By now, Dr. Atul Gawande’s article on McAllen’s high cost of health care has been widely read. The article spawned a number of responses and catalyzed a national discussion on cost controls and the business of medicine. It even made it’s way into the President’s address to the AMA.
Almost overnight, McAllen and the Rio Grande Valley were thrust into the national health care spotlight – the once sleepy border town became, not a beacon on a hill, but a balefire in the valley, representing much of what is wrong with the current medical culture.
But, McAllen wasn’t always like something from an old Western, where doctors run wild and hospital CEO’s compete like town bosses. I remember McAllen quite differently. I remember it, because as it turns out, it was where I was born.
It’s also where my father, Dr. David Kibbe, practiced medicine from 1980 to 1990. In order to find out how McAllen earned the dubious reputation it now has, I sat down with my Dad, and asked him what he remembers about that little border town on the Rio Grande.
Ian Kibbe: So Dad, what was your first reaction to reading Atul Gawande’s article?
David Kibbe: Well, Ian, it was sort of “oh-my-gosh, he nailed it.” And, of course, a flood of memories, good and bad, came back to me about our time there. My medical career began there, you and your sisters were born there, small town 4th of July parades, etc. But I left after great disappointment and frustration.
IK: What were you doing in McAllen practicing medicine anyway?
DK: The National Health Service Corps sent me there to work in a clinic for migrant farm workers. The NHSC had provided me three years of medical school scholarship, and so I owed three years of service in an under-doctored area of the country. I speak Spanish, and so working as a family doctor in the Rio Grande Valley of Texas, which is the home of many of the country’s Hispanic migrant farm workers, was a good fit. Hidalgo County, where McAllen is located, was the poorest county in the country, and there was a real physician shortage there in 1980.
I worked in a migrant farmworker clinic with ties to the United Farmworkers, Cesar Chavez’ group, in McAllen. As a young physician from outside the Valley, and working in the one clinic in the county where the poor could receive medical care for free or almost free, I got to see an amazing diversity of medical problems that many physicians in this country never see, such as Dengue fever and leprosy. It was a great opportunity to be of service, in my opinion.
And then in 1982 we started a family practice in Mission, Texas, about 4 miles west of McAllen, where the physician shortage was even more critical. You were born in the little 67-bed hospital in Mission the next year.
IK: So, what did McAllen’s health care system look like when you first got there?
DK: Well, it wasn’t really a system, it was a community. And I would characterize the medical culture as primary care-oriented for at least the first half of the decade. Family physicians, internists, and pediatricians were in charge of things, ran the county medical societies, provided most of the medical care including hospitalizing sick patients and delivering babies. We had a couple of surgeons, and one cardiologist who was board certified.
But starting in the early 80’s things began to change. In 1982 HCA opened Rio Grande Regional Hospital. Then in 85′ Universal Health opened McAllen Medical Center. Both were large for-profit hospital chains, with new facilities, and both recruited literally dozens of sub-specialists where there had previously been only a handful. So within three years, there was a significant change towards subspecialty care, and that trend intensified over the next few years.
At first, the influx of technology and subspecialty care was welcome. We, the primary care docs, had more help locally, and didn’t need to transfer patients to other parts of the state for subspecialty care or specialized surgery.
IK: Why the sudden interest in McAllen?
DK: Money, plain and simple. Most of the new subspecialists were guaranteed enormous incomes, by the hospitals. Since I was one of the first American-trained primary care physicians in the McAllen area, and I made an effort to reach out to retirees from the North, or “Snowbirds” as they were called, I guess I created sort of a beachhead as my practice grew. As a result, I was courted very heavily by the subspecialists for access to those retirees and the subspecialty care they could generate.
IK: So, in some ways it was like a medical “gold rush?”
DK: Exactly. What was initially exhilarating change and modernization turned into a “gold rush” atmosphere, as more and more subspecialty doctors came to town and competed to see who could make the most money, admit the most patients, or build the largest homes. McAllen went from having one cardiologist to having two competing cardiac surgery teams. They created a cascade of demand. The primary care docs slid to the bottom of the totem pole economically and socially. I now understand this as the disintermediation of primary care.
