Medical care costs and the entrepreneurial physician

Joe Gibe’s post last Friday about the incentives within US healthcare that drive the overuse of expensive technology made me think of an article I had read several years ago. In June of 2009 The New Yorker published an article by Atul Gawande describing his investigation of why McAllen, Texas had among the highest per capita Medicare costs in the country. He compared McAllen to the demographically similar city of El Paso and interviewed people involved in health care in both communities. His conclusion was that McAllen had an unusually large number of entrepreneurial physicians. These were physicians who saw medicine primarily as a source of revenue and who many times made much of their income from other things besides direct patient care.

He reached this conclusion after finding that the difference between McAllen and El Paso was that there was higher utilization of services for patients with the same medical problems in McAllen than in El Paso even thought the populations were similar and there was no evidence of those in McAllen having better results than those in El Paso. The thing that was different was how the physicians looked at medicine. Many more in McAllen saw it primarily as a business.

The point is not that being an entrepreneur is bad. There are many ways that we as a society benefit from those willing to take on risks and try new ventures. It just is not a good mix with caring for patients. To function well the practice of medicine needs to be a profession that is focused on doing what is best for the patient. We see that in the long tradition of Hippocratic medicine. The current model of medicine as a contract between physicians, patients, and payers sees medicine as a business and encourages the physician to be an entrepreneur. It puts the focus on maximizing revenue and not on the best interest of the patient. Even those who enter into medicine with the intent to put the interest of patients first can get caught up in the pressures of this business model.

As we look at ways to improve our broken “system” of providing healthcare we need to remember the importance of promoting the traditional focus of medicine as being a profession founded on beneficence. Gawande observed that those places where the best quality medical care is provided for the lowest cost are those where there is an emphasis on putting what is best for the patient above everything else.

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