Dr. Bilhartz Rebuts Dr. Gawande


“Alternative payment models are just another illusion for affordable care that has a different name. ACOs are merely one more bureaucratic experiment that shuffles chairs around on the deck of the Titanic, while the boat remains in fast pursuit of the iceberg.”

The problem of “less is more” in American health care

Rocky Bilhartz, MD | Policy | June 3, 2015

Dr. Atul Gawande is an American surgeon and public health extraordinaire. He is one of the most successful physician authors of this century, and he writes routinely for the New Yorker. His most recent article discussing unnecessary health care is, as expected, a good read.

I applaud Dr. Gawande’s passion towards advancing medicine. And, yes, there is universal agreement that we need to be better in America at providing high-quality low-cost health care. There just remains disagreement on what our biggest obstacles are, and how they should be overcome.

I agree with Dr. Gawande on some things, but after reading his most recent opinion piece, I must caution you about several medical inaccuracies found within it.

The “less is more” paradox

Dr. Gawande is correct that we have waste in medicine. No one disputes that you can smooth out a few edges and get more optimal use of health care resources. But, in an attempt to prove his rather “juicy” point about medical “overkill,” he disappointedly makes some inaccurate statements about medical testing.

Dr. Gawande states in his article that an electrocardiogram (also known as an ECG or EKG) provides “no useful information” in patients without symptoms. He’s wrong.

This non-invasive test, which costs $18 in my office, saves lives, and it does so in folks who never previously experienced any symptoms. You see, when you focus on real human beings with real names in medicine, you don’t forget that for many people, their first symptom is death. And, that’s why ECGs in asymptomatic people save lives.

But, I didn’t write this to correct Dr. Gawande about a minor point regarding a test that he doesn’t even oversee in his specialty. I wrote this because Dr. Gawande’s comments hint at a much greater misstep. In fact, Dr. Gawande is just one of the many apostles in medicine right now that have gotten mixed up believing that the medical care of an individual must always be entwined with public health. Let me explain.

The powerful players in medicine don’t want you to know that ECGs or mammograms save lives. They want you to believe that less is always more. They prefer that you should only do for the individual in medicine what is best for the entire group as seen from their perspective. And, they are wrong about that.

Public health is not always synonymous with individual medical care. And, if you are an individual out there, you need to understand this, because those powerful players, from your insurance company to our government, would prefer you be viewed as some number instead of somebody.

Take, for example, Dr. Gawande’s mention of an 82-year-old patient who was found to have severe blockage in the arteries of his neck. Dr. Gawande informs us that a team of doctors unnecessarily performed a surgery on this patient’s neck arteries that resulted in the patient having a debilitating stroke.

Dr. Gawande claims that the patient’s risk of stroke from the procedure was 15 percent. Then, Dr. Gawande explains that a successful procedure to fix the arteries would have resulted in a 1 percent lower stroke risk per year over the remainder of the patient’s lifetime. Using these calculations, the 82-year-old patient would have needed to live another 15 years before the benefit of the procedure would have outweighed its risks. And, from this information, Dr. Gawande concludes that we have “an epidemic of unnecessary care in America.”

I could go after Dr. Gawande’s fuzzy math and his risk score calculations, but I don’t even need to do that to make my point. Dr. Gawande’s problematic assumption rests in his belief that population health (i.e. what’s good for the group) is the only avenue for quality medical care.

I’ll even use the example that Dr. Gawande gives us. This 82-year-old guy is already a marvel of modern medical procedures. The patient wouldn’t even be alive without them. Dr. Gawande emphasizes that this patient underwent aortic aneurysm repair at age 65, pacemaker placement at age 74, and kidney dialysis three days per week since age 79.

What if a team of apostles had told this same patient at age 65 that “less is more” and that he shouldn’t be considered for his aneurysm repair? What if they told him at age 74 years old that he shouldn’t get a pacemaker? Indeed, if you believe only in population health, you would have given up on this patient a long time ago, because that’s what the statistics might have told you to do.

Oh, and let’s talk about the procedure that this patient undwerwent on those arteries in his neck. Population health tells you there is a perfectly charted line of so-called stroke risk with time, but individual health often pays no attention to this. Population health claims that the potential for stroke trends upward or downward at some statistical rate, but individual health frequently is immune from such statistical mumbo-jumbo.

