Health Care Rationing Rhetoric Overlooks Reality By DAVID LEONHARDT

June 17, 2009
Economic Scene
Health Care Rationing Rhetoric Overlooks Reality By DAVID LEONHARDT
Rationing.

More to the point: Rationing!

As in: Wait, are you talking about rationing medical care? Access to medical care is a fundamental right. And rationing sounds like something out of the Soviet Union. Or at least Canada.

The r-word has become a rejoinder to anyone who says that this country must reduce its runaway health spending, especially anyone who favors cutting back on treatments that don’t have scientific evidence behind them. You can expect to hear a lot more about rationing as health care becomes the dominant issue in Washington this summer.

Today, I want to try to explain why the case against rationing isn’t really a substantive argument. It’s a clever set of buzzwords that tries to hide the fact that societies must make choices.

In truth, rationing is an inescapable part of economic life. It is the process of allocating scarce resources. Even in the United States, the richest society in human history, we are constantly rationing. We ration spots in good public high schools. We ration lakefront homes. We ration the best cuts of steak and wild-caught salmon.

Health care, I realize, seems as if it should be different. But it isn’t. Already, we cannot afford every form of medical care that we might like. So we ration.

We spend billions of dollars on operations, tests and drugs that haven’t been proved to make people healthier. Yet we have not spent the money to install computerized medical records — and we suffer more medical errors than many other countries.

We underpay primary care doctors, relative to specialists, and they keep us stewing in waiting rooms while they try to see as many patients as possible. We don’t reimburse different specialists for time spent collaborating with one another, and many hard-to-diagnose conditions go untreated. We don’t pay nurses to counsel people on how to improve their diets or remember to take their pills, and manageable cases of diabetes and heart disease become fatal.

“Just because there isn’t some government agency specifically telling you which treatments you can have based on cost-effectiveness,” as Dr. Mark McClellan, head of Medicare in the Bush administration, says, “that doesn’t mean you aren’t getting some treatments.”

Milton Friedman’s beloved line is a good way to frame the issue: There is no such thing as a free lunch. The choice isn’t between rationing and not rationing. It’s between rationing well and rationing badly. Given that the United States devotes far more of its economy to health care than other rich countries, and gets worse results by many measures, it’s hard to argue that we are now rationing very rationally.

On Wednesday, a bipartisan panel led by four former Senate majority leaders — Howard Baker, Tom Daschle, Bob Dole and George Mitchell — will release a solid proposal for health care reform. Among other things, it would call on the federal government to do more research on which treatments actually work. An “independent health care council” would also be established, charged with helping the government avoid unnecessary health costs. The Obama administration supports a similar approach.

And connecting the dots is easy enough. Armed with better information, Medicare could pay more for effective treatments — and no longer pay quite so much for health care that doesn’t make people healthier.

Mr. Baker, Mr. Daschle, Mr. Dole and Mr. Mitchell: I accuse you of rationing.

•

There are three main ways that the health care system already imposes rationing on us. The first is the most counterintuitive, because it doesn’t involve denying medical care. It involves denying just about everything else.

The rapid rise in medical costs has put many employers in a tough spot. They have had to pay much higher insurance premiums, which have increased their labor costs. To make up for these increases, many have given meager pay raises.

This tradeoff is often explicit during contract negotiations between a company and a labor union. For nonunionized workers, the tradeoff tends to be invisible. It happens behind closed doors in the human resources department. But it still happens.

Research by Katherine Baicker and Amitabh Chandra of Harvard has found that, on average, a 10 percent increase in health premiums leads to a 2.3 percent decline in inflation-adjusted pay. Victor Fuchs, a Stanford economist, and Ezekiel Emanuel, an oncologist now in the Obama administration, published an article in The Journal of the American Medical Association last year that nicely captured the tradeoff. When health costs have grown fastest over the last two decades, they wrote, wages have grown slowest, and vice versa.

So when middle-class families complain about being stretched thin, they’re really complaining about rationing. Our expensive, inefficient health care system is eating up money that could otherwise pay for a mortgage, a car, a vacation or college tuition.

The second kind of rationing involves the uninsured. The high cost of care means that some employers can’t afford to offer health insurance and still pay a competitive wage. Those high costs mean that individuals can’t buy insurance on their own.

The uninsured still receive some health care, obviously. But they get less care, and worse care, than they need. The Institute of Medicine has estimated that 18,000 people died in 2000 because they lacked insurance. By 2006, the number had risen to 22,000, according to the Urban Institute.

