Important follow up to the Cost Conundrum in 2009, Atul Gawande’s Overkill has enormous relevance for the SA private healthcare sector which shares these issues and needs similar solutions.

The crux is the overall well-being that patients value (‘patient centered care’) gets lost under a tidal wave of services, many not needed or even harmful.  The anxieties, structures and incentives that cause this is well explored. The successful reform stories with better quality, less costs and improved doctors working lives, all rely on integrated teamwork and outcome measures and are very straight forward. Financial rewards must fund value for populations, not services for individuals.

Points from the article:

In his opening, Gawande says “unnecessary medical care is harming patients physically and financially.”  The answer to how to change that is illuminating…..

He attributes the plethora of low value care investigations and services to a few factors:

Firstly, clinicians are made overcautious by their harassed working conditions and uncertain follow up.  This might possibly mean missing a serious problem. Because doctors in SA typically work alone and without a structured patient care safety net, this is commonplace here too.

Another is that specialists have narrow measures of success for the interventions they provide, rather than the overall quality of life measure that is sought by their patients. They underestimate the evidence of limited gains and the high risk of problems. Generalists are far less likely to do this.

Finally, he quotes the seminal Rand study by Arrow that demonstrated financial gains by clinicians and the asymmetry of information with their patients inevitably leads to clinician income needs being a factor. I would add that conservative decisions are made even less likely where reimbursement rates are low and there are relatively too few Scheme funded patients, so that it is hard for every clinician to earn a reasonable income. Excessive testing and treatments causes’ harm, drives up costs and produces little improvement in overall outcomes.

Gawande points the way to improvement by reference to a Walmart programme in that nominates the best integrated care healthcare systems – Virginian Mason; Cleveland Clinic; Mayo etc – for their employees. The biggest savings they produce is from avoiding procedures that should not be done.

Finally, he returns to McAllen County in Texas, the subject of the Cost Conundrum, and finds an integrated primary care lead miracle. His original article highlighted that clinicians in that county just did more of everything. Subsequently, the article caused much local embarrassment and debate and lead to the successful entry of a medical group with a long experience of integrated primary care for geriatric patients in a ‘value contract’ with Medicare (for over 65 year olds); and the initiation of two Accountable Care Organisations funded by new Obamacare stipulations.

Admission and death rates are now significantly down, $1/2 billion dollars saved, and clinician’s work lives are more satisfying.

Can we do that here in SA?  

Read the full article here