McAllen, TX As Outlier? Why Not Houston?

Or Lubbock? Or Oklahoma City? Or New Orleans? Or any of a dozen major and minor metro areas throughout the South? According to the Medicare Payments Advisory Commission, all of them have significantly higher usage rates and costs per Medicare enrollee than McAllen, which was high-cost locale ground zero for Atul Gawande’s famous New Yorker article, “The Cost Conundrum,” which has become, to use the New York Times‘ formulation, “must reading in the White House.”

Gawande grounded his analysis on per-patient Medicare claims data compiled annually by researchers at Dartmouth Medical School. “The explosive trend in medical costs seems to have occurred here in an especially intense form,” Gawande wrote after the Dartmouth Atlas of Health showed McAllen as the highest spending region in the country outside Miami, where Medicare fraud is an especially virulent problem. Not so, MedPAC said. Adjust for prices and McAllen’s outlier status compared to the rest of Texas and large parts of the South all but disappears.

Don’t believe me? Check out the appendix to the report. Medicare service utilization rates compared to the national average: McAllen – 118%; Houston – 122%; Dallas – 117%. Other areas: Oklahoma City – 120%; New Orleans – 125%; Pascagoula, Gulfport or Biloxi, Miss. – 124%.

In other words, Texas and large parts of the South have a problem — not just McAllen. I’ll return to that in a moment.

Why am I writing about this issue today, since I wrote about it last December when the MedPAC report came out? Gawande will be the featured speaker at the National Governors Association meeting that convenes in Washington tomorrow morning. It appears that the Harvard surgeon has not only become must reading in the White House, but is also something of a rock star on the public policy circuit. If he stays on script, he’ll tell the governors that 30 percent of health care costs could be wrung out of the system if all the McAllens were magically transformed to be more like Iowa and Minnesota, where health care costs average 80 to 85 percent of the national average.

Unfortunately, Gawande still hasn’t publicly recognized the flaws in his presentation, at least according to his reaction yesterday on the New Yorker website, where he responded to a brief New York Times report this week questioning the Darmouth analysis. (Ironically, his spokeswoman passed along a “refused to comment” to Times reporter Gardiner Harris. GoozNews asks with Yiddishkeit inflection: “Reporters have spokeswomen?”)

The Times story was based on a commentary in the New England Journal of Medicine by Peter Bach of Sloan Kettering Memorial Cancer Center (a frequent source for my own writing, I should reveal), who argued adjusting the data for illness severity and outcomes — a measure of quality and efficiency — eliminates most of the differentials, at least at the hospital-provider network level.

A rejoinder by Dartmouth’s Jonathan Skinner, Douglas Staiger and Elliot Fisher rejected that conclusion. They said the cost differentials remain quite large even after quality and illness adjustments. But they do include an admission that regional variation is less significant than some interpreters (i.e. Gawande) claim:

The implication of these results is that excessive health care costs arise at the level of the hospital-provider network. Thus, incentives that are designed to reduce costs should be targeted to specific networks, rather than regions or states.

Now let’s return to what Gawande wrote yesterday in response to the Times, and presumably after reading the dueling commentaries:

The patterns of Medicare spending I found showed that McAllen’s medical community and culture simply did more-more surgery, more imaging, more specialist visits, more home-nursing visits-without clear benefit. . .There remains fierce disagreement about how much of the marked differences in spending between communities is the result of health differences between populations and how much is the result of differences in the care their clinicians provide to them. But it remains clear that there are substantial variations in the cost of care for people of similar health depending on which institutions they go to. . . Even if health reform disappears, these fundamental problems will not. The cost conundrum persists.

Note how he switches horses midstream. He starts by defending his work on regions, and concludes by claiming the problem is individual institutions.

Now back to the South. The most recent Medicare cost data revealed an interesting national phenomenon during this recession. Medicare costs soared while private health expenditures stagnated. As I wrote at the time, the most logical explanation for this trend is that local medical institutions made up for charity care given the newly unemployed and uninsured by soaking their best-paying customers: those on public programs like Medicare and Medicaid.

We’re seeing the same thing happen in the individual insurance market, where soaring rates are making headlines. In economically hard-hit California, Detroit and other troubled labor markets, the insurance companies are blaming rising rates on the declining number of workers buying policies. There’s less healthy people paying for the care of those who get sick.

