Patients Don't Want To (and Can't) Reform Healthcare System

Don't misinterpret the heading of this entry. It's not that patients don't want healthcare reform. It's that patients don't want the entire responsibility of reforming the healthcare system.

And who could blame them.

Although it appears that the federal government is working to reform the healthcare system, one will periodically hear experts talk about consumer driven healthcare. That is, give patients more financial responsibility for their health through higher deductibles and copays and health savings accounts. Seeing this increased financial burden, they will consequently make better choices about their health, shop around for the best care, and make more rational decisions about when to seek medical care much the same way they do for other services and goods.

Please.

Note how the the person in a story in the Economist managed to spend a lot of money for a strained muscle.

I would note that giving the public more responsibility for reforming a benefit program occurred decades ago with retirement planning. Employers stressed by the increasing obligations from pension plans opted many years ago to move from defined benefit plans to defined contribution plans. Pension plan now becomes a 401k plan. The burden of having enough assets to comfortably retire moved from employer to employee. Theory was individuals now would take charge and do better.

Right.

We now know that this was a disaster for nearly everyone, except for the financial services industry it created. Individuals didn't save money or invest in the right financial products. Many were in cash, which generally doesn't keep up with inflation. As a result, employers are becoming more involved requiring people to opt out of a 401k rather than opting in, choosing a target date mutual fund account as a default rather than cash, and spending resources on educating their workers more about financial planning.

So the problem with healthcare? Patients don't have the expertise and don't wish to grasp the nuances of medical diagnosis and treatment. They falsely believe that the answers to their problems and ailments come from the high-tech MRIs and CT scans, blood work, and other tools at our disposal as doctors. It could be due to television shows like ER or House or doctors doing extensive work-ups with little thought on costs or relevance. Nevertheless, with increasing co-pays, patients feel that to solve their problem, forgo the doctor visit and simply order a test.

Unfortunately, these tests are merely tools and can help provide doctors clues into what is happening, but don't provide the universal truth. In other cases, we don't need the test because it is quite clear what the problem is. However, Dr. Scott Haig notes in a recent Time article that it is practically impossible to convince patients otherwise. They want the tests even though it is obvious what is happening.

I see it in my office plenty of times.

• How do you know what the skin rash is without doing a biopsy? (Answer - do you know what acne looks like? You don't need biopsy that do you? The reason we go to medical school and residency programs for a minimum of seven years isn't to figure out what tests to order, but how to correctly diagnosis and treat illness and get you better).
  

• I'm having chest pain and I want at CT scan (which is the 64 slicer CT scan which rules out an pulmonary embolus - blood clot in the lungs, a dissecting aortic aneurysm, or a heart attack - acute coronary syndrome) as well as the medication PLAVIX to thin the blood. (Answer - After spending quite a bit of time asking questions about the symptoms and what made it better or worse, it was clear the symptoms were due to irritation of the esophagous due to increase alcohol usage. Had those tests been ordered, it would have cost the patient more as he would need to pay for the procedures, discovered that the tests were all normal, and at the end NOT solve anything. CT scans don't diagnose esophageal reflux. So this patient would have returned for a second office visit and say I'm still hurting and undoubtedly demand more tests. Is he better off healthwise or financially?).
  

• I'm having a migraine headache and I want an MRI. How do you know it's a migraine? (Answer - From your classic history of your mother having a migraine, when she was diagnosed MRI technology didn't exist and doctors got it right, your symptoms of a throbbing unilateral headache which worsens with physical activity, at times can cause nausea, vomiting, sensitivity to sounds and light, and typically better with quiet dark rooms, and a total episode time of 24 to 48 hours. Incidentially, when the MRI of the head comes back as normal, does that mean you don't have a migraine? If you still have pain does that mean the MRI was wrong? Did the MRI add any value to your visit?)

Why do patients behave this way? The reimbursement structure of our healthcare system provided incentives to do more. Doctors are paid piecemeal. Do a procedure, get paid. We get paid for quantity and volume not quality. As a result, patients fall into a trap thinking that getting more is better care when in fact research shows Americans get more spent on healthcare per capita than any industrialized country in the world and yet we rank dead last on health outcomes.

