The Patient's Role

John Commins, for HealthLeaders Magazine , September 10, 2009
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The unasked and unanswered reform question: What incentives will get patients to care about costs?

A big reason healthcare is so expensive these days—we are told—is the overuse of expensive services, too much needless imaging, too many redundant tests, and questionable surgeries, all of which produce negligible results. The argument has a lot of merit.

Overuse became the major issue in the national healthcare reform debate in mid-June after "The Cost Conundrum" appeared in The New Yorker. The article, by Atul Gawande, MD, flogged McAllen, TX, for averaging $15,000 per patient in annual spending on medical expenses, which is twice the national average. Gawande placed the blame for McAllen's high costs squarely on the white-smocked shoulders of the physician entrepreneurs there who perform a lot of imaging and other tests and formed hospital companies that keep patients longer than average. President Obama even plugged Gawande's article as a must-read to a room full of doctors at the annual American Medical Association meeting in Chicago.

That prompted the good doctors of McAllen to complain that Gawande failed to note that the patient mix in the Texas town tended to be sicker and poorer than the national average ("McAllen, Texas Docs Defend Region's Healthcare Spending," HealthLeaders Media Daily News & Analysis, June 24).

But Gawande paints a stirring case against the physicians of McAllen, noting that patient mix alone does not explain away the difference; rather, he contends, it is the culture that has developed there that contributes to such costs.

Indeed, culture is an inescapable factor. And nationwide, we see another cultural trend that plays into our growing healthcare cost concerns, and this one cannot be hung solely on the doctors. Here, we turn to the patients.

Remember them? They're the people in your waiting rooms, all of whom are getting older, and some of whom are getting fatter and doing little if anything to improve or maintain their health. Maybe they can't afford the health insurance. Maybe they're just indifferent and don't recognize the long-term consequences ("Obesity Costs U.S. $147 Billion Annually," HealthLeaders Media Daily News & Analysis, July 28). Whatever the case, the fact is that no healthcare reforms will work or save money unless the patient takes greater responsibility for his own health ("More Health Insurance Regs Without an Individual Mandate would Raise Health Costs," HealthLeaders Media Daily News & Analysis, July 28).

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