But this is a phenomenon that doesn’t necessarily depend on recessionary levels of unemployment. The South, where there’s no legacy of unionization, decent wages or decent benefits, has the lowest rates of insurance coverage in the nation, with Texas the worst state in that regard. Less than three-quarters of its population has health insurance.

The Dartmouth Atlas of Health looks only at Medicare claims. Isn’t it possible that the huge outlier status for most Texas cities is, in effect, a major cost shifting from the uninsured, who still show up on institutions’ doorsteps for care, to Medicare and Medicaid, which at least pay their bills?

But wait, you say. Even utilization rates are substantially higher in Texas. Agreed. But here’s where I leave data and logic behind and resort to anecdote. In my mother’s last years (in Maryland), she was incapacitated in a nursing home where the doctor would show up about once a week to make his rounds. He would stop in every room for a few minutes, check the chart and move along. He could usually cover a dozen rooms in about an hour. Since most of the patients were in the final stages of severe dementia, there wasn’t much to discuss. Sometimes there was a family member in the room. Those visits took longer.

My point is that utilization can be an imprecise metric. Hospitals and physician offices do what they do and bill whom they can. Overutilization is endemic throughout the health care system, regardless of region. Some institutions — those that are primarily fee-for-service medicine — are more prone to overutilization compared to those that operate with salaried physicians and have incentives to hold down costs. The Dartmouth Atlas of Health’s insights into that phenomenon are spot-on and enduring. But the differences it highlights can be found anywhere.

No doubt some regions have more institutions and physician practices that engage in inefficient and poor quality care. But when it comes to gross outliers — whether Miami, McAllen, Houston or New Orleans — I suspect the differences have more to do with exogenous factors like fraud or the uninsured than a local culture of medicine that encourages overuse. That, my reporting tells me, exists everywhere.

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27 replies »

  1. I have witnessed too often physicians who take advantage of this population, admitting people they know will not question why they need to be in the hospital. These predatory practioners are not hard to find. We just need the political balls to get it done.

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  3. No one has mentioned anything about the fact that that thousands of illegals are treated with taxpayer dollars in McAllen area hospitals every year. In a metropolitan area that isn’t all that big, that alone would exponentially increase the cost per patient, especially when you consider that they almost exclusively use the emergency room as their primary “doctors office”.

  4. If “Texas doesn’t take care of it’s poor” and we (Texans) don’t like to provide health care to poor people, as Maggie likes to state repeatedly, then we wouldn’t be spending so much money giving the poor people of McAllen Texas health care.

  5. In regards to Margalit’s comment “For example, there seems to be some correlation between high utilization and poverty and lower education and urban density and cultural aspects.” I have witnessed too often physicians who take advantage of this population, admitting people they know will not question why they need to be in the hospital. These predatory practioners are not hard to find. We just need the political balls to get it done.

