If doctors stick together, they can bring changes to health care

BOSTON — There will be time to talk about costs and coverage, about public and private plans, about reasoning and rationing in health-care reform. So the president began this week speaking to the workers in the system: doctors.

At the meeting of the American Medical Association, President Barack Obama tackled the model "that has taken the pursuit of medicine from a profession — a calling — to a business." He reminded doctors: "You didn't enter this profession to become bean counters and paper pushers. You entered this profession to be healers. And that's what our health-care system should let you be."

Listening to him, I thought of one small tale from the annals of medicine. A few days earlier, a friend had an appointment to consider a rather serious heart procedure. After 15 minutes, the cardiologist stood up to leave. My friend was startled. "I have more questions," she said. He answered, "I have another patient," and walked away.

I am sure that he didn't become a cardiologist to treat patients like travelers in a revolving door. I am also sure that no rational system would allot minimum time and payment for an office visit to decide on a procedure that will cost, on average, $35,000. But there we are.

Somewhere along the way, with the help of insurers and incentives, by paying for procedures rather than patient care, we have created a culture of medicine that pushes doctors away from the "calling."

In his speech, Obama mentioned McAllen, Texas. This little-known city has become the infamous poster town for runaway health-care costs since Atul Gawande wrote about it in The New Yorker. McAllen has the second-highest per capita health-care costs in the nation, a fact it doesn't post on its Web site. Costs are twice as high as those in its demographic twin, El Paso. Not because the people are sicker. Not because they are kept healthier. And not because of malpractice suits.

"The primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine," wrote Gawande. It was reminiscent of other high-cost areas where people "got more of the stuff that cost more, but not more of what they needed."

In McAllen, Gawande unhappily concluded that this overuse came because too many doctors saw their practice "primarily as a revenue stream." It wasn't just some aberrant character, it was the system that pays doctors for quantity, not quality — and pays them as individuals rather than as members of a team.