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Froma Harrop
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A Texas-Size Medical Lesson


McAllen, Texas, spends more per person on health care than any other metropolitan area in America, except for Miami. Why would this poor border town spend $15,000 a year per Medicare enrollee? Rochester, Minn., home to the famed Mayo Clinic, only spends about half as much. Find the answer, and we have the formula for national health-care reform — that is, controlling costs without cutting quality.

Atul Gawande, a Boston surgeon writing in The New Yorker, has landed on an explanation. It's the different medical cultures, and with them, the incentives for prescribing care. "The most expensive piece of medical equipment, as the saying goes, is a doctor's pen," Gawande notes.

Over-treatment is not necessarily harmless. More Americans die of complications of surgery than in car accidents.

My conservative friends resist this response. They believe that the market provides the best incentive system and that the government should keep its nose out of health care.

Let's first consider other possible reasons for these numbers:

Malpractice suits. The Rio Grande Valley is supposed to be one of those "judicial hellholes," in which doctors order extra tests to protect themselves. Actually, it's home to few medical malpractice suits, thanks to a Texas law that caps pain-and-suffering awards.

Unhealthy people. McAllen has high poverty and obesity rates. True, but so does El Paso County, where Medicare spending is half that of McAllen. Their populations are similar in size and numbers of non-English speakers, illegal immigrants and the unemployed.

Superior care. McAllen's facilities do offer superb technology. But on the Medicare rankings for quality of care, El Paso's hospitals outperformed McAllen's on 23 of the 25 criteria.

Dartmouth College's Institute for Health Policy and Clinical Practice compared treatments ordered in McAllen and El Paso.

Patients in McAllen received 60 percent more stress tests with echocardiography, 200 percent more tests to diagnose carpal-tunnel syndrome and 550 percent more studies to diagnose prostate problems. They provided two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations and so on.

The Dartmouth researchers found that patients in high-cost areas were less likely to receive inexpensive preventive care, such as flu shots. They had longer waits in emergency rooms and were less likely to have a primary-care physician.

"They got more of the stuff that costs more," Gawande writes, "but not more of what they needed."

The lower-cost centers had adopted measures to discourage doctors from piling on unnecessary treatment. Doctors at Mayo work on fixed salaries. Well-performing centers where physicians are paid by the procedure had taken other steps. For example, their doctors couldn't cherry-pick patients with good coverage and send them to specialty hospitals that they own.

McAllen is an extreme case of what routinely goes on in American health care. In 2006, U.S. doctors performed one surgical procedure for every five people! Furthermore, it's not true that Americans are especially unhealthy. They may be fatter than others, but they smoke and drink less.

The Obama administration believes that shrinking the expenditure gap between the Mayos and the McAllens will free up resources to insure everyone and curb growing federal deficits. Its critics argue that this is the road to rationing health care.

OK. Suppose you report heartburn symptoms to your doctor. Would you rather be started off with an antacid or have an endoscope shoved down your throat, with the risk of puncturing your upper GI tract? More than 70 percent of doctors in high-cost cities said they would immediately send you to a gastroenterologist and-or order an endoscopy.

The Tums-first route would seem more rational than rationing. The simpler treatment is also less expensive, but let's not hold that against it.

To find out more about Froma Harrop, and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate web page at




2 Comments | Post Comment
Healthcare reform will never occur until we get the insurance companies, including Medicare, out of the decision-making process. Most doctors are involved with insurance compaines as members of their panels whereby they exchange access to patients for a discounted fee. Patients then pay a co-pay or a small portion of the normal charge. This takes the patient out of the process because they have no real financial incentive ask questions about other low-cost effective treatments. Insurance plans should pay set amounts and the doctors should be allowed to balance-billl for the difference between the insurance reimbursement and the normal charge. Patients need to return to being the purchasers of healthcare instead of the recipients.
Comment: #1
Posted by: Bill Bird
Thu Jun 11, 2009 5:59 AM
Whoops, I posted this to the wrong page.....sorry about that:

Report this post Posted by: ValRae Lenius
Comment: #1
Fri Jun 12, 2009 10:16 AM
Re: "McAllen's Medicare Model One that need s fixing nationwide".

Dear Froma, I read with interest your article in regards to the exceptional spending ($15,000) per Medicare recipicant in McAllen, Texas. And, I immediately saw a potential statistical flaw with this argument.

I am wondering if those statistics could be skewed, because approximatly 6 months of the year, "the Valley" is flooded with "Winter Texans". And, without a doubt, the majority of those Winter Texans are Senior Citizens who more than likely are utilizing doctors there during that stay.

I know from personal experience from relatives and friends from Iowa, Minnesota, etc that they do use those services. So, I am wondering if you are utilizing the CENSUS DATA (which would not include the influx of Winter Texans) and office visits billed to Medicare to come up with your model? And, using the Mayo Clinic statistics is not a fair comparison, in my thinking.

Thanks for thinking about this and maybe giving me feed back...if you have time?

ValRae Lenius Canyon Lake, Texas

Comment: #2
Posted by: ValRae Lenius
Fri Jun 12, 2009 10:22 AM
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