Finding a smart doctor who knows how to diagnose you by asking the right questions and thinking is truly a blessing. If you find one that sits down, talks to you, and tries hard to understand your symptoms so it is clear in her mind what your problem is, never give her up. Anyone can order tests and xrays. Only a few can figure out when it is needed and when it is not.

I don't blame doctors who occassionally cave-in to patient demands. I do worry about those who do most of the time to placate a patient. Patients see us to get better and unfortunately they wrongly believe that requires extensive testing. If we continue to perpetuate the lie and if consumer driven healthcare advocates have their way, we'll see more healthcare costs and worse outcomes, not better.

What do patients really want? They want doctors to listen and order tests, imaging studies, and medications that are necessary to get them better or keep them well. They want healthcare to be affordable and accessible.

What they don't want is the responsibility of reforming the system. They don't have the expertise to do so.

I don't blame them.

Save Money on Medical Costs - 10 Tips from Money Magazine

The July issue of Money magazine article "Beat the rising cost of health care" has a quote from yours truly!

• Finally, ask about alternatives, says Davis Liu, a family doctor and the author of "Stay Healthy, Live Longer, Spend Wisely." For example, your doctor may suggest an MRI to figure out why your back is hurting. But if you push back a bit, she may also tell you that you can first try back exercises for a few weeks and see if the pain goes away on its own. It very often does.

Overall great tips. Without serious healthcare reform, the brutal reality is this. We are already rationing healthcare in this country. It's not based on your age, health, or research. It's based on your ability to pay.

Alternative Medicines Not Helpful

A recent article by the Associated Press noted that over the past decade federal researchers have invested $2.5 billion in trying to determine if alternative medicines or therapies are helpful.
The answer is essentially no. Were studies flawed in their design? Were politics involved (yes, even in academic research centers where science is practiced daily)?

Until researchers can clarify which alternative therapies are worthwhile, it might be best at this time, both to your health and your wallet, to hold off on purchasing any alternative therapies unless okay with your doctor or pharmacist. Federal law at this time gives alternative medicines a free pass. They are not as tightly regulated as over the counter medications or prescription medications. This is the reason each alternative medicine has the disclaimer we all know about, "This statement has not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease".

More about dietary supplements and the FDA's role are found here.

The entire Associated Press article follows:

By MARILYNN MARCHIONE, AP Medical Writer – Wed Jun 10, 5:02 pm ET

BETHESDA, Md. – Ten years ago the government set out to test herbal and other alternative health remedies to find the ones that work. After spending $2.5 billion, the disappointing answer seems to be that almost none of them do.

Echinacea for colds. Ginkgo biloba for memory. Glucosamine and chondroitin for arthritis. Black cohosh for menopausal hot flashes. Saw palmetto for prostate problems. Shark cartilage for cancer. All proved no better than dummy pills in big studies funded by the National Center for Complementary and Alternative Medicine. The lone exception: ginger capsules may help chemotherapy nausea.

As for therapies, acupuncture has been shown to help certain conditions, and yoga, massage, meditation and other relaxation methods may relieve symptoms like pain, anxiety and fatigue.
However, the government also is funding studies of purported energy fields, distance healing and other approaches that have little if any biological plausibility or scientific evidence.

Taxpayers are bankrolling studies of whether pressing various spots on your head can help with weight loss, whether brain waves emitted from a special "master" can help break cocaine addiction, and whether wearing magnets can help the painful wrist problem, carpal tunnel syndrome.

The acupressure weight-loss technique won a $2 million grant even though a small trial of it on 60 people found no statistically significant benefit — only an encouraging trend that could have occurred by chance. The researcher says the pilot study was just to see if the technique was feasible.

"You expect scientific thinking" at a federal science agency, said R. Barker Bausell, author of "Snake Oil Science" and a research methods expert at the University of Maryland, one of the agency's top-funded research sites. "It's become politically correct to investigate nonsense."
Many scientists say that unconventional treatments hold promise and deserve serious study, but
that the federal center needs to be more skeptical and selective.