You see, the truth is that every year, you either have a stroke or you don’t. This means that for the individual, the stroke line is flat at 0 percent until you have an event. Then, it immediately goes to 100 percent. There is no gradually sloping line that you wait to intersect with some other gradually sloping line so you can know for sure what to do. When you are dealing with the individual, you are dealing with bursts of various events, and this is not the same thing as population health. You should use population health as one tool to guide you, not as the only tool to determine absolutely whether an individual’s care is full of quality.

Dr. Gawande knows these things, which is why I’m frustrated by his angle. A patient’s stroke might occur at day one, at day ten-thousand, or not at all. And, there is no crystal ball. In fact, it’s because medicine is so complex, that I’d rather put my faith in a team of doctors instead of a bunch of apostles proud to be preaching “less is more.”

Medical centers of excellence

Throughout his article, Dr. Gawande demonstrates a favoritism towards large “centers of excellence.” He emphasizes that these centers are best equipped to provide affordable high-quality health care. Don’t get me wrong, I understand his point of view. I just want to point out that Dr. Gawande’s disclosure is that he works for one of these centers of excellence. In fact, I’ve also worked for one, and for that reason, I’ll reveal to you a more balanced perspective.

For every case that Dr. Gawande gives you about a patient who has a miraculous experience at a large facility with a so-called “high-quality” system in place, I’ll show you a patient who got terribly lost and misdirected within that same system. I call this the paradigm of lost accountability, and these centers of excellence have historically been plagued by it.

Large systems have accountability, but that accountability is often more directed to the actual system than the patient within it. Take Mr. Smith, a 76-year old who was evaluated at a center of excellence because he had a completely blocked blood vessel in his heart. The Center recommended he undergo a procedure to try and fix it. Unfortunately, not only was the procedure unsuccessful, but Mr. Smith had a stroke because of it.

When an adverse event occurs in medicine, even when it’s an understood potential complication, you, as the physician, feel terrible about it. The surgeon for Mr. Smith’s procedure felt the same way. But, this is where the paradigm of lost accountability begins to take shape.

Following Mr. Smith’s unsuccessful procedure performed by one physician, Mr. Smith gets admitted to a different team of doctors to be cared for in the intensive care unit (ICU). Two days later, this ICU team changes again, as new doctors replace the old team of physicians on the service. When the patient gets transferred to the hospital floor, it’s another group of folks and so on, and the same thing happens again when the patient follows up in the clinic.

You see, systems like the one above literally thrive on the fact that no one person is ever truly accountable for the care you receive. In fact, with Mr. Smith’s case, the original surgeon involved with the patient’s stroke never even had to see Mr. Smith again. This is a problem.

Don’t misconstrue my own comments, because I’m not telling you to avoid centers of excellence. I’m just pointing out that they often have inherent problems with patient accountability. They are not the “end-all-be-all” solution to our health care crisis as Dr. Gawande implies. Systems like these actually fail us when the “buck” stops with nobody. In fact, I strongly challenge all centers of excellence to be more conscious of this inherent concern and strive to overcome it.

The myth about physician businessman and businesswomen

Winning public opinion isn’t hard. First, you tell people what they should fear. Then, you explain who is to blame. Dr. Gawande uses this very tactic when his article quotes a “reformed” cardiac surgeon: “We took a wrong turn [in medicine] when doctors stopped being doctors and became businessmen.”

Dr. Gawande wants you to believe that medicine got off track when doctors became business people and not physicians. He couldn’t be more wrong. The problem is not businessmen or businesswomen. The problem is a few terrible men and terrible women.

Humankind’s best efforts have occurred time and time again when the innovation of business aligns with a “love, serve, and care” model (see Jon Gordon’s book). The problem is not business. The problem is the crooks who run a few.

Six years ago, Dr. Gawande exposed medical providers in McAllen, Texas, for fraudulent activities, and I applaud this type of journalism. The crooks deserve to be caught, because they screw things up for the rest of us. But, we won’t advance things by targeting physician businesses. And, we won’t solve things by thinking we can build systems immune from the crooks. The way you move the needle is by designing health care delivery systems around the work of the good people. You improve things by enabling them. Then, you go hire a “police force” to get the crooks.

Stating that the average physician is not naturally driven towards providing quality care is a pitifully untrue statement. And, when you imply that physicians are intentionally raising rattlesnakes so they can kill more of them and collect on a bounty, you are way off-base. I’m not sure why Dr. Gawande even writes these things. Build systems around the ambition of the virtuous, not a fear of the crooks.That’s one of the few ways you can get innovation to flourish.

