McAllen California

Dr. Gawande in an article published in The New Yorker in June

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

used the town of McAllen, Texas as a prototype of everything that is wrong in American medicine. Read the article and then the post below which will tell you how McAllen got to be the medical gold rush on the Rio Grande. You can substitute Stockton for McAllen and you will be close to te truth here



July 22, 2009
Return to McAllen: A Father-Son Interview
By IAN ROBERTSON KIBBE
By now, Dr. Atul Gawande's article on McAllen's high cost of health care has been widely read. The article spawned a number of responses and catalyzed a national discussion on cost controls and the business of medicine. It even made it's way into the President's address to the AMA.
Almost overnight, McAllen and the Rio Grande Valley were thrust into the national health care spotlight – the once sleepy border town became, not a beacon on a hill, but a balefire in the valley, representing much of what is wrong with the current medical culture.
But, McAllen wasn't always like something from an old Western, where doctors run wild and hospital CEO's compete like town bosses. I remember McAllen quite differently. I remember it, because as it turns out, it was where I was born.
It's also where my father, Dr. David Kibbe, practiced medicine from 1980 to 1990. In order to find out how McAllen earned the dubious reputation it now has, I sat down with my Dad, and asked him what he remembers about that little border town on the Rio Grande.

Ian Kibbe: So Dad, what was your first reaction to reading Atul Gawande's article?

David Kibbe: Well, Ian, it was sort of "oh-my-gosh, he nailed it." And, of course, a flood of memories, good and bad, came back to me about our time there. My medical career began there, you and your sisters were born there, small town 4th of July parades, etc. But I left after great disappointment and frustration.

IK: What were you doing in McAllen practicing medicine anyway?

DK: The National Health Service Corps sent me there to work in a clinic for migrant farm workers. The NHSC had provided me three years of medical school scholarship, and so I owed three years of service in an under-doctored area of the country. I speak Spanish, and so working as a family doctor in the Rio Grande Valley of Texas, which is the home of many of the country's Hispanic migrant farm workers, was a good fit. Hidalgo County, where McAllen is located, was the poorest county in the country, and there was a real physician shortage there in 1980.

I worked in a migrant farmworker clinic with ties to the United Farmworkers, Cesar Chavez' group, in McAllen. As a young physician from outside the Valley, and working in the one clinic in the county where the poor could receive medical care for free or almost free, I got to see an amazing diversity of medical problems that many physicians in this country never see, such as Dengue fever and leprosy. It was a great opportunity to be of service, in my opinion.

And then in 1982 we started a family practice in Mission, Texas, about 4 miles west of McAllen, where the physician shortage was even more critical. You were born in the little 67-bed hospital in Mission the next year.

IK: So, what did McAllen's health care system look like when you first got there?

DK: Well, it wasn't really a system, it was a community. And I would characterize the medical culture as primary care-oriented for at least the first half of the decade. Family physicians, internists, and pediatricians were in charge of things, ran the county medical societies, provided most of the medical care including hospitalizing sick patients and delivering babies. We had a couple of surgeons, and one cardiologist who was board certified.

But starting in the early 80's things began to change. In 1982 HCA opened Rio Grande Regional Hospital. Then in 85' Universal Health opened McAllen Medical Center. Both were large for-profit hospital chains, with new facilities, and both recruited literally dozens of sub-specialists where there had previously been only a handful. So within three years, there was a significant change towards subspecialty care, and that trend intensified over the next few years.

At first, the influx of technology and subspecialty care was welcome. We, the primary care docs, had more help locally, and didn't need to transfer patients to other parts of the state for subspecialty care or specialized surgery.

IK: Why the sudden interest in McAllen?

DK: Money, plain and simple. Most of the new subspecialists were guaranteed enormous incomes, by the hospitals. Since I was one of the first American-trained primary care physicians in the McAllen area, and I made an effort to reach out to retirees from the North, or "Snowbirds" as they were called, I guess I created sort of a beachhead as my practice grew. As a result, I was courted very heavily by the subspecialists for access to those retirees and the subspecialty care they could generate.

IK: So, in some ways it was like a medical "gold rush?"

DK: Exactly. What was initially exhilarating change and modernization turned into a "gold rush" atmosphere, as more and more subspecialty doctors came to town and competed to see who could make the most money, admit the most patients, or build the largest homes. McAllen went from having one cardiologist to having two competing cardiac surgery teams. They created a cascade of demand. The primary care docs slid to the bottom of the totem pole economically and socially. I now understand this as the disintermediation of primary care.