  6. Merrill–
    Usually, I agree with you, but here, I can’t.
    I’m wonder if you interviewed the folks at Dartmouth–or Gawande.
    Please see my recent post on that Times story– it’s filled with errors, and totally misquotes Ellliot Fisher. You’ll find my post here on HealthBeat: http://www.healthbeatblog.com/2010/02/the-new-york-times-garbles-the-fact-about-the-dartmouth-research–.html
    I have been talking to the people at Dartmouth and have spent weeks (literally) looking at attacks on the DArtmouth reserach that began last spring when some people became nervous that the DArtmouth reserach will be used to reduce overtreatment and over-spending by rewarding more efficient hospitals and penalizing those that overtreat. Others are very worried that anyone who looks at the Dartmouth reserach will realize that we have enough specialists in most parts of the country– too many in quite a few places–and don’t need to train more.
    Both Gawande and the reserachers at Dartmouth realize that we shouldn’t penalize or reward “regions” but rather, adjust pay to individual hopsitals.
    Dartmouth began drilling down to the level of individual hospitals about 8 or 9 years ago.
    The New York Times reporter completely garbled what Fisher said in a very brief interview: Fisher beleives we should use the data to adjust reimbrusemente to specific hospitals, not to regions.
    Gawande agrees.
    McCallen is not a “region” it is a very small town. And, according to the doctors in the town, all of the hospitals and most of the practioners have fallen into the habit of over-treating– it’s part of McAllen’s money-driven culture.
    After making certain adjustments, no doubt you could argue that there is more over-treatment in some other city or town.
    But the fact is that over-treatment is high in McAllen.
    And Gawnde chose to focus on McAllen not because it is the Capiol of Overtreatment, but becuase he could compare it to El Paso– right down the road, a very similar demographic– and yet much lower costs.
    As a jouranlist, you should appreciate the beauty of the ready-made apples-to-apples comparison. If I had discovered those two towns, sitting side by side while sifting through the DArtmouth reserach, believe me, I would have gotten on a plane and flown down to McAllen.
    You are, of course, right about overtreatment in Houston and in Lousiana.
    Texas and Lousiana have a larger number of phyysician-owned hospitals than any other state in the nation.
    Research shows that when physicians own a hospital, their patietns are mroe likely to find themselves in a hosptial bed.
    Physician-ownership also adds to the problem in McAllen.
    And no, high costs in TExas are not a result of cost-shifting from the uninsured. Interview some hostpial administrators and doctors in Texas. Talk to safety- net hospitals.
    What you will find is that in Texas, the Uninsured Simply Don’t Get Care. They are turned away from ERs.
    (Bush made it legal to turn patients away if they are able to walk into the ER (and out) under their own power. Read my book. As one Texas doctor told me “Texas never has, and never will take care of its poor.)
    In general, reserach done by Skinner and Fisher shows that hospitals in poor areas patients actually dont’ have higher expenses because they don’t have the resources to lavish care on their patients. They do a lot of “bedside rationing” deciding which patient should get the operation, which patient shoudl be sent home–or shipped to a nursing home.–without getting the treatment they need. (The Wall Street Journal has written about this.)
    In NYC, compare spending ang utliziation at Bellevue in Manhattan, to spending and utilization at NYU Medical Center, just down the street.
    NYU treats mainly affluent patients. The poor are not welcome there–and they know it. (I wrote about this in Money-Driven Medicine. NY Legal Aid did a great study of NYC hospitals, showing which ones treat the poor, and which ones shun them.)
    Medicare spends far less on patients at Bellvue (which is a public hospital) and those patients undergo fewer tests and treatments, see fewer specialists, etc.
    Spending and utilization is even lower at Harlem hospital. This hospital has so little funding and so few resrouces that I am told that much of the care is done by unsupervised residents.
    Poor Americans Need more care than the rest of us– they are sicker. But they don’t Get more care than the rest of us. The wealthy are far more likely to be overtreated.
    I spoke at the Texas Medical Assocation’s annual confernece a couple of years ago, and there was widespread agreement that much of Texas medicine is “money driven.” (A very interesting Medical Association, very unlike the AMA– a great many middle-aged women physicians, including the president.)
    They also talked about how few doctors take Medicaid patients, and how little treatment patients on Mediciad got.
    I’ve also spoken in Houston and in Dallas–very much like New York City–Money-Driven.
    In NYC , doctors have suggested that my husband needed an operation on three separate occasions. (Three different operatoins). Three times he refused. One was treatmetn for prostate cancer. The doctors said: “IF you were my father this is what I would recommend.” I suggested that my husband go back and ask “Why about watchful watiing?”
    Big smile form the doctor: “I think that’s an excellent idea.”
    When my husband told me, I asked: “What happened to if you were my father? ” That was 10 years ago, his PSA levels went down. No prostate cancer.
    No shoulder operation. (He worked it out on his own by stretching.)
    Looking at utilization, alongside dollars spent, stacked up against outcomes, is a very good measure of
    overtreatment vs. efficiency.
    I’ve now spent hours and hours looking at utilization and spending patterns in dozen of hospitals in Maryland (which I wrote about recentlty), at specific hospitals in Baltimore, and in specific hospitals at Manhattan,
    the Bronx and Brooklyn.
    NO matter how you slice or dice it, there is a high correlation between high spending and high utilization.(When I write part 2 of the post on the NYT/Dartmouth story, I’ll include charts)
    In addition, in NYC, hopsitals that treat wealthier patients do more and bill more. Hosopitals that treat poorer patients do less and bill less.
    As for the South, costs are high in part because the South is home to so many for-profit hospitals. (See my book) The reserach shows that their bills are higher– and outcomes are no better, often worse. They also shun the poor. (They dont’ build for-profit hospitals in areas where there are poor people)
    Finally, if you have met Gawande, you know that he is not a “rock star.” He is an extremely unassuming, soft-spoken and polite person. Read his book “Complications” and you will see how open he is about mistakes he has made as a physician. He is one of the most humble doctors I have ever encountered: he acknowledges that much of the time, doctors don’t know what they are doing. There is so much ambiguity in medicine: often they are working in the dark, guessing, doing their best, but not at all sure.
    If I were Gawande, I wouldn’t take a call from Harris either. The article was so badly done– you would have to be crazy to let a reporter who so clearly garbled the quote form Fisher interview you.
    The reporter didn’t bother to call the lead author on the study he was writing about– Jon Skinner.
    Gawande’s “spokesperson” is the New Yorker’s publicity person who handles press about his stories– which are widely read, and receive a huge amount of attention because he is one of the very best writers I have ever read–and when I refer to “writers”–I am including hte novelists and essayists I taught when I taught English literature.
    Neither Gawande nor the New Yorker need to “promote” his work. It promotes itself.
    Gawande is brilliant and that June 1 New Yorker piece about McAllen explained the Dartmouth Research to a great many people who would otherwise find it incomprehensible.
    That brilliance, combined with his dazzling ability as a writer, means that we’re probably now going to see a round of “Gawande-bashing.” Mediocre reporters loves to build people up and then tear them down.
    But you’re not a mediocre reporter, Merrill–you’re one of the very best bloggers in the blogosphere– so I’m not sure why you’re backing the Times.

