The Athens NEWS :: Athens, Ohio's only locally-owned newspaper :: National health-care reform: Former Athenian at center of debate

National health-care reform: Former Athenian at center of debate

Written by David DeWitt

Sunday, 03 January 2010 17:30

While historic health-care legislation moves through the U.S. Congress, an Athens native has had President Barack Obama’s ear on the subject.

Dr. Atul Gawande, M.D., grew up in Athens and is now a staff member of Brigham and Women’s Hospital and the Dana Farber Cancer Institute, both in Boston, and a contributor to New Yorker magazine. Obama held a special meeting with advisers in June after reading an article by Gawande in the New Yorker about health-care spending disparities across the country.

Gawande’s June article investigated why the border town of McAllen, Texas, was the country’s most expensive place for health care. The New York Times reported that the article had become “required reading in the White House.”

The article maintained that a major cause of the high costs in McAllen was “overuse of medical care.”

Gawande refers to what economists often say, that in our current system, doctors are paid for quantity, not quality. “As they point out less often,” he adds, “we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.”

He drew a comparison with building a house, noting that the task requires a variety of different specialists, expensive equipment and materials, and a lot 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 1,000 outlets, faucets and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later?”

He noted that “getting the country’s best electrician on the job” won’t solve the problem, nor will “changing the person who writes him the check.”

Now that the health-care legislation has gone through debate and taken shape, Dr. Gawande has penned another article for The New Yorker. In this one, Gawande states that the bill “has no master plan for curbing costs,” but goes on to ask, “Is that a bad thing?”

Gawande states in the Dec. 14 article that in the next 10 years the average cost of family insurance will rocket to $27,000 or more a year at the current rate of increase. That's more than a fifth of every dollar earned, per family. More significantly, he says spending, unless checked, will devour all future wage increases and economic growth.

He acknowledges in the article that the U.S. Senate version of health-care reform does not end “medicine’s destructive piecemeal payment system” or replace paying for quantity for quality, and neither does it enact national changes that reduce costs and raise quality. However, he notes, “what it offers is… pilot programs.”

Later in the article, he states that both the House and the Senate bills prevent insurance companies from excluding patients, though the Senate plan imposes an excise tax on the most expensive, “Cadillac” insurance plans. “This pushes private insurers to make the same efforts that public insurers will make to test incentives and programs that encourage clinicians to keep costs down,” he writes.

He admits that it’s difficult to know which of the congressional health-reform programs will work, and that’s why the Congressional Budget Office doesn’t assess any substantial savings for either of them. He notes that the Senate package pays for subsidies through taxes and short-term payment cuts to providers. The good news, he adds, is that the program “contains a test of almost every approach that leading health-care experts have suggested.” (The only one missing is malpractice reform, he acknowledges, which is one of Republicans’ main criticisms of Democratic health-care reform proposals.)

“None of this is as satisfying as a master plan,” Gawande concludes in the article, “but there can’t be a master plan. That’s a crucial lesson of our agricultural experience. And there’s another: with problems that don’t have technical solutions, the struggle never ends.”

Gawande’s reference to agriculture is a key theme in the article, which compares health-care reform to the reform of the U.S. agriculture system at the start of the 20th century. At that time, a number of pilot farming programs were put in place using “extension agents” as resources of comparative data for local farmers, he writes.

He cites the agricultural situation here in Athens County as an example of the continuing benefits of employing extension agents to try out new programs and methods.

Gawande includes his talks with Athens County agricultural extension agent Rory Lewandowski in a large part of the New Yorker article.

The physician writes that Lewandowski had told him that “Athens is a green, hilly county at the edge of the Appalachian Mountains, and the farms there are small — an average of 150 acres. There are 660 of them, with, (Lewandowski) estimated, as many as 100 kinds of produce and livestock. His primary task is to help farmers improve the productivity and quality of their farms and to reduce environmental harm. And 100 years after agricultural pilot programs were put in place, “the difficulties have changed but they haven’t gone away.”

Gawande recalls a story that Lewandowski told him about a beef farmer who had an offer from a microbrewery to give him distiller’s grain for his cows. “Lewandowski had no idea, but he called the program’s beef extension expert and got the answer.”

In another case, according to Gawande, a large organic farm called with questions about growing vegetables in “high tunnels,” a recent innovation that the farm had employed to extend its growing season. Though Lewandowski had no experience with this, an extension agent in Wooster, Ohio, supplied details on what had worked elsewhere.

Gawande writes that he asked Lewandowski if he had “any victories.”

“‘All the time,’ he said. But he had no illusions: his job will never end,” Gawande adds.

Contacted Sunday, Lewandowski said the article was an interesting way of looking at the health-care issue, and praised the parallel Gawande drew between the role of extension offices and the health-care pilot programs.

“Obviously it’s two very different fields, but yet this idea of educating to help people understand, recognize choices and make choices does have merit,” Lewandowski said. “It seems as people have more information and find out about things, they do make better choices. He does have merit in looking at that type of system and considering how it might be applied to health care.”

When it comes down to it, the extension agent said, the discussion is about education and promoting best practices.

“You have small trials, so you’re not putting all your eggs into one basket,” he said. “You wait to see how it works, and you evaluate through it all. You ask what did we learn from this and where do we go from here, what’s the next step.”

Getting our medical communities, town by town, to improve care and control costs isn’t a task that we’ve asked government to take on before, Gawande says in his article. “But we have no choice. At this point, we can’t afford any illusions: the system won’t fix itself, and there’s no piece of legislation that will have all the answers either.”

He concludes that the task will require dedicated and talented people in government and communities “who recognize that the country’s future depends on their sidestepping the ideological battles, encouraging local change, and following the results. But if we’re willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity. We’ve done it before.”

Gawande begged off repeated requests for interviews, saying that he’s been too busy. His parents, who emigrated from India, still practice medicine in Athens. They could not be reached for comment.