IK: Can you give me an example of what you're talking about?

DK: Sure. So, in 1983 I'd see a patient with intermittent chest pain, and that day refer him to the cardiologist for evaluation. He'd call me on the phone and say, "David, I've seen your patient Mr. So-and-so, examined him, listened to his heart, and have done a tread mill stress test. Everything seems ok, so I'm sending him back to you for further evaluation for his problems." Fine.

But by 1987, I'd make the referral and never hear another word. Running into the cardiologist in the hospital hallway or locker room, and asking what happened to my patient, I'd get this response: "Oh, well if I remember correctly I admitted him to the hospital and we did angiography, which was normal. But he was having a headache, so the neurologist ran some CT scans, and I asked the gastroenterologist to do endoscopy because there was a question of some GI problems. As I recall, everything was normal, but I still see him every month for his blood pressure."

So, an evaluation that used to cost a couple hundred dollars turned into many thousands of dollars worth of testing and procedures; and this happened day in day out, week after week, year after year.

Another issue was quality assurance. I was the hospital staff physician in charge of the quality assurance program at Rio Grande Regional Hospital. But we could never make any improvements. There was one cardiac surgeon who kept leaving several tiny needles inside his patients' chest cavity after heart surgery, and we couldn't figure out a way to cut that out. He was too important to the hospital, I guess, to offend. And he knew he could just blow us off. It was all about the money.

IK: What role did you see the large for-profit hospitals playing in this change?

DK: It seemed to me that the hospitals encouraged the newly arriving doctors' attitudes about making money. These were young doctors, for the most part, right out of training. The hospital would pay them large guaranteed incomes to get them to locate in McAllen, and pay the rents on their offices for a number of years, too. The hospitals were competing openly for procedures and tests, unlike in some towns where there are agreements to share high cost facilities, like heart surgery or cancer treatment centers. But in McAllen there was out-and-out financial war between the doctors on each of the hospital staffs.

IK: And you were right in the middle of this war?

A: Well, yeah! As I said, I was courted very heavily by the subspecialists for access to my patients, but at some point that dynamic changed from seeking my referrals to taking my patients.

IK: So why did you hang around for so long?

Well these changes didn't happen overnight. I was practicing medicine and taking care of patients. Also, think I didn't know any better. Eventually I got my business degree because I wanted to figure out what the hell was going on! So, I went to the University of Texas business school part-time during those last two years we were in McAllen, primarily to try to understand what was happening to health care. It was clear that one needed a business degree to understand medicine in McAllen, Texas. Also, at the time, getting an MBA seemed like a good idea because everyone was saying medicine was a business now.

IK: Who was saying that?

Many of the doctors and the hospitals, the journals and the literature.

IK: So when did you say "enough is enough?" What finally made you decide to leave McAllen?

DK: We left in 1990 to come to Chapel Hill, North Carolina. There were a number of reasons I wanted to leave the McAllen area, but the main reason professionally was that the medical culture had become so subspeciality dominated and oriented towards profiteering, that it simply was no longer rewarding to be in family practice there. I mean, in 1987 there were more MRIs in McAllen than there were in all of Canada! And most were owned by doctors or groups of physicians.

May I ask you a question?

IK: Sure.

DK: What was your best memory of living in the Rio Grande Valley during the first eight years of your life?

IK: Wow, that's tough. But I'd have to say I had the best times at those big cookout's out in the country. There was something really magical about running through the orange groves with my friends and the smell of ripening oranges mixed with the smell of charcoal, and Texas barbecue. It was a pretty care-free time for me. Oh yeah, and the fireworks. Eight year olds love fireworks.
Well, thanks Dad. This was fun.

DK: Love you, son.

Ian Kibbe is Associate Editor for The Health Care Blog. He is also a writer, actor, video producer and editor.
David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

Putting patients first

Just read this

http://www.seefirstblog.com/2009/07/21/my-reaction-to-putting-patients-first/

A Time For Revolutions???

The Role of Clinicians in Health Reform
Source: New England Journal of Medicine
July 22 2009

William Beveridge, the economist whose 1942 report led to the founding of Britain's National Health Service (NHS), famously said that "a revolutionary moment in the world's history is a time for revolutions, not for patching."1 Given the combination of the global downturn and the time bomb that is health insurance costs, there is no denying that health care in the United States has reached such a moment. This matter is too important to be left to the politicians and policymakers; there is an urgent requirement for professional clinicians to step up and lead the debate.