  7. The problem in McAllen , Texas is too many are people are receiving Kickbacks and Bribes. Overutilization of services is largely attributed to ordering more services because it is profitable. Health care shouldn’t be for profit.

  8. It must be true that regional variation in health costs is explained as “supply-induced demand”, because, well, the left has invested entire careers in it being true. (Cue chorus: “The science is settled.”)
    Also, the health system in America is about to be re-engineered based on Dartmouth research so IT MUST BE TRUE.
    As the progressive pundits like to remind us: it is hard to get someone to see something when their paycheck depends on them not seeing it. In their world this only applies, of course, to evil insurance executives, not to “health care journalists”, who are the pure in heart of the gospels. Don’t say out loud that they, too, have careers which are heavily invested in one version of reality.
    Is it possible for an entire generation of thinkers to go astray after investing their egos in a bad paradigm?
    Not only possible, but common.

  9. “Actually, Peter, the price per pill is lower with wider utilization.”
    Well we might both be partly wrong according to this study published by the the Archives of Internal Medicine.
    I don’t think drug companies advertise to break even on the advertising costs.
    “The total cost is higher, which is exactly my point.”
    Your point being that demand IS provider driven, not patient driven?

  10. Pharmaceutical’s has No Business in advertising their Drugs on Television.I’m feed up with their boner commercials and prefer a ban on all Pharma Commercials.
    They are only driving cost up and manipulating Patients to “Ask Your Doctor.”Hell! Pharma has put some of these ideas in your patients heads that never were conceived until now. Does the AMA object to these methods? I doubt it.
    The system drives itself and when it exploits and manipulates behaviors. The system is at fault and not the Patient. “We treat anxiety with cardiac caths and MRI’s.” I have anxiety and I have never had anyone suggest such a procedure. Is it scientifically proven to relieve anxiety? If Not. I would say it is irresponsible and fraudulent to provide services that have not served in the best interests of the patient. The cost services are foremost and loss off income. I would deny this procedure. Even with insurance.
    Contrary to popular belief,the insured have out of pocket expense for every Procedure and anyone who is associated with it.While insurance companies claim to pay 80 percent of your plan. The facts; if disclosed from the insurer/provider contract, would be far less.
    Peer review and self regulation within the industry has failed to address issues that Patients care about and so tort’s are the last vestige of accountability.
    Patient Safety, Medical Error,Hospital Acquired infections and accountability are strong issues that Patients have expected from a Health industry that often ignores Best Practices. Until the Behaviors change about these subjects of critical Interests and the mutual admiration society (Peer Review) becomes a viable avenue of enforcement. I Believe tort’s are the only enforceable measure of accountability in the Health Care System. It is not my contention to claim rewards for actions of “good Faith” but rather actions and /or inaction’s that cause extreme bodily harm and Financial disability.

  11. Actually, Peter, the price per pill is lower with wider utilization. The total cost is higher, which is exactly my point. Glad we finally agreed on something.

  12. “The demand for care determines the size of the system and the “fixed” costs in it.”
    like the demand generated by drug advertising that boosted the price of drugs about 30%?

  13. The demand for care determines the size of the system and the “fixed” costs in it. There is too much demand for unnecessary care. Patients will not take “no” for an answer any more. They are entitled to receive all the care they want; just ask them.