IK: Can you give me an example of what you’re talking about?
DK: Sure. So, in 1983 I’d see a patient with intermittent chest pain, and that day refer him to the cardiologist for evaluation. He’d call me on the phone and say, “David, I’ve seen your patient Mr. So-and-so, examined him, listened to his heart, and have done a tread mill stress test. Everything seems ok, so I’m sending him back to you for further evaluation for his problems.” Fine.
But by 1987, I’d make the referral and never hear another word. Running into the cardiologist in the hospital hallway or locker room, and asking what happened to my patient, I’d get this response: “Oh, well if I remember correctly I admitted him to the hospital and we did angiography, which was normal. But he was having a headache, so the neurologist ran some CT scans, and I asked the gastroenterologist to do endoscopy because there was a question of some GI problems. As I recall, everything was normal, but I still see him every month for his blood pressure.”
So, an evaluation that used to cost a couple hundred dollars turned into many thousands of dollars worth of testing and procedures; and this happened day in day out, week after week, year after year.
Another issue was quality assurance. I was the hospital staff physician in charge of the quality assurance program at Rio Grande Regional Hospital. But we could never make any improvements. There was one cardiac surgeon who kept leaving several tiny needles inside his patients’ chest cavity after heart surgery, and we couldn’t figure out a way to cut that out. He was too important to the hospital, I guess, to offend. And he knew he could just blow us off. It was all about the money.
IK: What role did you see the large for-profit hospitals playing in this change?
DK: It seemed to me that the hospitals encouraged the newly arriving doctors’ attitudes about making money. These were young doctors, for the most part, right out of training. The hospital would pay them large guaranteed incomes to get them to locate in McAllen, and pay the rents on their offices for a number of years, too. The hospitals were competing openly for procedures and tests, unlike in some towns where there are agreements to share high cost facilities, like heart surgery or cancer treatment centers. But in McAllen there was out-and-out financial war between the doctors on each of the hospital staffs.
IK: And you were right in the middle of this war?
A: Well, yeah! As I said, I was courted very heavily by the subspecialists for access to my patients, but at some point that dynamic changed from seeking my referrals to taking my patients.
IK: So why did you hang around for so long?
Well these changes didn’t happen overnight. I was practicing medicine and taking care of patients. Also, think I didn’t know any better. Eventually I got my business degree because I wanted to figure out what the hell was going on! So, I went to the University of Texas business school part-time during those last two years we were in McAllen, primarily to try to understand what was happening to health care. It was clear that one needed a business degree to understand medicine in McAllen, Texas. Also, at the time, getting an MBA seemed like a good idea because everyone was saying medicine was a business now.
IK: Who was saying that?
Many of the doctors and the hospitals, the journals and the literature.
IK: So when did you say “enough is enough?” What finally made you decide to leave McAllen?
DK: We left in 1990 to come to Chapel Hill, North Carolina. There were a number of reasons I wanted to leave the McAllen area, but the main reason professionally was that the medical culture had become so subspeciality dominated and oriented towards profiteering, that it simply was no longer rewarding to be in family practice there. I mean, in 1987 there were more MRIs in McAllen than there were in all of Canada! And most were owned by doctors or groups of physicians.
May I ask you a question?
DK: What was your best memory of living in the Rio Grande Valley during the first eight years of your life?
IK: Wow, that’s tough. But I’d have to say I had the best times at those big cookout’s out in the country. There was something really magical about running through the orange groves with my friends and the smell of ripening oranges mixed with the smell of charcoal, and Texas barbecue. It was a pretty care-free time for me. Oh yeah, and the fireworks. Eight year olds love fireworks.
Well, thanks Dad. This was fun.
DK: Love you, son.
Ian Kibbe is Associate Editor for The Health Care Blog. He is also a writer, actor, video producer and editor.
David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.
- The Road from McAllen to El Paso
- McAllen: A Tale of Three Counties
- Gawande Nails It on Healthcare Costs