On Sun, 21 Jun 2009, Joanna wrote:
> Michael wrote
>
> "This is the article that Obama cited recently as so important for his own
> perspective:
>
> http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande "
>
> Yes, I read it. What was odd about it was that it purports to show that
> the problem is not for-profit medicine, that there are other issues that
> play a part....but it winds up showing that the profit motive (on the
> part of doctors rather than insurance companies) plays a part both in
> bad and in expensive medicine.
>
> So, though I appreciated the scholarship, the overall argument didn't make
> much sense.
I don't think that's quite right. As you say, it makes a distinction between the profit motive on the part of doctors from that of insurance companies. One way to read that is that the former will remain a problem even if the latter is changed. Switching to single payer will save us tons in administrative costs and drug costs. But Gawande's argument is that overutilization costs will only be fixed by profoundly reorganizing doctors -- not only how they do things and get paid but also how they get trained and think.
One way to read this argument is that if you are really concerned about cost, single payer doesn't go far enough. The only way to replicate things like the Mayo approach is to institute a VA type system where doctors are paid salaries, but with more collective democratic control over their workplace by doctors (which is necessary for them to become conscious of what works better or worse and fix it -- to create an alternative work culture aimed as health results).
It looks like the Obamaites read this as saying they can replicate the savings and improved quality of the Mayo approach through information technology and other cute bells and whistles. Which seems pretty fatuous when phrased like that. But reading this at least you can see where they get the conviction that there is really is lots of "waste" that theoretically could be cut. You can, as I said, see where they are coming from and where they make their mistake, which is more surprising than I thought it would be.
I don't think this article really leads to a policy prescription that is applicable at the moment. It doesn't really proffer a solution. It's more a thick description of a problem. It's turns over new soil and makes you think a bit more. Which is pretty rare in this debate.
It's also interesting for being widely and (I think) wrongly applied. Gawande has some guilt for that -- his phrase at the end "It doesn't matter who pays the bill" is easy to misinterpret. And maybe he misinterprets it himself. But that doesn't make it a less interesting contribution to the debate.
Michael