Medical Economics Feature - September 2009
Tex Med. 2009;105(9):45-48.
By Ken Ortolon
Physicians in McAllen probably never thought the president of the United States would mention them in a major address. But that's exactly what President Barack Obama did in his speech to the American Medical Association House of Delegates in June, and many McAllen doctors aren't happy about it.
President Obama cited a June article from The New Yorker that concluded McAllen spends nearly twice as much on health care per Medicare enrollee as the other parts of the nation do. And, the president bluntly blamed those high costs on physicians who overtreat or provide unnecessary care.
McAllen physicians and health care economists say the president, and the article, are wrong.
The New Yorkerarticle , written by Harvard Medical School professor Atul Gawande, MD, was based on Dartmouth Atlas data that showed that Medicare spent nearly $15,000 per enrollee in McAllen in 2006, second only to Miami. By comparison, El Paso spent only about $7,500 per enrollee, Dr. Gawande wrote. He also compared McAllen to Rochester, Minn., home of the Mayo Clinic, and Grand Junction, Colo., both communities where per-enrollee Medicare spending also was less than half of that in McAllen.
After visiting McAllen to see firsthand how the medical community there operates, Dr. Gawande concluded that "the primary reason for McAllen's extreme costs was, very simply, the across-the-board overuse of medicine."
While they don't dispute that Medicare costs are high in McAllen, Rio Grande Valley physicians and a number of prominent health policy experts took issue with Dr. Gawande's conclusions. They say he ignored cultural, socioeconomic, and other factors that could account for the high costs in McAllen.
Edinburg gastroenterologist Carlos Cárdenas, MD, says Dr. Gawande disregarded data that might have led him to draw other conclusions.
"From that point of view, I don't think we got a fair shake," Dr. Cárdenas said.
And Richard A. Cooper, MD, professor of medicine at the Leonard Davis Institute at the Wharton School at the University of Pennsylvania, says Dr. Gawande is "incompetent and irresponsible in his interpretation of the facts."
The Cost Conundrum
In his article, entitled "The Cost Conundrum," Dr. Gawande conceded that the McAllen hospital service area, which includes Hidalgo and Starr counties, has high rates of poverty and obesity, but he dismissed the notion that people there might have more health problems than in other parts of the country.
He also dismissed the idea that doctors and hospitals in the area might provide unusually good care, even though he was impressed with the medical facilities in the community.
Dr. Gawande's conclusions even led President Obama to contend that residents in McAllen were no sicker than those elsewhere. McAllen spends twice as much as El Paso "not because people in McAllen are sicker and not because they are getting better care," President Obama told the AMA delegates. "They are simply using more treatments - treatments they don't really need; treatments that, in some cases, can actually do people harm by raising the risk of infection or medical error. And the problem is this pattern is repeating itself across America."
But health services researcher Daniel Gilden, president of Massachusetts-based JEN Associates, Inc., says both President Obama and Dr. Gawande are wrong. Writing on The Health Care Blog , Mr. Gilden says the answer to McAllen's high costs very well may be that people are sicker there.
"Is McAllen an extreme example of bad physician culture, or is there another explanation?" he asked. "Our analysis of Medicare data from McAllen, Texas, demonstrates that exceptionally high rates of chronic disease and poverty explain much of the variation in cost."
Texas Medical Association's Border Health Caucus also says Dr. Gawande failed to take into account "many unique challenges" to providing health care in the Rio Grande Valley. The caucus pointed out in a statement that the McAllen hospital service area has the nation's poorest population, the fewest physicians per capita in the entire United States, and the second highest uninsured rate in the state. High rates of obesity, diabetes, lack of exercise, and overall poor health status plague the area, they said.
Dr. Cárdenas chairs the board of directors for Doctors Hospital at Renaissance in Edinburg, which Dr. Gawande visited and described almost derisively as "sleek and modern, with recessed lighting, classical music piped into the waiting rooms, and nurses moving from patient to patient behind rolling black computer pods." He says data clearly show that health care providers in McAllen deal with a "disproportionate number" of impoverished people.
"And that impoverished population is also unhealthy, many of whom access their care late. So it stands to reason that you would see more expenditures," he said.
Valley physicians and the health policy experts also took issue with Dr. Gawande's comparisons of McAllen to El Paso, Rochester, and Grand Junction. McAllen internist James R. Stewart, MD, president of the Hidalgo-Starr County Medical Society, said comparing McAllen to El Paso is "like taking Manhattan and saying its demographics somehow represent the surrounding states of Connecticut and New Jersey."
Dr. Cooper, Mr. Gilden, and health economist Peter McMenamin, PhD, say comparisons of McAllen and El Paso are not valid due to significant demographic differences. Dr. McMenamin points out that the McAllen hospital service area includes only two counties, while the El Paso service area spans a large area of both West Texas and New Mexico and includes four to five counties in each state.
McAllen also has a higher poverty rate and a higher percentage of Hispanics than does El Paso.
"El Paso is very different," said Dr. Cooper. "It has a much larger middle class, it's been a stable community for a long time, and it has much less poverty than McAllen The whole social structure in El Paso with the nearby military facilities is very different. You're dealing with an absolutely different culture."
Dr. Cooper also says comparing McAllen to Rochester and Grand Junction is "madness." Those communities are largely middle and upper class with little poverty and better health status, he says.
In his blog, Mr. Gilden pointed out that many disease rates for the McAllen population are more than double those for Grand Junction. "If the Medicare population in McAllen is truly that much sicker, wouldn't we expect the payments to be greater?" he asked. "A comparison of expenditures for Medicare enrollees without a diagnosis of diabetes or heart disease in the last year shows that costs for these standard populations are statistically very close."
Extending an Invitation
The Border Health Caucus invited President Obama to visit McAllen and see for himself the cultural and socioeconomic factors that may be producing high Medicare costs there. As of late July, the president had not responded to the invitation.
Meanwhile, U.S. Rep. Michael Burgess, MD (R-Lewisville), has called on the Government Accountability Office to conduct a study to determine the reasons health care costs are so high in McAllen.
"I am concerned that without an independent analysis and without further examination of what exactly is taking place in McAllen's health care spending, Congress will be inclined to make broad assumptions that lead to inappropriate legislative decisions about how to control costs in health care," said Representative Burgess, chair of the Congressional Health Care Caucus. "These decisions will likely not properly address the challenges of overall spending reductions in McAllen or elsewhere in the country."
Dr. Cooper also expressed concern about where the hoopla over McAllen's health care costs could be taking the health reform debate.
"The whole thing is a terrible distortion," he said. "It's gotten health care reform off track. It makes people believe that the only problem is doctors are overusing the system, when in fact it's patients. They are using more because they need more. There may be ways to make them need less, but we aren't focusing on that."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
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