"There's not all the money in the world and you have to choose" what most deserves tax support, said Barrie Cassileth, integrative medicine chief at Memorial Sloan-Kettering Cancer Center in New York.

"Many of the studies that have been funded I would not have funded because they seem irrational and foolish — studies on distant healing by prayer and energy healing, studies that are based on precepts and ideas that are contrary to what is known in terms of human physiology and disease," she said.

In an interview last year, shortly after becoming the federal center's new director, Dr. Josephine Briggs said it had a strong research record, and praised the many "big name" scientists who had sought its grants. She conceded there were no big wins from its first decade, other than a study that found acupuncture helped knee arthritis. That finding was called into question when a later, larger study found that sham treatment worked just as well.

"The initial studies were driven by some very strong enthusiasms, and now we're learning about how to layer evidence" and to do more basic science before testing a particular supplement in a large trial, said Briggs, who trained at Ivy League schools and has a respected scientific career.
"There are a lot of negative studies in conventional medicine," and the government's outlay is small compared to drug company spending, she added.

However, critics say that unlike private companies that face bottom-line pressure to abandon a drug that flops, the federal center is reluctant to admit a supplement may lack merit — despite a strategic plan pledging not to equivocate in the face of negative findings.

Echinacea is an example. After a large study by a top virologist found it didn't help colds, its fans said the wrong one of the plant's nine species had been tested. Federal officials agreed that more research was needed, even though they had approved the type used in the study.

"There's been a deliberate policy of never saying something doesn't work. It's as though you can only speak in one direction," and say a different version or dose might give different results, said Dr. Stephen Barrett, a retired physician who runs Quackwatch, a web site on medical scams.

Critics also say the federal center's research agenda is shaped by an advisory board loaded with alternative medicine practitioners. They account for at least nine of the board's 18 members, as required by its government charter. Many studies they approve for funding are done by alternative therapy providers; grants have gone to board members, too.

"It's the fox guarding the chicken coop," said Dr. Joseph Jacobs, who headed the Office of Alternative Medicine, a smaller federal agency that preceded the center's creation. "This is not science, it's ideology on the part of the advocates."

Briggs defended their involvement.

"If you're going to do a study on acupuncture, you're going to need acupuncture expertise," she said. These therapists "are very much believers in what they do," not unlike gastroenterologists doing a study of colonoscopy, and good study design can guard against bias, she said.

The center was handed a flawed mission, many scientists say.

Congress created it after several powerful members claimed health benefits from their own use of alternative medicine and persuaded others that this enormously popular field needed more study. The new center was given $50 million in 1999 (its budget was $122 million last year) and ordered to research unconventional therapies and nostrums that Americans were using to see which ones had merit.

That is opposite how other National Institutes of Health agencies work, where scientific evidence or at least plausibility is required to justify studies, and treatments go into wide use after there is evidence they work — not before.

"There's very little basic science behind these things. Most of it begins with a tradition, or personal testimony and people's beliefs, even as a fad. And then pressure comes: 'It's being popular, it's being used, it should be studied.' It turns things upside down," said Dr. Edward Campion, a senior editor who reviews alternative medicine research submitted to the New England Journal of Medicine.

That reasoning was used to justify the $2 million weight-loss study, approved in 2007. It will test Tapas acupressure, devised by Tapas Fleming, a California acupuncturist. Use of her trademarked method requires employing people she certifies, and the study needs eight.
It involves pressing on specific points on the face and head — the inner corners of the eyes are two — while focusing on a problem. Dr. Charles Elder, a Kaiser Permanente physician who runs an herbal and ayurvedic medicine clinic in Portland, Ore., is testing whether it can prevent dieters from regaining lost weight.

Say a person comes home and is tempted by Twinkies on the table. The solution: Start acupressure "and say something like 'I have an uncontrollable Twinkie urge,'" Elder said. Then focus on an opposite thought, like "I'm in control of my eating."

