This article by Atul Gawande in the New Yorker is the single best thing I have read on how we should do healthcare. He makes a very strong case that it is not ultimately who pays (private or public insurance) that matters: it’s whether the delivery of health services is coordinated for the good of the patient, and with accountability. It’s actually about putting the care back into healthcare: in detail, with examples.

Gawande compares the most expensive city for healthcare in the country (McAllen, Texas) with places that give equally good or better care at half or even a third the cost. The most distressing angle in the story is the degree to which doctors have identified maximizing their own income as a primary goal, and the discovery that this culture only really took off in McAllen 15 years ago. The best parts are the descriptions of locations where doctors have got together to make sure that it is the patients who benefit, as in Grand Junction, CO. It is clear that an ethic of care shared by the medical providers in an area is the critical factor that both reduces healthcare costs and improves outcomes.

In McAllen the government is already the biggest payer for healthcare. But a great of deal of the “care” is care for the doctors’ incomes not the patients’ health. In Grand Junction the doctors got together and agreed on a system that evens out fees from different payers (private insurance or government) and shares information about patients. At the Mayo clinic all the docs are on salary, so they don’t personally benefit from providing more operations or tests: the docs are paid as a team to provide the best results for patients.

I am a supporter of single payer, because it seems much the most rational way to go, but how to find the most caring way to go is actually another whole issue. It’s a mistake to focus healthcare reform entirely on single payer, rather than on the quality of care and on the creation of a culture among health care professionals that prioritizes providing care over increasing incomes. Gawande has great examples about how that has been done locally and so could be done nationwide.

I found it fascinating that another article in that New Yorker on the psychology of the banking sector quoted Richard Posner saying that Greed had not been the problem. Posner is one of the most prominent conservatives to admit that deregulation of the economy went way too far. But he doesn’t like the idea of tagging the mice who played while the cat was away with the Greed word. “Greed” seems such a big slavering ghastly description of someone that I can see how people avoid using it. Does “Greed” with a capital G adequately describe the profit-maximizing docs in McAllen? No: they are concerned about their patients, they deliver very fine medical services, they take pride in their work. But compared to the way the Mayo Clinic or Grand Junction docs operate it becomes clear that concern for the patient is not as strong, and concern for their own profit is much stronger. A culture of profitmaking can overwhelm a culture of service: it’s happening all over, and it’s no wonder that banking and medicine are becoming dysfuntional: both should be ways to serve the people, not to make you much richer than other people. But it takes a good description of a Grand Junction system to see just how greed has made a McAllen system cost three times as much, and it would take a good descritpion of service-oriented banking to show just how greedy our bankers have become.