As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. Atul Gawande
As Gawande puts it, we are now witnessing a “battle for the soul of American Medicine.” There is a lot of blame going around but there is a trend that is starting to emerge: we need a redesign how care is delivered. Gawande likes the idea of having integrated healthcare delivery systems, like the Mayo Clinic, where salaried physicians work in multidisciplinary teams and there is a fair amount of collective thinking. As the CEO of the Mayo Clinic told him, “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing.”
If we conclude that the Mayo Clinic model is applicable to other parts of the country, replicating it requires reforming the system in such a way that it does not financially threaten physicians (less than 10% of healthcare dollars go to physicians) but changes the incentives from doing more to thinking more. Most physicians would find getting paid for their time this way more fulfilling but are currently burdened by a payment and malpractice environment that promotes doing more that’s needed and disregards the cognitive aspects of medicine (Although the issue of malpractice is downplayed by some, physicians of all specialties and creed practice defensively).
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.
