A "HealthTweep" Pulse Check

Exploring transformational potential of social media

Mayo v. McAllen – The Battle for the Soul of American Medicine?

with 15 comments

In a June article in the NewYorker, surgeon and writer, Atul Gawande brought life to the landmark ‘small area analysis’ work of team Darmouth, i.e., Wennberg, Fisher, et al. The Darmouth crew has been studying and documenting the widespread and unjustifiable variations of medical practice patterns by US geographic regions for quite some time.

Gawande’s genius insight was to put a timely face on this ‘value proposition inequity’, by comparing Medicare’s practice patterns and cost profiles from two demographically comparable Texas communities – El Paso and McAllen.

For historical context, this inexplicable and unjustifiable range of practice variance including cost profiles, is not news. I recall circa the 1986 timeframe when Deak Wooten, the then Director of Blue Cross of California’s ‘Prudent Buyer’ plan (an innovative PPO), under the stewardship of Leonard Schaeffer (pre Wellpoint roll-up, or better yet ‘Mashup’ of healthplans), presented the concept of ‘small area analysis’, stressing the need to minimize variation both as a quality enhancing as well as cost savings ‘management initiative’. Yet, here we are today, some 20 plus years later, and the concept is only making its way into the American psyche as a result of the intense national debate we are witnessing relative to US health reform initiatives.

While Gawande brings the issue to main street, the bigger and perhaps more strategic question is nested in his narrative on ‘who will ascend to “anchor model” status in US medicine’, Mayo or McAllen? Few in the popular press or even healthcare sector seem to focus on the profound implications of even calling the question!

Worse yet, Gawande cautions:

Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing.”

This strikes me as an urgent call to action. Especially when considering, when Gawande refers to “Mayo”, he’s referring to that class of medicine as represented by Geisinger, Kaiser, Cleveland Clinic, Intermountain Health, and other group practice cultures that have spawned progressive integrated delivery system (IDS) network models; where ‘integrated’ means merging both direct care & financing platforms.

If the “Mayo’s” of the world fail, then there is no hope for a public/private market solution to the chronic ‘whack a mole’ phenomenon of US health care. The government will step in and put the private sector out of it’s collective misery – not a picture I favor!

Written by 2healthguru

July 13, 2009 at 1:59 PM

15 Responses

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  1. […] 3+ decades and often can’t understand the nature of the beast we’ve created. The ‘healthcare conundrum‘ so aptly tagged by Atul Gawande quite some time ago is a complex and unwieldy beast I have […]

  2. […] received little if any attention and/or discussion, yet it goes to the fundamentals of our ‘healthcare cost conundrum‘. Might it’s reception be different today? Are we really ready to tackle the issues, or […]

  3. […] For more context on the nature of that ‘grip’ and it’s persistent hold see: Mayo v. McAllen – The Battle for the Soul of American Medicine? […]

  4. […] Since he authored ‘The [healthcare] Cost Conundrum‘ piece some three years ago, positing the question of who will emerge as the ‘anchor tenant’ business model in healthcare, I’ve been ‘waving’ at Atul Gawande via social media including Twitter and blog. […]

  5. […] Since he authored ‘The [healthcare] Cost Conundrum‘ piece some three years ago, positing the question as who will be the ‘anchor tenant’ business model in healthcare, I’ve been ‘waving’ at Atul Gawande via Twitter and blog. […]

  6. […] this desperation metaphor to our rather creatively change resistent healthcare industry, aka ‘healthcare conundrum‘, given decades of serial failure [or success depending upon your interest]. Yet, with Dr. […]

  7. […] If social media is to create ‘real value’, then it must be able to tame the beast aka ‘the healthcare borg’ or ‘conundrum‘ that passes for the American healthcare system […]

  8. Hi. I’m Deak Wooten, several jobs and many years later. I’m amazed you remembered me from the mid 80s!

    Deak Wooten

    March 19, 2011 at 11:35 AM

    • Hi Deak!

      Of course I remember you, Gertner, et al. It was the beginning of the run no? Where are you these days? I am publishing ACOWatch.com to track the rollout of ACOs. Here we go again?

      2healthguru

      March 19, 2011 at 3:44 PM

  9. […] landmark piece ‘The  Cost Conundrum‘ and the selective emergence of the ‘Mayo v. Mc Allen‘ mantra, I’ve been tweeting of late on the ‘irony’ of certain Texas health […]

  10. […] sure care is done right.  It’s already happening at some medical centers, but it’s not the norm.  It should […]

  11. Gregg,

    You know I agree with this formulation! Well-said.

    And Dr. Onyeije, you’re right that there isn’t enough time to really educate the public on these issues, at least between now and the President’s deadline. It’s a pity, because this is a tremendously important subject and it’s getting lost in the machinery of politics.

    Evan

    Evan Falchuk

    July 14, 2009 at 11:49 AM

  12. I read Gawande as saying the payment system must change in order to incentivize Mayo-like behavior systemwide, not that Mayo is in danger. In the future, all players will have to change to accommodate new payment/incentive systems (VBP, P4P, global payments) if they’re rolled out as mandatory. The provider culture will change to accommodate new rules of the game, just as the existing culture grew up to maximize income under current rules. If new rules benefit patients and providers simultaneously (and that’s the idea …) then everybody wins. Mayo-watchers say that docs recruited into Mayo’s southern outposts took a year or so to get acclimated to the totally different environment … but those who stayed got acclimated and internalized the Mayo ethos. I’d expect the same to happen on a broader scale: lots of bitching and moaning, followed by settling into a new equilibrium that works better. For another peek at global payments at work, see today’s feature on Mt. Auburn in Cambridge, MA from WBUR’s CommonHealth blog: http://bit.ly/xxhmU .

    As you wrote, none of this is new. And I don’t really think that positive change will lead to massive system failure.

    David Harlow

    July 14, 2009 at 10:37 AM

  13. Way too of a compressed timeline to expect on-point and purposeful health system reform. No doubt we’ll be treated to more political theater, and a ‘best case’ claim to “look, we did something'; yet, no true re-engineering of a very complex industry can be fairly treated under the schedule of a compressed legislative time line.

    Yes, we’ll see. The good news is the visibility of the cause!

    2healthguru

    July 14, 2009 at 6:02 AM

  14. You are absolutely right when you frame this as a battle for the heart and soul of American medicine. The problem is that we in medicine and certainly the mainstream media DO NOT have an idiom to properly describe the phenomena which lead to “inexplicable and unjustifiable range of practice variance including cost profiles”. Most doctors and patients simply believe that “more is better”. Indeed, any talk of quality has to overcome this built in bias that any restriction of unnecessary and costly services is equivalent to “rationing” and is by its very nature not just bad, but evil.

    This is indeed a battle. I’m afraid that the August time limit set by the President will not allow enough time to educate the public and all other shareholders of the need to adopt a healthcare model similar to Mayo, Geisinger, Kaiser, Cleveland Clinic, Intermountain Health, and other group practice cultures.

    If there is not proper education regarding what is at stake I’m afraid the public will acquiesce to the purveyors of easy sound-bytes.

    As I always say. “We’ll see”.

    Thanks for the insightful post.

    Chukwuma Onyeije

    July 13, 2009 at 5:26 PM


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