  14. So consumption of the product or service is what drives costs? So why seek Patients or advertise medical services? However, I disagree that cost are zero as if there are no obligations. Such as tuition expenses, Utilities,staffing,furniture,licensing fees,credit card machines,loans,benefits etc. The rate of return to cover your fixed costs are directly associated to the Cost of providing care. I can only assume that the rates are fixed to a targeted amount to cover all of this and maintain a projected profit ratio.
    Interestingly enough; the Consumer(patient)is not zero either. The absence of medical attention is costing them as well. As a Home owner or even a renter we pay for services for the establishment of fire stations and ambulance services.Federal,State, Counties and Cities use tax dollars to support community Hospitals. Please ,lets not forget the insurance companies take their weekly draw as well.
    “It is greed because they consume all the resources they can possibly comandeer for themselves, regardless of their real need and regardless of anyone else’s needs.”
    This is true of Corporate Behavior as well. Health Care has become a advertisement for expensive procedures and a manipulator of patient Codes to maximize Payment returns from insurance. Providers feel they are being shafted by Insurance and so the consumer is a safe target to justify their ends. However,it doesn’t end there! No! Not by a long shot. The Consumer also feels disenfranchised by excessive fees ,out of Pocket expenses,and the endless testing just to prove to insurance ,you need another Test? Do you think Patients are getting their monies worth? I often wondered if we needed a self serve lane to avoid waiting to be seen.
    Wal-mart provided Americans with greater costs than some realized. Wal-Mart’s driving down prices included demanding manufacturing to China.America lost jobs and manufacturing.Wal-mart opened mega stores in small towns and priced Mom and Pop stores out of business.The employees they hired were told to use Medicaid for health insurance because (like most business’s) they wanted to cut overhead. Someone always pays.
    Don’t think for a minute that Health Care can not be outsourced. Third World Countries basing Hospitals in the United States and Bringing in Doctors and Nurses at a fraction of the costs. This is what I see in the future for Health Care,if real solutions are not found.Future Graduates may indeed need to seek work overseas.Certainly at lower wages.

  15. You ask me, it’s all those New York doctors who have flocked to McAllen. All those citrus groves, palms, verdant fields (ever see a periwinkle field in full bloom?), no end of “gated communities,” high-end malls awash in petrodollars, the Gulf Coast in easy reach, and tropical winters. Beats the aspirated “L” out of the “wretched desolation” of NYC.

  16. MD as HELL, would you prefer that the patients begged for care instead of demand it? Or maybe they should just never show up at all and just go away and die or suffer stoically somewhere out of sight.
    There are plenty of costs before the patient actually shows up. They are somebody else’s costs. It costs tons of money to keep a hospital operating even if there are no patients in beds. There are costs to employers, families, producers/sellers of goods and the economy in general if patients don’t receive treatment and don’t get better.
    If you think that patients, or people, are a bunch of spoiled cry babies, and medical care is really not necessary, then why practice medicine?

  17. Wendell,
    I have no customers. Customers get Percocet on demand, so the doctor’s patient satisfaction scores don’t cause administration to fire his ass.
    You failed to address my contention that there are no costs until the patient shows up and demands care.

  18. I read everything quoted in this post and all sorts of other reports from CMS, Kaiser, RAC and others, and what I find fascinating is the obsessive concentration on three factors to explain these variation: physicians over treating, patients over demanding and fraud (including deliberate over treatment by hospitals solely in order to increase revenue).
    Whenever the Dartmouth/Gawande discussions came up on this blog, I always asked about the root cause. Why are these things happening in one community and not another? Never got a good answer.
    Shouldn’t we look at the numbers in the MedPAC report, and even the Dartmouth Atlas, ignoring the bickering about which hospital is better, and try to superimpose seemingly unrelated regional statistics and differences in culture, geography, personal values, etc.?
    For example, there seems to be some correlation between high utilization and poverty and lower education and urban density and cultural aspects.
    Medicare folks that retire to a gated community in Miami have different outlooks on life and death than a farmer in Vermont who continues to get up at 4 AM until the day he dies. Seniors who live in areas where children usually move five states away are more likely to substitute payed care for family support. Certain spiritual values and beliefs may discourage over utilization at the end of life. Even something as foolish as scenic surroundings as opposed to wretched desolation may affect one’s perceived well being and therefore perceived need for medical care.
    Maybe no one is looking at these things because there really isn’t much we can do to change them, if indeed there is a correlation, but shouldn’t we at least try to understand? Who knows, we may find something useful. Isn’t this what science is all about?