President Barack Obama has brought health care reform to the forefront of people's minds, and it is now a matter of when, not whether, change will come. Repeatedly quoted statistics — on the numbers of uninsured Americans, for example, or the high, rapidly growing expenditures on health care — leave no room for ambiguity, and groups across the political landscape recognize that the U.S. health care system is unsustainable in its current form.

Every country in the developed world confronts a similar challenge right now: finding a way to create a well-resourced but sustainable system that provides care of the highest quality to those who need it. One would be hard-pressed to find credible opponents — regardless of their political stripe — to the goal of providing "universal health care." The disagreement arises when the discussion turns to the best way to achieve this aim. Each country needs to discover the formula that suits it best.

The outcome of health care reform in the United States will no doubt be very different from that in Britain, despite what some U.S. lobbying groups would have Americans believe. Britain's NHS lies at the opposite end of the spectrum from the current U.S. system, in terms of both its structure (a tax-funded public program as opposed to mainly private, employment-based insurance) and the problems it faces (historically, a lack of resources and slow uptake of new treatments as opposed to bulging costs), but in the late 1990s Britain had to confront reform on a scale as challenging as that being contemplated in the United States today.

In 1997, Britain had a new government, which had inherited a health care system that was chronically underfunded and suffering from a lack of capacity, with average waiting times of 18 months from referral to treatment. Funding for 1997 was £35 billion; for 2010 it is £110 billion, and waiting times are now as short as they've ever been — 10 years ago, patients waited approximately 18 months for treatment, and now they wait only a few weeks. Although both the causes of and responses to reform were very different from those in the United States today, the NHS's experience can provide some valuable lessons.

A key insight to be gained from the post-1997 NHS "revolution" is that it is important for clinicians to be involved in both informing and leading change. Successive attempts at top-down regulation and reform in Britain damaged clinicians' morale and bred distrust between them and politicians. Not having been central to the decision making, clinicians subsequently didn't trust the proposals or fully understand their purpose.

Last year saw the publication of the report High Quality Care for All, of which I, as a health minister, was lead author. Based on the findings of the Next Stage Review conducted by 2000 clinicians from all fields of care, it redefined the NHS, setting out a bold 10-year vision rooted in evidence of what matters to patients, the public, and NHS staff members. It established the mission of providing high-quality care — driven by clinical leadership, best evidence, and innovation — as the organizing principle of the service and has put the NHS firmly on the path toward systemic improvement in outcomes and efficiency.

Similarly, placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be the ambition of any new structure in the United States. Such an approach will lead to a health care system that has a democratic mandate and clinical leadership.

U.S. clinicians should bear three things in mind as they consider how to approach this debate. First, politicians must be made to recognize the role of clinical leaders in shaping a transformed but effective health care system. If clinicians can redefine the debate so that it focuses first and foremost on patients and health outcomes, that will provide a strong common purpose for efforts to tackle the challenges of funding structures and access to care.

Second, clinicians need to be involved in defining the link between funding and the care provided. It is for the patients at greatest risk that the U.S. system has the greatest difficulty providing access. The United States needs to find a model that best meets its needs while also being socially acceptable. Clinicians will have to find a brave voice if funding structures are to be reviewed in a way that puts quality of care before financial gain.

Finally, clinicians must educate both policymakers and the wider public about appropriate levels of care. Health care systems all suffer from a disproportionately heavy focus on the treatment of acute illness and injury — the type of medical work glamorized on television — which consumes by far the most resources. But primary care accounts for most of the health care that is delivered: nearly a billion visits are made to physicians' offices every year in the United States, but there are fewer than 40 million hospital stays. The current system of insurance and referrals can often lead to the unintended consequence of unnecessary referrals for the most expensive tests and treatments. Health problems related to lifestyle, such as obesity, smoking, and diabetes will be solved not by high-tech robotics and bigger hospitals but rather through access to family doctors, innovations in public health, and lessons from the emerging discipline of behavioral economics.

The best outcomes can be achieved only when the system itself is healthy and built on real partnerships between patients and clinicians. Britain's experiences to date, both good and bad, have proved this to be true. Building a health care system centered on clinical professionalism and responsibility is the only way to achieve such partnerships and to ensure that all patients are well served.

Beveridge's characterization of revolutionary moments echoes in our ears today as the NHS goes through a period of radical reform. And as the United States, for its part, does what it does best — summoning up its revolutionary spirit — clinicians should step up and shape the debate, not wait to be handed a possibly misguided reform as a fait accompli.

No potential conflict of interest relevant to this article was reported.


Source Information

From the Health Ministry, U.K. Department of Health, and Imperial College — both in London.

Who are the uninsured????