In Chinese medicine, the pressure is said to release natural energy in a place in the body "responsible for transforming animal desire into higher thoughts," Elder said.

In a federally funded pilot study, 30 dieters who were taught acupressure regained only half a pound six months later, compared with over three pounds for a comparison group of 30 others. However, the study widely missed a key scientific standard for showing that results were not a statistical fluke.

The pilot trial was just to see if the technique was feasible, Elder said. The results were good enough for the federal center to grant $2.1 million for a bigger study in 500 people that is under way now.

Alternative medicine research also is complicated by the subjective nature of many of the things being studied. Pain, memory, cravings, anxiety and fatigue are symptoms that people tolerate and experience in widely different ways.

Take a question like, "Does yoga work for back pain?" said Margaret Chesney, a psychologist who is associate director of the federally funded Center for Integrative Medicine at the University of Maryland.

"What kind of yoga? What kind of back pain?" And what does it mean to "work" — to help someone avoid surgery, hold a job or need less medication?

Some things — the body meridians that acupuncturists say they follow, or energy forces that healers say they manipulate — cannot be measured, and many scientists question their existence.

Studying herbals is tough because they are not standardized as prescription drugs are required to be. One brand might contain a plant's flowers, another its seeds and another, stems and leaves, in varying amounts.

There are 150 makers of black cohosh "and probably no two are exactly the same, and probably some people are putting sawdust in capsules and selling it," said Norman Farnsworth, a federally funded herbal medicine researcher at the University of Illinois at Chicago.

Even after a careful study, "you know one thing more precise and firm about what that agent did in that population with that outcome measurement, but you don't necessarily know the whole gamut of its effectiveness," as the echinacea study showed, Briggs said.

The center posts information on supplements and treatments on its Web site, and has a phone line for the public to ask questions — even when the answer is that not enough is known to rule in or rule out benefit or harm.

"I hope we are building knowledge and at least an informed consumer," Briggs said.

Federal agency: http://www.nccam.nih.gov

Prevention Won't Save on Health Costs

The Wall Street Journal recently reported that the belief that a focus on preventive health won't save on healthcare costs. In the article, "Prevention Efforts Provide No Panacea on Health Costs" noted that

• The Congressional Budget Office, in a December report, concluded that greater use of preventive care would at best generate modest reductions in costs over 10 years, and might even result in increases.

Saying that prevention will save money is the wrong goal. What prevention does is free up dollars that would have been spent on other treatments and interventions that would have occurred without being proactive and allow them to be spent on improving coverage. As Federal Chairman Ben Bernanke noted in 2008 when addressing the Senate Finance Committee on Healthcare Reform, "that improving access and quality may increase rather than reduce total costs" and the better question may be, "whatever we spend, [are] we are getting our money's worth?"

Without improving prevention, both the insured and uninsured aren't getting their money's worth.

Medical Home Won't Save Family Medicine Specialty

My letter to the editor was published in the May 15, 2009, issue of Family Practice News. Essentially, all of the buzz about the Patient-Centered Medical Home as being the solution to improving the lives of primary care including the specialty of family medicine is just that. It is just buzz.

Like most letters to the editor, the publication chooses the title. Incidentially, Dr. Ted Epperly is the president of the American Academy of Family Physicians.

Family Medicine Is Losing Ground

While I would like to share Dr. Ted Epperly's optimism that the patient-centered medical home is gaining traction, the hard reality is that U.S. medical graduates are not convinced.

While this model has gained momentum among employer groups, insurers, and legislators, medical schools and family medicine residency programs have yet to adopt it.

As a result, students are still exposed to the increasingly demanding, busy family medicine practice with administrative hassles, financial pressures, and paper-based system with the potential for errors.

The promise of the patient-centered medical home is not their reality. They are too smart to base a career choice on an idea that they haven't experienced firsthand.

Without rapid change in the educational curriculum, the number of new graduates will simply decrease as more practicing family physicians leave medicine. I'm worried that our specialty will simply disappear.

Davis Liu, M.D.

