Culture, Not Who Pays, Is Real Problem in Healthcare

The New York Times columnist David Brooks just came out with his Sidney Awards for the best magazine essays in 2009.  I always read them because Brooks is among the very best writers/thinkers in journalism today.  One of the award winners is “The Cost Conundrum” by Atul Gwande, the surgeon, author and MacArthur genius award recipient.  Brooks describes Gwande’s essay as the most influential essay written this year.  I highly recommend that you take the time to read it.

What I found especially interesting in Gwande’s essay is that he concludes that culture — or more specifically, the values of doctors — is at the heart of America’s heathcare cost crisis rather than who pays the costs.  Gwande takes us to McAllen, Texas where in 2006, Medicare spent nearly $15,000 per enrollee, twice the national average, but achieved no better than average quality of care.  Like a good investigative reporter he roots out the truth by conducting qualitative interviews and looking into quantitative data.  He discovers that the average doctor in McAllen orders more procedures than the average doctor in America.  Upon further investigation he learns that in towns like McAllen it’s a handful of doctors who drive up the cost per patient by ordering unnecessary procedures. He explains how these doctors benefit financially from ordering unnecessary procedures. The financial benefits come in the form kickbacks to admit patients to hospitals and revenue to partnerships of physicians who own diagnostic equipment such as MRI and CT-scans.  He sums it up this way:

“When you look across the spectrum from Grand Junction to McAllen–and the almost threefold difference in the cost of care–you come to realize that we are witnessing a battle for the soul of American medicine.  Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor.  And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.”

In some ways, this is a matter of identity. Does a doctor think of him or herself primarily as a physician whose calling is to heal or as a businessman or woman whose calling is to maximize profit?  And, of course, there are points all along the continuum because doctors need to be both healers and businesspeople.   The doctor who doesn’t pay attention to the business may not generate sufficient income to survive.  The doctor who always games the system to maximize profit will eventually destroy the system.

Another issue to consider that Gwande doesn’t go in to is that a doctor’s character affects supporting healthcare workers.  I have seen how patient-oriented cultures get a huge positive lift in performance (in terms of patient outcomes and cost) from their highly engaged employees. In part, this is due to the fact that many people who are attracted to medicine have altruistic values.  Working in a culture that is consistent with their altruistic, caring values energizes them whereas working in a revenue-maximizing cultures has a negative impact on their energy, the discretionary effort they exert, and eventually burns them out.

Another point that should be considered is that the differences in culture tend to be local in nature.  Some workgroups, practices, hospitals are more patient care-centric than others.  You may find one practice of doctors that is patient-centric and walk across the street to a “concierge” practice that is revenue maximization-oriented.  That’s where the battle must be fought.  Ultimately, it’s an issue of leadership, and the identity and character values of doctors.   Changing identity and character is something I address in the Connection Culture Manifesto and in  Fired Up or Burned Out.  From a system’s standpoint, an area I think government should focus on, we should establish checks and balances such as making sure every patient has to pay some reasonable cost for healthcare and has access to cost and quality of care data.  There is much wisdom in the words of U.S. Supreme Court Justice Louis Brandeis who once wrote that “sunlight is the best disinfectant.”

I hope you’ll read “The Cost Conundrum.”  Another Sidney Award winner that addresses the topic of healthcare and is worth reading is David Godhill’s essay entitled “How American Healthcare Killed My Father” that appeared in The Atlantic.

In future posts, I’ll be writing more about the topics of culture, leadership and employee engagement in health care.


Michael Lee Stallard speaks, teaches and writes about leadership, employee engagement, productivity and innovation at leading organizations including Google, GE, NASA, Lockheed Martin, General Dynamics and the Darden Graduate School of Business at the University of Virginia. Most recently, Michael and his colleague Jason Pankau filmed a 90-minute program for Linkage’s Thought Leaders Series that will be released in January of 2010. Michael wrote the guest editorial for Talent Management magazine’s January 2010 edition and last month his article on how the force of connection boosts productivity and innovation was featured as the lead article in the UK’s Developing HR Strategy Journal. Click on these links to learn more about Michael and Jason in the media and their speaking engagements.

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