Tag: Atul Gawande

Save Money on Medical Costs – Get Your Old Medical Records

Apr 1, 2011• 23

By DAVIS LIU, MD

There are many tips to saving money on medical costs like asking your doctor only for generic medications, choosing an insurance plan with a high deductible and lower monthly premiums, going to an urgent care or retail clinic rather than the emergency room, and getting prescriptions mailed rather than go to a pharmacy.

How about getting your old medical records and having them reviewed by a primary care doctor? It might save you from having an unnecessary test or procedure performed.

Research shows that there is tremendous variability in what doctors do. Shannon Brownlee’s excellent book, Overtreated – Why Too Much Medicine Is Making Us Sicker and Poorer, provides great background on this as well as work done by the Dr. Jack Wennberg and colleagues on the Dartmouth Atlas. Some have argued that because of the fee for service structure, the more doctors do the more they get paid. This drives health care costs upwards significantly. Dr. Atul Gawande noted this phenomenon when comparing two cities in Texas, El Paso and McAllen in the June 2009 New Yorker piece.

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

Doctors apparently seemed to order more tests. Patients, not surprisingly, agreed. After all, without adequate medical knowledge or experience, how sure would you be if a doctor recommended a test and you declined?Continue reading…

Atul Gawande and the Art of Medical Writing

Aug 15, 2010• 13

By BOB WACHTER, MD

Don’t read this.

That is, if you have a limited amount of time for reading today, I’d rather you read Atul Gawande’s essay on end-of-life care in this month’s New Yorker than this blog.

But if you can spare a little time, I’ll be focusing on some of the techniques Gawande uses to make his writing so lyrical and memorable. Whether you write yourself or limit your storytelling to cocktail parties and presenting H&P’s on morning rounds, lessons abound. Here are a few, gleaned from this month’s piece, “Letting Go: What Should Medicine Do When It Can’t Save Your Life?”:Continue reading…

EMRs, Checklists and Meeting Atul

Aug 6, 2010• 12

By JONATHAN BUSH

Recently, I got to shake hands with and also have lunch with doctor-writer extraordinaire Atul Gawande! He was nearly everything I had made him out to be. He wore a snappy blue blazer, a jumble of ID tags, and round specs befitting a prominent Harvard academic doc … only he wore them in a manner that suggested a man of action. Am I gushing? Sorry. I’ll stop … except to say that he had the chicken salad on white, which sat largely untouched as he drove through the conversation.

One of the greatest storytellers in the history of health care, Atul has discovered something very important about the way we deliver complex procedures … a series of checklists that bring down costs and improve outcomes … and yet adoption of his findings is incredibly low! He is seriously considering raising money to fund—NOT to continue his research and writing—but to literally fund a team of Maoist-like activists to cajole the ranks of docs and hospitals into adopting these bloody checklists!! These checklists are real bluebirds. Nobody loses their job from the adoption of these things. Except for a few embarrassing ‘re-operations to fix terrible mistakes, nobody loses any money either. So what gives?

Atul told me the story of penicillin adoption … I was stunned at how long it took for this miracle drug to be mainstreamed. I remember from my OB-GYN days the number of docs who were still doing continuous fetal monitoring during labor, twenty years and five studies after it was shown to be counter-indicated … and episiotomies, and circumcisions (ouch)!

How frustrating.

These are good people. I have met literally tens of thousands of docs and can count the truly questionable people on one hand. So what is it?

There is no market mechanism for the solution. That’s what.

If a payer came to me and gave me Atul’s checklist and said they’d pay even 5% more for a surgery done according to his checklist, I’d build it into an EMR and flick it in within a week! It’s a no-brainer for me and it’s good money for the doc! Ya know what that would be an example of? That would be MEANINGFUL use of an EMR.

God Bless you, Atul. I’m in for a donation … but not for the Maoists. You go find the truth and we’ll go make a market for it.

PS … Atul signed my copy of his book!

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School.

Gawande’s “Checklist Manifesto”

Feb 8, 2010• 5

By BOB WACHTER, MD

Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.

In this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history of “the lowly checklist,” the impact of checklists on various industries, how he came to understand the value of checklists to medical care, and what makes a useful checklist. Most of this content could have been written by a thoughtful healthcare journalist. But Atul put his interest in checklists to practical use, spearheading a WHO initiative to test a checklist-based “safe surgery” program in 8 diverse hospitals around the world, an effort that saved hundreds of lives. His description of this program forms the core of the book.