Cancer Causes Personal Bankruptcy

From the Today show both financial expert Jean Chatzky and chief medical correspondent Dr. Nancy Snyderman discuss the disturbing truth about the healthcare crisis that those with insurance are going bankrupt, particularly with cancer diagnoses.

Visit msnbc.com for Breaking News, World News, and News about the Economy

I particularly thought that Ms. Chatzky should be commended for calling attention to that fact that people do spend more time researching vacation rather than understanding their health insurance benefits! They neglect their health not understanding that having good health is the most powerful financial asset they own.

If you are healthy you can always earn more money. If you are ill, you can have all the money in the world and never get back good health. The public doesn't get the right preventive care 1/2 the time in this country. Cancer caught early can be less costly with better survival.

The complex relationship between the ability to pay and the ability to get well is only going to get worse. That's why I wrote my book Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System.

Medical costs are the leading cause of personal bankruptcy in this country. There is a financial reason that healthcare reform must occur. It is highly likely that President Obama will make it happen.

What it will look like is another story.

Eight Tests That Could Save Your Life - Forbes

Refreshing to see this article in the recent June issue of Forbes titled Eight Tests That Could Save Your Life. It's the boring and unsexy stuff that we need to focus on, like maintaining a healthy weight, lowering blood pressure and cholesterol, getting cancer screenings done, and screening for diabetes. Using the US Preventive Services Task Force guidelines, this piece is anchored is in the science and not theoretical hype of whole body scans and genetic testing.

From the article:

• If you're healthy and trying to stay that way, the important tests are few and relatively low-tech: Measure your cholesterol, step on a scale, check for signs of a small number of cancers and tell your doctor if you feel depressed.
• 
  This advice may run contrary to what might be characterized as "test madness"--the tendency of doctors and patients to want to test in all sorts of ways, using dozens of parameters that purport to measure how well your internal bodily engine is running. More are proposed and touted by entrepreneurs all the time--such as exotic new genetic tests and whole-body scans. They claim they will spot disease before symptoms arise. But most have no data proving that taking the test will improve your health or lengthen your life.
  

Absolutely true about the "test madness". We'd like to believe that more tests and scans are better when in fact there is no evidence that is the case. This article is far different than others aimed at the high net-worth individuals which convince them that executive physicals can save lives (perhaps anecdotally, but not significantly).

Kudos to the authors and Forbes for publishing the truth and not falling into the allure of the hype. If more Americans worked on these simple common yet vitally important measures, then we as a nation would be far healthier and spend less than we do today.

Doctors Critical To Save Healthcare System, But Will They? Doubtful.

Two critical articles over the past few weeks give a good sense of where our healthcare system will be in a decade and it isn't good.

An insightful survey from the Kaiser Family Foundation, NPR, and the Harvard School of Public Health asked the public about key issues currently tossed around the topic of healthcare reform including the use of electronic medical records, coordination of care, and also comparative effectiveness. The report titled The Public and the Health Care Delivery System demonstrates the great disconnect from reality. If we were as good in delivering and coordinating care as the public believes, the United States would be the first among industrialized countries in health quality outcomes like cancer screening, blood pressure and cholesterol control, and infant survival, rather than last.

Books like Overtreated have illustrated quite convincingly that we fail to do basic proven treatments routinely in our country and we often don't provide the least expensive option which is equally as effective as more pricey options.

But the public doesn't think so. Perception is reality regardless of the truth.

From the survey, these questions show that the majority of Americans believe, wrongly I might add, that doctors recommend less expensive therapies which are equally as effective as more expensive ones.

Q28. In the past two years, do you think your doctor has ever recommended an expensive
medical test or treatment for you when a less expensive alternative would work just as
well, or hasn’t this happened?

• 9 Yes, doctor has recommended expensive treatment when less
• expensive alternative would work just as well
• 87 No, this hasn’t happened
• 4 Don’t know
• -- Refused

The public wrongly believes that in the majority of cases, the right care and scientific evidence is not available on how to treat certain illnesses, when in fact there is more precision and diagnostic ability.

Q13. When doctors make decisions between different treatment options for a patient, do you
think there is usually CLEAR scientific evidence about which treatment is likely to work
best, or do you think the scientific evidence is not always clear about which will work
best?

