed to these troubles. Our country’s health care is by far the most expensive in the world. It now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government at every level—squeezing out investments in education, our infrastructure, energy development, our future."

"We are now that village..." he told the med students.

And all of us share the burden of responsibility. Patients need to take better care of their health. Patients need to push doctors to fully explain the benefits and costs of certain treatments.

Doctors need to responsibly use the vast array of treatment, technology and services we have available to us today.

We are all that village - and we are all responsible.

He ends his speech with some advice to the new docs:

"No one talks to you about money in medical school, or how decisions are really made. That may be because we’ve not thought carefully about what we really believe about money and how decisions should be made. But as you look across the spectrum of health care in the United States—across the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. And as you become doctors today, I want you to know that you are our hope for how this battle will play out.

As you head into training and then further onward into practice, you will be allowed into people’s lives in a way that no one else in society is permitted. You will see amazing things. And you will develop extraordinary abilities.

Along the way, you will sometimes feel worn down and your cynicism taking over. But resist. Look for those in your community who are making health care better, safer, and less costly. Pay attention to them. Learn how they do it. And join with them.

If you serve the needs of your patients, if you work to ensure that both overtreatment and undertreatment are avoided, you will save your patients. You will also save our country. You are our hope. We thank you."

Read Gawande's speech. Watch the positive deviants in action.

Absorb their positive behaviors as your own. It's our best and brightest hope.