Taking Another Look at McAllen
Atul Gawande published an article in The New Yorker about a month ago, laying out in great detail what he viewed as the inadequacies of the health care system in McAllen, Texas, and compared them to what he views as far superior systems in Grand Junction, Colorado and Rochester, Minnesota (home of the Mayo Clinic). He concluded that we needed to replicate the management systems (not-for-profit, salaried employees, team approaches to service delivery) of the Mayo Clinic in places like McAllen, and indeed, throughout the United States. Voilà! Problem solved.
Now comes the Texas Medical Association with a reality check, including some things Dr. Gawande overlooked about McAllen:
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Its population is the poorest in the entire United States;
- It has the fewest physicians per capita in the entire United States;
- It has the second highest uninsured rate in a state that is the Uninsured Capital of the United States;
- It is heavily reliant on Medicaid and Medicare payments to finance its entire health care system; and
- It is plagued by very high rates of obesity, diabetes, lack of exercise, and overall poor health status.
The article explains, "Where there is poor availability of outpatient care, patients are far more likely to seek routine care in hospital emergency rooms, where costs are high and diagnostic testing is more frequent. This is also far more likely to result in costly hospital admissions. The data that Dr. Gawande depended on – but did not report – show just this. McAllen has a pattern of unusually high inpatient costs, while outpatient costs are close to average."
Good post.
Gawande’s article is supposed to be required reading at the White House. I wonder if Greg’s response will also be required reading?
I’m starting to think the whole Gawande/McAllen thing was a set-up that the White House orchestrated from the get-go. I’m not usually conspiratorial, but you’ve got to wonder why he went to McAllen, which is the 2nd worst place in Dartmouth Atlas-world, and not Miami, which is the worst. The media follows wherever the White House leads it. The last thing the President wants is a bunch of over-excited journalists telling Miami’s senior citizens that he’s going to cut their access to Medicare by 1/2. It just wouldn’t play well for November 2012, would it?
You conveniently forgot to mention that a town just north of McAllen with the exact same patient demographic had costs of about half. That’s the crux of this article that the Texas Medical Association is not talking about.
Actually, John, the town of El Paso is mentioned in the linked article. The Texas Medical Association points out that contrary to the xenophobic beliefs espoused in the Gawande article, a mere shared proximity to the Mexican border does not imply that two cities are otherwise identical.
True, Mark, but John’s right. In the article, Gawande mentions that McAllen and El Paso not only have similar geography, but also similar demographics. What’s more, Gawande addresses to the rest of your concerns here: http://www.newyorker.com/online/blogs/newsdesk/2009/06/atul-gawande-the-cost-conundrum-redux.html
Dr. Gawande blames the old bugbear: physician-driven supply, which I suppose is why the Texas Medical Association felt the need to respond. However, in the post to which Laura links, Dr. Gawande asserts that McAllen experienced a surge in physician-owned imaging capacity and other facilities since the mid-1990s, but El Paso did not.
This brings us full circle: The doctors in El Paso must be astonishingly inattentive to their business prospects if they were not able to observe and replicate their neighbors’ opportunities. This is really not credible.
Gawande doesn’t tell us whether the proportion of residents on Medicare is higher in McAllen than El Paso but if this is the case it would support Cooper’s suggestion that physician-induced demand is more characteristic of Medicare than private payers. Furthermore, I see from Dr. Gawande’s 2nd post that he reports cancer incidence in McAllen of 516.6/100,000 versus only 420.1/100,000 in El Paso – 23% higher. So, the population is definitely a lot sicker, despite similar socioeconomic profile.
Gawande’s article suffers from statistical selectivism. He freely compares McAllen (the city) to El Paso. McAllen is the wealthiest part of Hidalgo County (the real service area for McAllen hospitals and physicians) and it is home to only 15% of the county inhabitants. El Paso is both a city and a county where the city is home to 85% of the county population. The true socioeconomic and disease incidence differences can only be appreciated by comparing county to county, or by comparing McAllen to the wealthiest 15% of El Paso County.
What about the costs associated with defensive medicine in McAllen? Isn’t Hidalgo County statistically one of the counties in Texas with exceptionally high damage awards in injury and malpractice suits based on their jury pool composition?
I suggest everyone read the link to Gawande’s follow-up article in Laura’s post above.
More importantly, I wonder why the Texas Medical Association and many members of the medical community are preoccupied with questioning Gawande’s numbers or reasoning instead of simply looking in the mirror and asking “How am I part of the problem?” The American public needs to do the same.
Has anyone noticed that these places with “low medical cost” usually are associated with institutions where interns and residents are abound (cheap slave labor). Tha amount of care these providers dish out in El Paso(UT system) or in Rochester (Mayo Clinic) is paramount to a defacto subsidy to the cost of the care delivered. McAllen does not have this scape valve. Do not be fooled Medicare has exact figures where the money goes, what billing patterns are aberrant, and who is profiting the most in this “parallel universe”. Let’s see the figures,
Has anyone noticed that these places with “low medical cost” usually are associated with institutions where interns and residents are abound (cheap slave labor). Tha amount of care these providers dish out in El Paso(UT system) or in Rochester (Mayo Clinic) is paramount to a defacto subsidy to the cost of the care delivered. McAllen does not have this scape valve. Do not be fooled, Medicare has exact figures where the money goes, what billing patterns are aberrant, and who is profiting the most in this “parallel universe”. Let’s see the figures, Show us the money
Atul Gawande has replied to this criticism. It’s hard to look at his chart comparing McAllen with El Paso (6th poorest place in the US) and conclude that the 2:1 ratio of medical costs is because McAllen is so much poorer & sicker!
[…] country of unjustifiably high Medicare spending. Yet as Greg Scandlen has previously pointed out at this blog, McAllen is a poor city with many health problems and very little private insurance. So Medicare is […]