The words that changed McAllen
There are some pieces of journalism that are so gut-wrenching that they can have immediate effects. The recent investigative series on the terrible conditions of nails salons that came out in the New York Times, for example, was so horrific that it caused the governor of New York to, within 3 days of its publication, order emergency measures to protect nail salon workers. But in healthcare, we complain that change often doesn’t get executed so fast. The New York Times also published the 10-part, alarming “Paying Till It Hurts” series on costly medical care over the last couple of years, but progress on these identified problems is often slow, however clearly a need for change may be recognized. Is it a waste of effort, then, for doctors to identify and write about healthcare problems?
This month, a lot of us are marveling at bestselling surgeon-writer Atul Gawande’s most recent New Yorker article, “Overkill.” Gawande talks about an “epidemic” of unnecessary medical procedures and costs, a topic most readers are familiar with. What is surprising are his two positive examples of places reversing the trend of unnecessary medical procedures. The first is a program by Walmart to reward employees for choosing certain “centers of excellence” that provided smart care. The second is McAllen, Texas.
Why should we be surprised by the choice of McAllen? Those familiar with Gawande’s writing will remember that back in 2009, six years ago in his New Yorker article “The Cost Conundrum,” Gawande skewered the very same city of McAllen, Texas for having the second-highest medical costs in the nation. In his recent article, however, Gawande finds that since 2009, the Affordable Care Act, federal prosecution of physician fraud, rise of meaningful access to primary care, and yes—strong reactions to his article—have all led to a dramatic decrease in healthcare costs in McAllen. “Between 2009 and 2012, its costs dropped almost three thousand dollars per Medicare recipient…the total savings to taxpayers [are projected] to have reached almost half a billion dollars by the end of 2014,” writes Gawande. “The hope of reform had been to simply ‘bend the curve.’ This was savings on an unprecedented scale.”
Compare that to the statistics in 2009, where he wrote about McAllen: “In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.” Back when Gawande spoke with doctors in McAllen in 2009, he wrote that “some were dubious when I told them that McAllen was the country’s most expensive place for health care.” Most doctors didn’t even know about the relative waste of their own healthcare system. The one critical McAllen doctor who Gawande spoke to, a cardiac surgeon named Lester Dyke, was the source of a strong statement: “We took a wrong turn when doctors stopped being doctors and became businessmen.” Dyke told Gawande he was pilloried for his critical words in the wake of that article, and became a “persona non grata overnight,” losing so many patient referrals that he considered retirement. But Dyke told Gawande he didn’t regret being a critic. “I don’t think you often get a chance in life to stand up to all the badness,” he said.
After the “Cost Conundrum” article was published in 2009, television crews descended on the city, McAllen was in the spotlight, and doctors and hospital executives were angry. But, Gawande says, when McAllen hospitals were finally goaded to run their own analyses, they were forced to come to the same conclusions about wasteful spending and care. McAllen’s notoriety also made it a destination for emerging primary care medical groups like WellMed who were looking for places in dire need of preventative and results-driven care for seniors, which would decrease medical spending in the long run.
Ultimately, there are a lot of factors to explain why McAllen healthcare costs and outcomes have improved so much in just six years—and Gawande does a great job of describing them, especially the rise of meaningful primary care, which he gives most of the credit to. But there’s undeniable credit due to Gawande himself, for writing this article and choosing to scrutinize McAllen. There’s credit to him, as a physician-writer, for putting non-writing physicians like Dyke in the spotlight and giving them “a chance in life to stand up to all the badness.” Gawande doesn’t live in McAllen, Texas (he lives and works in Boston). He was not there on the ground to drive change, to force the article to linger in people’s minds. But change still happened, simply because he was curious enough to investigate and write about something that bothered him. The insights of these articles are taken more seriously coming from a physician, an “insider” who does not stand to benefit personally from lower medical costs, just like the surgeons he describes in his article. To me, this is a compelling example of why we must encourage physicians to write, because there’s a chance it might change—not just challenge—the status quo.