Physicians

Return to McAllen: A Father-Son Interview

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?

IK:  Sure.

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.

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32 replies »

  1. Hi there, simply turned into aware of your blog via Google, and located that it is really informative. I’m gonna be careful for brussels. I’ll be grateful in case you proceed this in future. Many people will probably be benefited out of your writing. Cheers!

  2. Deb: So nice to hear from you! Yes, I’m sure Ian would love for you to share his work with others. dCK

  3. Great interview. I know David, but didn’t realize he had been in McAllen. As a family physician with similar sensibilities, I am also disheartened by the fragmentation of the healthcare “system” and the disintegration of the Family Physician as manager of a patient’s total care. I had been sending around Dr. Gawande’s NYT’s article. Would you mind if I shared this interview?

  4. Dear EHR Guy: You’re from Donna! I met Jessee Jackson at a rally in Donna for the United Farmworkers, and did some kick dancing there myself. And those Friday nights out for dinner in Reynosa were often very, very pleasant. (Although I didn’t do anything more exciting after than cross the international bridge back into the US of A.)
    Regards, dCK

  5. Hey thePRGuy,
    Hmmm, what I remember of McAllen is going to Reynosa on Friday nights and waking up Saturday at noon in a place I will not publicly disclose. 🙂
    But I was bornt and raised in Donna and was a typical “kicker” which was an honorable title back then yonder and cowboys were expected to do certain things and portray certain behavior or else be ridiculed forever. But now I am 35 years beyond that!
    Well, on another note, keep on writing!
    Good luck!

  6. PR manager? I think I’ll stick to son and occasional interviewer!
    Thanks to everyone who enjoyed the article. It was an incredible pleasure to write. Prior to the interview, my only real memories of health care in McAllen consisted of sneaking bouncy balls from the toy drawer usually reserved for child patients at my Dad’s practice, and getting trapped in the elevator at the HCA hospital (I didn’t ride an elevator for at least 7 years after that!). So, all the recent attention McAllen has been getting and the interview with Pops has been very interesting to me. It’s supplemented not only my health care knowledge, but also my personal history. But thanks again to all those who read and enjoyed.
    Cheers

  7. Ben: I think you’re quite right about this phenomenon. Thanks for your comment. DCK

  8. Beautiful piece! I have felt the same slippage into the maw of greed-driven care in California, New Hampshire, Missouri and Vermont over the past 25 years. McAllen may be the grossest example, but the trend is very widespread.

  9. Dear Joe and Jos: For me the story of medicine in the past 25 years has been the structural disintermediation of primary care. My own career, and the story told here, is repeatable all across the land. McAllen isn’t an isolated problem spot, it’s the metaphor for health care in the nation.
    There may be more of a maldistribution of doctors as opposed to an outright shortage. But the effects of a shrinking percentage of care providers being in primary care are obvious now to most observers.
    Thanks for your comments. DCK

  10. Hi Dave, nice interview. To Joe Blow, the problem is both a lack of physicians when the nation is seen globally, the gross maldistribution of Docs (suburban, areas of wealth, areas where Hospitals have located becuase of Market Analysis) and finally the wrong KINDS of Docs. 30 % Primary care Docs, the base of the health care pyramid, rather than 50% to 70% Family Docs as in other advanced countries.
    And yes in many areas we have to few if ANY neurosurgeons, general surgeons, and people travel miles to see and OB or a family Doc who does deliveries, but then they also coe from Canada to the U.S. cause they have big problems also…

  11. Dr Kibbe,
    I think that the McAllen story illustrates one thing: there is no nationwide doctor shortage.
    Lets recall that McAllen is a small rural poor bass ackwards area of the country. Its not exactly an ideal hotspot for doctors to relocate to.
    If McAllen has all these docs running around ordering tests, how much more of that is going on in a doctor mecca like Boston, LA, Chicago, NY, etc?
    Its ridiculous to suggest that there is any kind of doctor shortage when we have McAllen (freaking) Texas just busting at the seams with all these subspecialists.
    United States has too many doctors, not too few.

  12. Absolutely!
    And if you had me as your marketing manager you would probably be the most notorious healthcare IT leader! 😉
    Thanks,
    The EHR Guy (formerly the HL(6+1) Guy)

  13. Dear EHR Guy: Hah! So, you think I need a PR manager? 😉
    Actually, I’d take all the help I can get! At least he can write. And better than drive by blog posts, any day. Regards, dCK

  14. Hear, hear! and hurrah for your candor, Dr. Kibbe. Congrats to you also, Ian.
    Pam Drew

  15. @pel: please read the excellent comments on the post you link. These are incredibly thorough, and they completely debunk the Gilden analysis…which, by the way, would never survive peer review at a respectable journal (unlike the decades of Dartmouth research, which have consistently been published in top-tier journals).

