Dr. Gawande's View Of Cutting Health Costs

Dr. Atul Gawande, a surgeon, a professor at the Harvard School of Public Health and a staff writer for The New Yorker is among the experts the Obama administration is consulting about health care policy. Gawande and other physicians studied 74 communities across the country where health care quality is up while costs are down. He tells Guy Raz about the study.

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GUY RAZ, host:

One man who has the ear of President Obama on health care is Dr. Atul Gawande. He's a surgeon who also teaches at the Harvard School of Public Health. He says the debate over how to pay for expanding coverage to the uninsured has focused on only two options, raising taxes or rationing care.

But Dr. Gawande says there's another way to save money. He and several colleagues studied communities all over the country that cut health care cost significantly.

Dr. ATUL GAWANDE (Professor, Harvard School of Public Health): Places like Cedar Rapids, Iowa, Asheville, North Carolina, Richmond, Virginia, Sacramento, California, Temple, Texas. These were the places that turned up to be these positive outliers. And what's going on in these places was what we have been ignoring, I think, in the debate and also in just our thinking about what we want to do about health care.

RAZ: Some of these communities stopped paying doctors to perform more procedures. Others kept that model but they all had one thing in common.

Dr. GAWANDE: All of them have found ways to try to blunt a financing system that only pays doctors for doing more procedures and pays us very little for actually just spending time with people. And if we had a system where other cities were doing what they were doing, our health care crisis would be over.

RAZ: Dr. Gawande told me how Cedar Rapids cut costs.

Dr. GAWANDE: The physicians got together and said, you know, let's just look at how many CT scans we're doing for our city. And they found last year that they did 52,000 CT scans for a town of 300,000 people.

RAZ: Hmm.

Dr. GAWANDE: And they said, whoa, this is embarrassing. And we want to do something because we just don't need that many expensive CT's. And actually, CT scans have a thousand times the radiation exposure of a chest X-ray and can be harmful. And they did, indeed, find that the vast majority were finding just normal findings, that you had people getting scans that didn't necessarily have to have them.

And so, we need, on a national level, a payment system that rewards communities like Cedar Rapids for doing that. Just for looking and seeing, are we doing too much back surgery here? Have we taken care of our cancers well? We want to take what's happening in Cedar Rapids and reward every community for doing that.

RAZ: And how do your reward them?

Dr. GAWANDE: On a simple level, one of the provisions that are in a few of the bills is paying physicians for their quality of their care. Rewarding them by saying, if you look at the data, if you measure yourself, and if your results are improving over time, you'll actually be paid for that.

RAZ: We keep hearing in this sort of debate about health care overhaul. We keep hearing the word rationing being thrown around, and it sounds scary. But what do you say to someone who sort of wonders whether cutting back on procedures that you would argue are unnecessary, is a form of rationing?

Dr. GAWANDE: If there is any government or insurance company that is making the decisions about whether you need a CAT scan or don't need a CAT scan that is both bad medicine and rationing. If what you have is a physician who you have a relationship with, taking care of you and they're just making good evidence-based decisions about the right kinds of recommendations for you, that is rational care.

And what we've been missing in the system is rational care. The irrationality turns up in all kinds of ways. It turns up in the physician who wrote to me describing a situation where he's a part owner of a imaging center. They started losing money because the doctors weren't doing enough CT scans and he found that they were in board meetings where they were sitting around trying to figure out how to get more people to get more CT scans.

It had nothing to do with whether they had good care or bad care for those scans. And that's the disaster of our system is when you have medicine become a business rather than something about what the patient's needs are. And...

RAZ: But I mean, couldn't doctors make the argument that they're entitled to be paid well and maybe not just limited to receiving a salary but to receiving money based on the services they provide.

Dr. GAWANDE: I think that we are well compensated and that we're very lucky to live in a country that has valued the services of the medical profession so highly. There is nowhere else in the world that values their medical profession as well, and I think we have found real advantages to doing that.

But whether it is a salary or being paid a fee for each time that I take out a gall bladder, I still am in a country where we are well compensated, and I think it will continue to be that way.

RAZ: The issue that comes up a lot is lawsuits, medical malpractice. And doctors, many doctors argue that they're doing these tests even if they may seem unnecessary to protect themselves.

Dr. GAWANDE: Yeah. I've been a fierce critic of the malpractice system. The defensive costs are probably part of what's going on here.

RAZ: The insurance cost.

Dr. GAWANDE: Yeah. So in other words, physicians ordering tests because they're afraid someone will sue them even if they don't think it's the right thing to do. The only reason that I don't think it's the linchpin is that we have these communities that are already producing better quality care at lower costs and doing it in the context of a system that still has our malpractice problems.

RAZ: Dr. Atul Gawande is a surgeon at Brigham and Women's Hospital in Boston, a staff writer at The New Yorker, and an associate professor at the Harvard School of Public Health.

Dr. Gawande, thanks so much for speaking with us.

Dr. GAWANDE: Thank you.

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