The paper "The Cost Conundrum by Atul Gawande" is a delightful example of an article on nursing. The article by Atul Gawande (2009) published in the New Yorker raises fundamental issues about the way American citizens receive their health care from their local hospitals and doctors. It has already been demonstrated that there are some differences in the allocation of resources according to the racial and ethnic neighborhood that people live in (Nelson, 2002) and there are ongoing debates about how to reform health services in order to eliminate this kind of unfairness. Some scholars suggest that the system has drifted out of control: “Through no planned design or evil intent, our health care system has evolved in ways that better serve a myriad of economic, professional, and political interests than those of patients and families, and the larger public” (Mechanic, 2006, p. ix). Gawande, however, sees a much bleaker picture and suggests that there are areas in America where doctors and administrators are financially tied into the provision and that this encourages massive amounts of over-treatment, with no benefit to patients.
Gawande’s article describes a huge discrepancy in the per capita costs of medical care in two comparable districts, McAllen and El Paso, Texas, while there is no evidence that the higher cost location (McAllen) offers better care or achieves better results. This gives rise to a serious ethical problem: in El Paso patients have much lower rates of access to all kinds of tests and treatments, while in McAllen, they have much higher rates. The variation is due to doctor behavior, and not down to the demographics of the citizens since the two regions are very similar. This is the kind of situation that led to the passing of the 2010 Health Care Reform bill which aims to extend health coverage to from 83% to 95% of the legally resident population. (Tumulty, 2010, p. 1) Unfortunately, however, huge variation in the way that this money is spent will mean that a fair and equal service is not likely to happen.
From the point of view of justice or fairness, such unequal practices cannot be defended, since all American citizens should have equal access to the benefits of our modern technologies.
From a utilitarian point of view, there is a deviation from best practice, since in the McAllen hospitals there is little effort to gain the greatest benefit to patients for the lowest cost. Increasing the amount of testing in order to maximize revenue is the very opposite of ethical behavior on the part of institutions where doctors earn more for ordering more procedures and tests.
Gawande suggests that the problem lies with the structures of delivery, and describes the McAllen healthcare model as “as a system that has no brakes” (Gawande, p. 14). He cites the example of the Mayo Clinic, where doctors receive a fixed salary, as a potential solution. Fewer scans are done, and more discussion between doctors takes place to minimize unnecessary treatments, all of which come with risks as well as benefits, and to try to ensure that patients have what they need, rather than what can be sold to them for profit. There is little incentive to cherry-pick patients in this kind of system, and hospitals which follow this style find that overall costs are lower, and quality of care goes up.
This analysis takes a refreshing look at the way the whole system is set up, and this gives the reader an overview of things rather than just the view of an economist, or a health professional, or an administrator. It highlights the error that patients, and some doctors, often make, in thinking that more testing is always good. The point is to do what is best for the patient, and not what sustains the system. If there was more of this kind of benchmarking across hospitals with comparable patient characteristics, then perhaps more could be done to eliminate wasteful use of resources and concentrate attention on those patients who really need the most care.
The process of analyzing this issue reminds health professionals of the need to observe protocols that separate financial issues from the question of patient need. It is important to question the systems we work in and to contribute to a continuous improvement of efficiency as well as effectiveness so that resources can be distributed as widely and fairly as possible.