Which is as it should be, since these autobiographical elements highlight what is unique about Atul, and his book. Yes, he is a gifted journalist (of course, aided by a surgeon’s insider knowledge and access – as demonstrated by last year’s game changing article about healthcare in McAllen, Texas). But he is also a healthcare leader, whose clear aim is not only to explain attitudes and policy, but to change them. It would be as if Malcolm Gladwell had tried to create a Tipping Point himself, and written up the experience. The whole thing gets very “meta” very quickly, and in the hands of a lesser person, might even threaten to become a bit dicey. (Is he a medical George Plimpton – trying out checklists in the OR to provide fodder for his writing?) But there’s no such worry here: Atul’s passion for patients and humility are so obvious that one never questions his methods or motives.

Check Lists and Decision Trees versus Spontaneity and Imagination

Feb 1, 2010• 5

By KENT BOTTLES

The task of health care reform in 21^st century America is to decrease per-capita cost of care and to increase the quality of care delivered to patients. It’s complicated. A famous Rand study concluded that Americans only receive 55% of the care that science dictates. Patients intuitively believe that more health care is always beneficial. Medicare reformers would like to do comparative effectiveness research so that CMS and private insurers could wind up paying only for therapy that actually works. Some estimate that 30% of all care delivered in the United States is waste. What some call waste, others label revenue, and Atul Gawande becomes famous for identifying waste/revenue in McAllen, Texas (http://bit.ly/ENlli).

Neuroscience tells us that the smartest human can only keep track of seven variables at one time, and physicians tell us that diagnosis and treatment of a complicated patient can involve as many as 100 such variables. Computers are good at cataloging, organizing, and retrieving information, but physicians are not yet routinely utilizing them at the point of care. Computers are also good at allowing us to analyze large data sets and learn from experience. Patients yearn for the warmth and caring of a doctor who really knows and cares about them. Behavioral economics pioneered by Amos Tversky and Daniel Kahneman taught us that human brains are designed with inherent biases that make us less than rational decision-makers. We now know that human physicians and patients suffer from biases such as Pygmalion complex, confirmation bias, focusing illusion, incorrectly weighing initial numbers, and being more impressed with single cases than conclusions based on large data sets (http://bit.ly/49q4Uy).Continue reading…

Enthoven beats up Gawande

Dec 22, 2009• 17

By Matthew Holt

I finally got around to reading Atul Gawande’s New Yorker piece on why the current reform bill mirrors early 20th century agriculture. I learned lots about the role of the Department of Agriculture in teaching farmers what to do. In post-war Britain the radio soap opera The Archers did much the same thing.

I was actually encouraged to remember that in almost every industrialization process, intelligence, leadership, and usually money, from the government was a key factor.

But I felt very uncomfortable with the analogy. First, the incentive for the farmers was to be more productive—even if in the long run productivity meant a relative fall in the price of food and eventually the rise of agri-business decades later. If they did things right there was an immediate market reward. Whereas we know that (from the Virginia Mason and Intermountain examples) increasing quality and productivity in health care leads to negative financial consequences.

Secondly, Gawande seems to be fine with saying that “we don’t know how to be more efficient, productive and effective, so let’s do pilots for years and figure it out.” This is just crap. We’ve both done pilots for decades, and have examples of organizational forms (you know who I mean!) that get it right. It’s just made no sense for most of the health care system to adopt those techniques and organizational forms because they make more money by doing what they’re doing—and government and employers keep paying them.

I was going to write a long piece detailing my complaints blow by blow, but luckily Alain Enthoven has done it for me!

This doesn’t mean I’m against the current bill as I suspect Enthoven is. There is some hope that ACOs and other modern terminology for the types of organization he’s espoused over the years, will arise more quickly from the “pilots” in the bill than Enthoven suspects. But more importantly, I support the bill because the saving money part is the second of my “two rules to judge a bill.” The first and most important rule is

Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.

And the current bill just about does that….although Maggie Mahar is pretty doubtful, especially for near-seniors in the first few years.

Improving the Harvest: Farming and Health Care

Dec 16, 2009• 14

By BILL KRAMER

I love Atul Gawande’s writings on health care.

He has a rare talent for describing technical details of health care, insurance and finances in terms that most people can understand. His recent article in the New Yorker discussed the current health reform bills’ approach to curbing costs, using the agricultural industry as a potential model.

One of his basic points is similar to one I have made before. He describes two kinds of problems: “those which are amenable to a technical solution and those which are not. Universal health care coverage belongs to the first category . . . Problems of the second kind [referring to rising health care costs], by contrast, are never solved, exactly; they are managed.”

I would frame it somewhat differently. The two basic kinds of problems are those, which are amenable to a government solution, and those which are best addressed using decentralized market forces.