The real problem with alternative payment models

You should know that our government really believes that they are steering us towards a new utopia in medicine. “We are headed in a vastly different direction,” says the health department. We are finally going to focus on quality in medicine!

Dr. Gawande seems supportive. He pleads his case by mentioning a patient who has been cared for by a  new government-supported pilot program called an accountable care organization (ACO). An ACO is basically a large bureaucratic health care organization that’s given a large sum of money to care for a large population of people. It’s basically an entire system designed on the principle of paying people to do less.

In Dr. Gawande’s example, he tries to make an ACO appear favorable to physicians by describing a bizarre scenario that seems unlikely to be reproducible. He describes a patient who is cared for by an ACO, who immediately gets worked in to see a doctor on the same day, and who receives great care. Then, Dr. Gawande goes on to explain how the doctors providing care within this ACO are making all this money. That’s right, the doctors are making more money, and how are they doing it? You guessed it, by doing less.

Folks, if you’re still blinded, I’ll open your eyes to the obvious. Alternative payment models are just another illusion for affordable care that has a different name. ACOs are merely one more bureaucratic experiment that shuffles chairs around on the deck of the Titanic, while the boat remains in fast pursuit of the iceberg.

In order to even come close to making an ACO work, you first have to be able to measure quality. We can’t, and I’ve already explained that to you in excruciating detail here, herehere, and here. Second, you still have to somehow incentivize work within an ACO, or everyone will always be taking a siesta when you actually need a test ordered. So, usually ACOs themselves (as most have done to date) create internal incentives to their providers to see and do more. That’s right, in a recent 119 page report published about ACOs, the greatest financial incentive facing nearly all physicians in these systems was related to increased “productivity” as measured by revenues or relative value units. These systems are literally just running around in circles stepping on their own tails.

And, what about the value component of medicine that ACOs are supposed to be able to provide us? Well, it’s really just another game of figuring out computer software check boxes. One more activity on the deck of the Titanic that really has nothing to do with quality at all. Charades like this ultimately just steal more moments away from the one thing in medicine that actually should matter: the patient-physician relationship.

Since I’m a physician, I especially enjoy Dr. Gawande predicting that physicians will start getting paid more within an ACO. Seriously? When these things are all said and done, who are we kidding? The people that will walk away with all the money in an ACO will be the people running the ACO, and trust me, it won’t be the physician pawns who are doing the work.

It seems obvious that ACOs will provide “less” overall care, so perhaps it’s more of interest how much this “less” care will save us. Dr. Gawande might quote you two recent studies that indicate that you save about a hundred dollars per year for each patient enrolled in an ACO. However, I find it interesting that the ACOs studied were the government-picked top performers, and none of these studies included any of the exorbitant bureaucratic costs to setup and run an ACO. That’s like saying you can print an entire book for only $2, while failing to mention the cost of developing your printing press. In fact, it appears like the only certainty regarding ACO cost is that practically all additional expenditures will flow, yet again, as Margalit Gur-Arie has eloquently stated, to “more computers and more administrators.”

Let the doctor practice medicine

You can always do less in medicine, but you’re amiss by thinking that less is always more. What’s good for the group is not always good for the individual. And, this is one of the many reasons you can’t always base the quality of individual care on some population health experiment.

Often, more than 9 out of 10 people screened for a clinical trial get excluded from the trial for some reason. Over 90 percent of folks in the group of interest never even get studied! Even the best of evidence-based medicine is really just the evidence gathered on a finite few. That’s why quality doesn’t always fit in a government-issued checkbox.

Build your centers of excellence by devoting resources to train the people who’ve dedicated their lives to the Hippocratic Oath and lifelong learning. And, then, let the doctor practice medicine. Embrace, and don’t hinder, or even worse, create more obstacles for those who have established their businesses on a foundation of “love, serve, and care.”

You can either keep fee-for-service or move toward ACOs. But, one thing is for sure: you will still find crooks in both systems. I’m just in hopes someone like Dr. Gawande will continue to police them. The main problem, however, remains that there’s still an unknown fee for nearly every type of medical service, and until more transparency exists in a less bureaucratic marketplace, we’ll continue to pay the same outlandish prices for both the necessary and the “unnecessary” care.

Rocky Bilhartz is a cardiologist and the author of Finding Truth in Transparency: Our Broken Healthcare System and How We Can Heal It. He can be reached at BilhartzMD.com.