  16. Texas Catheterizer: A cardiologist, I presume? 😉
    Let me be very clear about the hospitals’ influence: the competition between two hospitals for specialists, for equipment, eg MRIs, for patients, and for procedures is what drove the medical inflation in my opinion. The fact that the hospitals were both for-profit may not have been very important, as not-for-profit hospitals can and sometimes do engage in this same kind of competition in a city or region. Regards, DCK

  17. Dear EHR guy: The HCA of today is not the HCA of old. Remember, HCA was investigated for Medicare fraud in the 1990s, and three of its top executives of HCA/Columbia, as it was known at the time, were indicted. Personally, I never experienced anything close to fraud by administrators at the HCA hospital in McAllen, where I admitted many of my patients from 1983-90. I was always on good terms with the hospital administrator and the management of that hospital. The care we provided our patients was excellent, but as I recall my experience there, over time the prevailing atmosphere trended toward medicine as a business, rather than as a service and profession, and it was quite open and acknowledged by 1990. And I think the hospital played a role in that transformation, which was unhealthy. Regards, DCK

  18. If HCA had a detrimental influence in McAllen then we would be witnessing a worse situation in Nashville, TN.
    I have never heard of this systematic problem occurring in this state or others where HCA operates.
    I have been in projects with HCA hospitals and I have found their clinicians quite content and not exploited as some have said in this comments space.

  19. The for profit Frist owned HCA moved in and Senator Frist, the Congress’ medical educator under Bush, put all of his holdings in a blind trust.
    Funny that Gawande does not mention the HCA influence in McAllen and in other parts of the US; influence that has generated a business model for the “not for profits” that earn $ billions, manipulate staff doctors, exploit nurses, churn patients through unnecessary tests and operations bankrupting them, and pay executives, like the one in Pittsburgh, over $4 million.
    According to proposed health plans, doctor owned hospitals will not be permitted. Hmmm is the word.

  20. Could the McAllen disparity be the result of a combination of factors, or is it really primarily due to physician culture?
    For instance, the snowbird issue is not even mentioned in the Gawande article, but it it seems to be a rather large concern for Hidalgo county.
    Additionally, the research work by Daniel Gilden (cf: https://thehealthcareblog.com/the_health_care_blog/2009/06/mcallen-is-now-a-tale-of-three-counties.html) points to far higher occurrences of heart disease and diabetes, complications of which can run up the cost.
    Lastly, there is the excessive poverty of Hidalgo county, which exceeds even that of El Paso, to which it was compared.
    It is seeming more and more that the McAllen Medicare disparity is a basket of problems and not particularly easy to distill into a single physician culture explanation.

  21. David
    Thanks.
    As one who never lived there but visited often and read quite a bit I will still have to yield to your view.
    Each state I suppose has its unique assets and quirks.
    Be Well,
    Rick Lippin

  22. Dear Rick: I’m going to give you some friendly heat 😉 about dissing Texas. I loved many respects of living in the Rio Grande Valley, and loved going to business school at the University of Texas in Austin.
    Having said this, there is no question that Medicare and Medicaid fraud was indeed rampant while I was practicing in the Valley. A colleague general practitioner in Mission while I was there would routinely see one child in the family, but charge for every member of the family. Most of his patients were Medicaid recipients. Everyone in the community knew and tolerated this behavior, myself included.
    But this kind of abuse isn’t and wasn’t unique to Texas!
    Kind regards, dCK

  23. Thanks for this helpful father-son dialogue.
    I know I will take “heat” for this but the culture in many parts of Texas remains among the most dysfuntional in the nation for many reasons.
    I had travelled there extensively in the 1980s and 90s and was offerred a very high paying job there in 1999.
    But I could not bring myself to move to Texas and do not regret that decision.
    Dr. Rick Lippin
    Southampton,Pa

  24. Being from the Rio Grande Valley area myself I can attest that the healthcare system in that area is plagued with corruption as well. It is probably second to Houston in Medicare fraud.
    Corruption and fraud do raise costs at exhorbitant levels. Additionally, the healthcare domain there has to deal with serving illegal immigrants which do not pay for the services given.
    McAllen and many places in Texas should be examples of what never to do in healthcare!
    My humble 2 cents.
    Thanks,
    The EHR Guy

  25. Thank you for a fascinating post.
    This type of entrepreneurial medicine is a direct result of the AMA designed and maintaned RVU system.

  26. I was trained and practiced at the largest Osteopathic hospital in Texas in the 80’s and 90’s. Over the years I saw it grow in exactly the same way that Dr. Kibbe describes in this interview. From a primary care driven system with almost no subspecialists to many subspecialists who fought each other for the primary care referrals. Eventually, each primary care admission was used as a profit center for the subspecialists and the hospital. Exotic work ups that could have easily been done on an out patient basis were done in hospital. Many times the problem a patient was admitted for was barely focused on. Many nursing home patients were simply admitted to do extensive referrals. It was distressing to witness and participate in such a system. Thankfully that hospital is now gone. But it is easy to see how expenses are driven up by an over abundance of subspecialists. During the years I was there Medicare paid for an extraordinary amount of unnecessary care. Many physicians were part or whole owners of CT’s MRI’s or the out-patient surgery center which greatly supplemented their incomes. These doctor’s practiced what an M.D. friend in town referred to as “entrepreneurial” medicine. And he meant it as a compliment.

  27. Excellent firsthand testimony, especially valuable coming from a primary physician. Agree this should be read with Dr. Gawande’s. Thanks.

  28. This should be as read alongside the Gawande article. This is an excellent story which puts a face on the data.

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