  19. “Adjust for prices and McAllen’s outlier status compared to the rest of Texas and large parts of the South all but disappears.”
    Adjust for prices! Well dah. Isn’t it the prices that’s killing us? Why does that get McAllen off the hook? Isn’t that what the article, “A Look Inside: The Massachusetts Health Reform Law” and their Attorney General’s office investigation found?

  20. MD as HELL apparently has never discovered the truism in the USA that the customer aka patient is always right. Not only that, but it is the patient who keeps MD as HELL in his chosen occupation, not the other way around.

  21. Gary,
    How can it be anything else? There is zero cost to anyone until the patient shows up and demands care. And demand they do. We treat anxiety with cardiac caths and MRI’s. It’s like they all get Munchausen’s; they will have healthcare, even if it kills them. Of course they don’t pay for anything.
    If they had to pay a part of it, they would not consume as much. Certainly families would have to measure end of life decisions against end of estate and depletion of same. Is it illegal to resell grandma’s scooter after she is done with it?
    It is greed because they consume all the resources they can possibly comandeer for themselves, regardless of their real need and regardless of anyone else’s needs.
    Real tort reform will let me tell people they don’t need their third MRI or their 10th cardiac cath. People would be set free from the fear of not getting healthcare. It would be a new standard that they were entitled to nothing unless they paid for it. Just like Wal-Mart.
    I do expect people to clean up their act, because I expect they will be paying real money in the future for care they want, or they won’t get it. The government is broke. Pretty soon we will demand gold instead of Federal Reserve notes.

  22. http://www.newyorker.com/online/blogs/newsdesk/2010/02/the-cost-conundrum-persists.html
    The New Yorker
    February 18, 2010
    The Cost Conundrum Persists
    Posted by Atul Gawande
    A New York Times article I just read suggests that a data set I used in my piece “The Cost Conundrum” has been questioned. Not so. A recent opinion piece in The New England Journal of Medicine does take issue with a particular analysis offered by the Dartmouth Atlas of Health Care. But it doesn’t dispute the Dartmouth data I drew on.
    Rest of the story at the above link.

  23. MD as Hell. I just wonder how greed of the American Patient drives Health Care Cost? I understand the narcisstic tendencies of a large part of the population.Would it not be the greed of CEO’s, Stock Markets ,Medical Device and durable Companies? What about Pharmasuetical and all these companies that feed off Health Insurance and Providers.
    Come on! Lets get real about the cost associated with any Procedure, Device,or Service. What are the actual Costs! What is the Mark Up? I dare anyone to Post Publicly the cost of any one Procedure.Explain to me why a wholesale price of $800.00 ends up to be Five Thousand Dollars. How many freaking middle men are their siphioning off the Patient?
    How many Office Staff could be Cut to put more nurses on the Floor to care for Patients?Why can’t Hospital staff perform more than one function?
    I think doctors should personally hand the Patient the Bill so they can Guage how effective they are or if they can actually justify their billing.Do you think doctors actually consider Costs to the patient before preforming a procedure? The facts are that Doctors seldom think about it as long as the bottom Line is in the Black.
    Please, dont expect the patient to clean up their act when the most educated and affluent Profession can’t clean up their own. Reducing Medical Errors and Preventable Hospital Acquired Infections. Of which; cost 12 billion dollars of “wasted” Tax Dollars each year.

  24. Merill, I don’t quite understand this.
    How do you shift costs from Medicare/Medicaid to uninsured? You can’t charge more, so the only thing left is to, knowingly, over treat Medicare folks. Is that where the high utilization is supposed to be coming from?
    In that case why is New Mexico not an outlier too? They have very high uninsured rates. And Arizona should be as bad as Louisiana, but it isn’t.

  25. The greed and Narcissism of the American patient is what drives healthcare costs. It is very strong in the south.
    The system was built by the last reformers to fix the same problems.
    I’ll be happy to fix it for you all.

  26. I’m sorry, but I don’t think this post adds anything to the current discussion about health care costs. All it says is that you can use statistics to prove anything – something we all learned long ago. That is why there are always letters to the editor challenging the methodology and conclusions of virtually every article appearing in any medical journal. So shall we waste time arguing about methodology, or adhere to the basic point – we need to cut medical costs across the board and there is going to be pain on the provider side, as well as elsewhere?