Eye-Opening Perspectives for Heroic Hearts

Eye-Opening Perspectives for Heroic Hearts

Monday, January 24, 2011

Hot Spotting Atul Gawande's Healthcare Conundrums

Anlibbe Dugamadanga Follows Atul Gawande's Assessment of America's Healthcare Dilemma

by Winsip Custer CPW News Service

Benny Marx was the 109 year old Chicagoan who loved the short-lived Chicagoan Magazine.   It was published from 1926 to 1935. Marx and others were working to see it resurrected before he died. Marx was hoping to put a spotlight not only on the Big Apple, but on The New Yorker's healthcare super sleuth, Atul Gawande.

The first edition of Marx's resurrected The Chicagoan Magazine, was to have come out in May with an article titled "Hot Spotting the Conundrums of Atul Gawande" by Anlibbe Dugamadanga. Sadly, Mr. Marx passed away on January 20th at his home on the South Side. Marx had taken under his wing Dr. Dugamadanga, a health science stasticisian trained at the University of Lahore, India. Dugamadanga had shadowed Dr. Gawande's studies in New Jersey and Texas and was set to unveil his findings in The Chicagoan's first edition in over eighty years.

"Mr. Gorbachev, 'tear down this wall' is the mantra of all red-blooded conservative American capitalists who looked to Ronald Reagan as Conservatism's standard bearer," begins Dr. Dugamadanga's penetrating analysis.

"The wall of American socialism around the healthcare industry has not only not fallen, but it has provided protection for a new breed of entrepreneurial physicians who see poor patients as profit centers and external payers as unrestricted resources for their own enrichment," or so Dugamadanga asserts. "When Dr. Gawande tried to make comparisons between the high cost of healthcare in Miami, Florida and McAllen, Texas he failed to first ask 'what are the similarities between these two states during the time period under study following the 2000 census?' It was those census figures that proved so important. They showed the connections, but not the reasons. The reasons are illusive, like why California had rolling brown outs or why Enron fell, or why the Housing bubble burst or the S&L scandal brewed before that. Or why Columbia Healthcare folded and morphed back into Hospital Corporation of America (HCA) which Columbia had purchased from Tennessee Senator Thomas Frist and his father with the help of George W. Bush's partner in the Texas baseball franchise, Richard Rainwater. Follow the money through the states from the money mill of Washington D.C. and you will see the octopus. Columbia had the largest Medicare fraud fine in U.S. history and provided a Pitre dish for understanding corporate healthcare malfeasence by unspoken business policy, corporate culture and design," reasons Dugamadanga.

"While Gawande's census numbers and Medicare and other demographic figures are very important, they did not show the cultural climate that exists in these two states with the leading profit centers for Medicare payments that are 100% higher in Miami, Florida and McAllen, Texas than the national average. Gawande, like all scientists, knows that what Albert Einstein said is true... "Not everything that counts can be counted and not everything that can be counted counts." But then Gawande's articles avoid drawing the cold, hard conclusions that Dugamadanga paints with the artistic skill of Picasso and scientific objectivism of Jonas Salk working on his first polio vaccine.

Photo from Anlibbe Dugamadanga's first article which was
scheduled for first edition of the new
Chicagoan Magazine.
Dugamadanga credits Gawande with rightly observing that one can't say that the higher costs in these two Southern cities are because of the retirees in McAllen who are also called 'Winter Texans' nor because of elderly New Yorkers or Philadephians or Bostonians in Miami that skew the numbers there. Medicare payments are always traced to their permanent home addresses. The two states have one other overarching similarity. They have been the home states of George W. Bush and his brother, Jeb," wrote Dr. Dugamadanga.

Atul Gawande's 2009 New Yorker Magazine article, "The Cost Conundrum", shined a bright light on Hidalgo County, Texas where the nation's lowest per capita income meets the highest dollar per Medicare patient per capita. Hidalgo County's average $12,000 annual income receives approximately $15,000 in per capita of Medicare coverage. Twice the national average. The reason? The ordering of unnecessary procedures and medications. When Gawande was told by some of the region's physicians and hospital administrators that the numbers were because of the litigious nature of the South Texas culture, Gawande reminded the keepers of the local history and myth that Texas had passed tort reform that limited malpractice cases to $250,000. This should have had the exact opposite effect as the reason Gawande was being given. Texas was less litigious, not more.  Physicians could not blame the higher costs on higher malpractice insurance cost.

Gawande writes in "The Hot Spotters".....his latest New Yorker article which follows Jeffrey Brenner who has assessed healthcare costs in Camden, NJ.  He quotes Brenner....
"In the next fews years, we're going to have absolutely irrefutable evidence that there are ways to reduce health-care costs, and they are 'high touch' and they are at the level of care," he said. 'We are going to know that, hands down, this is possible.' From that point onward, he said, 'it's a political problem.' The struggle will be to survive the obstruction of lobbies, and the partisan tendency to view success as victory for the other side."

