Monday, February 1, 2010


Dear Dr. Gawande:

I am a former Chief Justice of Michigan, and founder of the nation's largest accredited school of law, The Thomas M. Cooley Law School with four campuses in Michigan.

After writing a blog about health care, [] I got a note from a friend referring me to your excellent article about McAllen, Texas in the June 1, 2009 issue of the New Yorker magazine.

One paragraph stood out, and prompted this email:

The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: "They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?" He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? "I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U."—that sort of thing? Dyke shook his head. "Who comes up with this stuff?" he asked. "Any plan that relies on the sheep to negotiate with the wolves is doomed to failure."

Ridicule, of course is a powerful form of polemic, but the assumption that discussion about the cost of an operation would take the form of haggling only reveals the profit-making mind set of the doctor you were talking to.

A more reasonable and accurate assumption would be this: They discuss the blockages, operation, risks AND COST of the operation. The patient says she can't afford it. The doctor says he will send her a bill and if she can't pay it, he will sell the account to Medi-Fex, a government agency created to assure that all Americans have affordable health care. She asks him what the government will do to her and he hands her a brochure which describes the way Medi-Fex works.

If she has no money, obviously she won't go to debtor's prison. If she has some money and can afford to pay something, Medi-Fex would set up a payment plan. If she wins a lottery or inherits a fortune, it will ask for full payment of the bill.

Here's a reality check. The elderly woman has a $150,000 home, free and clear, and $95,000 in a savings account. She plans to leave it all to her daughter. If Medi-Fex will make a claim against her estate for the cost of the operation, she may decline the surgery. Her daughter may urge her to do so, or may insist that she have the operation. Or, as happens too often these days, she may transfer all her assets before the operation. There is no system which people will not seek to beat, if there is money involved.

The point is that 'affordable' is a subjective standard, which can only be determined on a case by case basis. What is important here is that the legal and moral obligation to pay for the medical service needs to rest with the recipient.

It doesn't take a degree in economics to realize that when you separate the duty to pay for a benefit from the right to receive the benefit, the demand and hence the cost will escalate.

Consumer reticence results in cost containment in a free market. We're not using it.

Thomas E. Brennan

NOTE: A surgeon and a writer, Atul Gawande is a staff member of Brigham and Women’s Hospital, the Dana Farber Cancer Institute, and the New Yorker magazine. He received his B.A.S. from Stanford University, M.A. (in politics, philosophy, and economics) from Oxford University, M.D. from Harvard Medical School, and M.P.H. from the Harvard School of Public Health. He served as a senior health policy advisor in the Clinton presidential campaign and White House from 1992 to 1993. Since 1998, he has been a staff writer for the New Yorker magazine. In 2003, he completed his surgical residency at Brigham and Women’s Hospital, Boston, and joined the faculty as a general and endocrine surgeon.

He is also Associate Professor of Surgery at Harvard Medical School, Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health, and Research Director for the BWH Center for Surgery and Public Health. He has published research studies in areas ranging from surgical technique, to US military care for the wounded, to error and performance in medicine. He is the director of the World Health Organization’s Global Challenge for Safer Surgical Care.

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