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The high-cost capital: Key to health reform?

There's been so much talk lately about health care reform and runaway costs, but nothing really quite gets to the heart of it as much as a recent piece in the New Yorker. The writer, Harvard surgeon Atul Gawande, MD, decided to try and sort it all out with a visit to McAllen, Texas, a border town with the dubious distinction of being the country's biggest health care spender. What he found was a place with a pernicious pattern of medical overuse, with patients getting many more tests, more hospital treatment, more surgery and more home care than in comparable cities. The result: In 2006, Medicare spent $15,000 per enrollee there, almost twice the national average. And the folks in McAllen were no better off because of it; in fact, when it comes to medicine, studies suggest that the more care you get, the worse you do, as everything in medicine has its risks, Gawande notes.

His investigation led him to believe that McAllen's practitioners had gone down a path of treating patients as "profit centers," prescribing more care to maximize their revenues. By contrast, he points to the example of Grand Junction, Colo., where doctors and insurers actually work together to keep costs down and quality up by meeting regularly and sharing information about patients. Wouldn't it be nice, he says, if other cities did the same, with joint efforts to "increase prevention and the quality of care, while discouraging overtreatment, undertreatment and sheer profiteering."

His conclusion: The move toward universal coverage won't work if we can't bring costs down. And the way to do that is through incentives that will encourage cities to move away from the McAllen model of waste to the Grand Junction model of collective accountability.

"The piece illustrates the need for health reform to get to the creation of more accountable structures for delivering health care," agrees Stanford health economist Laurence Baker, PhD. "But it also points out the real challenge of getting those structures in place."

Gawande acknowledges that creating a system of accountability is a tough prescription to follow. But if we ignore it, the prognosis for our sick health-care system seems otherwise grim.

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