"Meanwhile," said Dugamadanga, "the Republican Congress will push for smaller government and private sector answers to the problem. They will be correct in the case of Miami and McAllen, because that will remove the artificial wall created by the physicians and politicians. Their protectionism works to create and sustain physician entrepreneurial practices which deliver a poor patient base that serves as guinea pigs for their profit-based, inflated, Medicare-paid procedures and testing. In the end the Republicans in Texas and Florida will fight tooth and toenail to keep Medicare while Dr. Gawande's backers in Boston, whoever they are, will have their own reasons for blowing the whistle on Miami and McAllen. It's a gold mine for them like wars are for KBR and Halliburton...and they are protected by the politicians whose pockets are lined by the lobbyists," said Dugamadanga.

"When Gawande visited McAllen and reported that the problems in the McAllen area started before the building of the new physician-owned Renaissance Hospital, Gawande said that this was some kind of proof that the Renaissance physicians were not part of the problem. Gawande should have asked about the cultural climate leading up to that point rather than the time-line itself and this takes great intuitive abilities that verge on psychic-artistic sensibilitues and a retinue of sleuths like Gawande all working together to get to the truth of it. Even then we are not without our own non-impartial motivations. The physicians followed their own culture to the next logical conclusion and said 'Let's own this gold mine ourselves'," said Dugamadanga. "But I don't think one could be totally sure of who really owns these enterprises. The physicians may own the hospitals, but they may have agreements with others that never show up in the state incorporation records," said Dugamadanga.  "In fact, such associations are essential for the enterprise to carry on as it does."

Gawande writes in "The Cost Conundrum Redux" in the June 2009 New Yorker Magazine "What about McAllen's
Many 'Winter Texans'---retirees who live elsewhere, but come for the warm weather in the winter and inflate local
costs of care?  But in the Dartmouth Atlas, the Medicare costs for an enrolee are counted against their permanent
place of residence.  The cost of these 'snowbirds' are excluded for McAllen."

"Both Miami and McAllen have something else in common. They are largely Hispanic. They are Hispanic areas that have been largely supportive of Bush family initiatives in Mexico, South and Central America. That is to say, they are Bush-backers, as we have seen with an increasing number of Hispanic Republicans in Texas and Florida. Whether it was the ex-patriot Cuban community in Miami supporting Operation Zapata, also known as the Bay of Pigs, or the South Texas Hispanic community supporting GWB in Texas, the cultural climate has been ripe for the picking of Medicare fruit. You could say that it's a case of a few bad apples, but that would be to miss it by a few million miles. We are talking about sea-beds of apple sauce here," said Dugamadanga.

Dugamadanga described to me what he thought was happening with the rise of Harvard's Dr. Gawande as a Boston-based authority on health-care costs. The new Chicagoan article read..."I don't have to tell you, Mr. Marx, that Boston and Harvard are Kennedy strongholds as is Chicago with its huge Irish Catholic population. When your beloved Chicagoan Magazine was in full swing with the support of Martin J. Quiqley, an Irish Catholic, in the 1920's....the roaring twenties....it was the talk of the town. Then came the Great Depression and flushed away The Chicagoan like it did the U.S. economy. Quigley, who was also a Hollywood insider had been inspired years earlier by D.W. Griffith's film Birth of A Nation that fueled the resurgence of the KKK in America. It's a tangled mess with many seeking a piece of the financial pie with a variety of motives...none of which have much to do with shared values, patriotism, or medicines' Hippocratic oath, though it is obviously filled with hypocrisy." said Dugamadanga. "Doctors are not angels," he concluded. "There aren't any angels, only human beings trying to decide what is right and what is wrong....or maybe not. That part of humanity's education and instruction is best left to religion, I think, but religion is in a state of crisis, too, and that is sad, because in this milieu of seeking the deep pockets of profitability in difficult times it is easy to lose one's soul," he said.

"That is something that the guru of free-market capitalism, Milton Friedman, often avoided talking about, though Martin J. Quigley sometimes did in your Chicagoan Magazine, just as Gawande is doing now in The New Yorker, but we are made in such a way that we cannot avoid talking about it. We are now and have always been in the place where if we throw out this element of the human soul and psyche we lose the leaven in the loaf and and salt in the stew. We Indians know from Ghandi the importance of salt.  Even these fat-cat physicians in Miami and McAllen know at some level that even a steady diet of lobster will eventually taste like a bar of Ivory soap. And I know whereof I speak, because the temptation for all minorities, like myself, is to justify our greed by saying that we are supplying the world with a good example of a blessed ambition among our kind. There is some truth in that idea, but there is also a half-truth."

For University of Chicago's Nobel Laureate, Milton Friedman's discussion of greed see....

For Princeton's Nobel Prize winner John Nash's take on  Milton Friedman's restatement of Adam Smith's ideas on pursuit of individual ambitions see

For Atul Gawande's take on the state of healthcare in the U.S. as discussed with Charlie Rose see

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