• 23 Usually clear scientific evidence
• 72 Scientific evidence is not always clear
• 5 Don’t know
• * Refused

Doctors often use medications that are "off-label" not approved by the FDA or backed by clinical trials. Although in the case of cancer, this might be acceptable, there are plenty of examples that this is deadly and dangerous. About a decade ago, it was touted that the best chance for survival for a woman with metastatic breast cancer was a bone marrow transplant, that is, wipe out the entire immune system, and transplant a new immune system with stem cells. It worked for blood cancers, like leukemia. Tragically, there was never any evidence and the only one study that showed survival advantage the investigator made up data. Women died unnecessarily from complications of the bone marrow transplant and over time we discovered they did worse, not better, not even as well as those who chose "traditional" chemotherapy and treatment.

Yet, women were clamoring to get the procedure done (thankfully no one does now, I hope...). Who held the line? Insurance companies noting that there was no scientific research. Naturally and understandably people went to the press and insurance companies buckled under mounting pressure that they were denying care. But do doctors really make the right choice for you? For the record, I don't believe in for profit health insurance companies.

Q15. If your doctor recommends an expensive medical treatment, but it has not been proven
to be more effective than other, less expensive treatments, do you think your
insurance company should have to pay for it, or not?
Based on one half of total respondents (N=619)

• 55 Insurance companies should have to pay for it
• 38 Insurance companies should not have to pay for it
• 4 (Vol.) Depends
• 3 Don’t know
• * Refused

Doctors can't say no and we can't even provide you the least expensive care which is equally as effective. Why? Part of the reason is how the majority of doctors are reimbursed. The more they do, the more they get paid. Why would they ever say no to you? You might not come back. Also, it's no skin off their back as the costs don't come out of their pocket. Of course, it does increasingly come out of yours. But you aren't equipped to make the right decisions on when to skip and when you need to spend to get better.

Q30. In the past two years, has a doctor denied you a medical test or treatment that you
wanted because they thought it was not medically necessary, or not?

• 10 Doctor has denied medical test or treatment you wanted
• 89 Doctor has not denied medical test or treatment you wanted
• 1 Don’t know
• * Refused

This last question is the most important. The public feels that doctors try to keep the cost of health care down for the individual, yet from the previous question it is clear that what you want, you get. Fact is we spend more per capita than any other industrialized country in the world and aren't even healthier for it, that is, we die sooner!

23. Do you think your doctor tries to keep the cost of health care down for you, or not?

• 63 Doctor tries to keep cost of health care down
• 29 Doctor does not try to keep costs of health care down
• 1 (Vol.) Don’t have a doctor
• 7 Don’t know
• * Refused

The second piece an article by Dr. Atul Gawande in the New Yorker, The Cost Conundrum - What a Texas town can teach us about health care illustrates that it is doctors that dictate the rising costs of healthcare. Until we align and change the delivery system so that they will do more of the right thing, that is recommend the most effective care, not necessarily the most expensive when a least pricey one will work, and when we make doctors accountable for the entire healthcare system not just piecemeal will we have money to cover all Americans and have everyone be healthier.

The type of reform, which Dr. Gawande notes is the most important, would require doctors to say no to patient requests to unproven treatments or the latest heavily marketed medication (can you say Vioxx?). Are we capable of doing that? 89% of the time we can't rather we let insurance companies do that. Will doctors routinely provide treatment based on scientific evidence and based on effectiveness as well as cost rather than relying on drug reps touting their latest products and free samples?

Unfortunately, I tend to agree with Dr. Gawande. I think the country will not have more Mayo Clinics even though it is the right thing to do because frankly the type of reform needed may be too much for our doctors as they now need to have candid but important conversations about effectiveness and cost in a country always fooled into thinking newer is sexier and better, when in medicine that is far from the case.

Excerpts from the article -

It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.

McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

...Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.

...The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country.

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients...

The Mayo Clinic is not an aberration...

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital... When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.

...In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

...As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.