Atul Gawande on the Secrets of a Puzzle-Filled Career

; Atul Gawande, MD, MPH


December 06, 2013

In This Article

"Shocking" Healthcare Costs

Dr. Topol: I wanted to ask about a few of your New Yorker articles that are particularly interesting. The first one I wanted to talk about was "The Cost Conundrum," where you went to Texas[1] and made all of these discoveries -- that was pretty extraordinary. I think right after that article was published, President Obama had an emergency meeting to discuss the Gawande New Yorker article. What was your sense about that? You had a lot of concrete disclosures that you captured there.

Dr. Gawande: The puzzle I discovered -- and it's the kind of puzzle I like diving into with New Yorker pieces -- taught me about costs in healthcare. What I knew was that there was a serious cost problem that we were probably responsible for as doctors, because most of our decisions are the ones that drive costs. And I knew from data, like that compiled by the Dartmouth Institute, that there was wide variation in both the quality of care, depending on where you go for your care, and the cost of care. And the last thing I knew was that the places that cost the most were not the ones that had the best results.

That led me to want to understand better what's going on underneath that. The Dartmouth data are available online, and you can find the places, at least for Medicare, that are the most expensive places in the country for care, and you can see what the quality metrics are. McAllen, Texas, when you adjust for labor costs, was the most expensive county or market in the country for healthcare, and it had very average quality of care. The cost there at that time was $17,000 per person on Medicare, compared with $8000 per person in El Paso, which was 400 miles up the border -- identically poor, a similar number of illegal immigrants, similar number of hospitals. So what was the difference? I went there just to talk to physicians and say, "Do you know you're the most expensive place? And what do you make of it? Do you buy this data? What's wrong with this data?" The fascinating conversation that came out of that was that a lot of the doctors genuinely knew that the care was among the most expensive. They could see what was going wrong. They saw lots of inappropriate care. They saw inadequate primary care. And then there were parts of it that I didn't even want to touch, which was layers of some degree of fraud.

Dr. Topol: It was amazing what you uncovered there. Did you spend a lot of time hanging out in McAllen?

Dr. Gawande: I spent a lot of time doing research beforehand and then I went there for the better part of a week, which is not that much time to really get to know a place.

But by that point, I had gotten to know a lot of people and started talking with them and understanding who I should talk to, who I would see, and how I get a frame on this. I had talked to the insurers who paid the bills for people there, and I had talked to people who owned home healthcare. I talked to surgeons, owners of hospitals, board members, and chiefs of staff of hospitals and that kind of thing.


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