The final form of rationing is the one I described near the beginning of this column: the failure to provide certain types of care, even to people with health insurance. Doctors are generally not paid to do the blocking and tackling of medicine: collaboration, probing conversations with patients, small steps that avoid medical errors. Many doctors still do such things, out of professional pride. But the full medical system doesn’t do nearly enough.

That’s rationing — and it has real consequences.

In Australia, 81 percent of primary care doctors have set up a way for their patients to get after-hours care, according to the Commonwealth Fund. In the United States, only 40 percent have. Over all, the survival rates for many diseases in this country are no better than they are in countries that spend far less on health care. People here are less likely to have long-term survival after colorectal cancer, childhood leukemia or a kidney transplant than they are in Canada — that bastion of rationing.

None of this means that reducing health costs will be easy. The comparative-effectiveness research favored by the former Senate majority leaders and the White House has inspired opposition from some doctors, members of Congress and patient groups. Certainly, the critics are right to demand that the research be done carefully. It should examine different forms of a disease and, ideally, various subpopulations who have the disease. Just as important, scientists — not political appointees or Congress — should be in charge of the research.

But flat-out opposition to comparative effectiveness is, in the end, opposition to making good choices. And all the noise about rationing is not really a courageous stand against less medical care. It’s a utopian stand against better medical care.

So Many Flat-Panel TVs. Which Is Right for You? By ERIC A. TAUB

June 18, 2009
So Many Flat-Panel TVs. Which Is Right for You? By ERIC A. TAUB

Just a few years ago, consumers interested in purchasing an HDTV set had to ask themselves just one simple question: Do I have a spare $10,000?

Today, as prices for LCD and plasma HDTVs race to the bottom, flat panel TVs have approached commodity status; stand outside many big-box retailers and you’ll see waves of customers rolling TVs to their cars.

As a result, both well known and virtually unknown TV manufacturers are introducing new features and system tweaks intended to differentiate themselves from the competition and get consumers to buy.

Buying a flat panel TV today means figuring out what resolution you need, how well the set produces a wide contrast ratio, whether the sound system is adequate, whether you can connect the set to the Internet and — most importantly — how to separate important features from marketing gimmicks.

If you’re ready to buy a new TV, here’s a rundown of the latest marketing angles and some tips on how to make a decision.

PLASMA VS. LCD VS. LED While LCD TVs have captured the public’s imagination and the bulk of TV market share, plasma TV still has a leg up when it comes to perceived image sharpness, the richness of its blacks and, often, price. Smaller sets, those below 40 inches in size, are only available as LCD models. In larger sizes, 50 inches and up, plasma tends to be cheaper than LCD.

In an attempt to increase sales and profit, several manufacturers, including LG, Samsung and Toshiba, have introduced so-called LED TVs. There is no such thing as an LED TV; they are simply LCD TVs that use LEDs, rather than fluorescent lamps, to light the screen.

Depending on the type of LED configuration used, some LED-lit LCD TVs — those that use a so-called backlight array — create richer blacks than standard LCD TVs, approaching the level that plasma sets have already achieved. But beware: if you opt for an LED-lit LCD today, you will probably pay a hefty price premium compared with a standard set. The Toshiba Regza SV670, for example, is a 46-inch LED-backlit LCD. It has a suggested retail price of $2,300. A 46-inch plasma from Panasonic costs as little as $1,100.

DISPELLING MYTHS ABOUT PLASMA Early plasma sets were plagued with problems of image burn-in, high power consumption and a relatively short display life. But today’s sets have conquered those issues.

Plasma panels from Panasonic, for example, offer 100,000 hours of life before the image has dimmed to 50 percent of its original brightness. If you watch TV four hours a night, every day of the year, that milestone wouldn’t be reached for 68 years.

When it comes to picture quality, plasma TV remains the benchmark, generally achieving higher black levels (and hence higher perceived resolution), better motion rendition and better viewing angles than most LCD TVs.

“The best LCD sets are now approaching plasmas in their ability to display black levels,” said Jim Willcox, Consumer Reports’ senior electronics editor.

VIEWING ANGLE If you typically watch TV with family members on the floor, or have friends sprawled across the couch to watch the big game, LCD TVs, with their limited angle of view, may not be for you. As you move away from the center of the screen, LCD TVs tend to lose their contrast and color saturation.

“LCD viewing angles have gone from poor to good, but there are still a number of sets that are only fair,” said Mr. Willcox.

MOTION DETECTION LCD TVs have traditionally had more trouble displaying motion than plasma sets. If you generally watch sitcoms and news shows, that won’t be a problem. But if you’re into fast-moving sports you’ll want a set that won’t turn a slide into first base into a blurred mess.

Manufacturers have improved the way that LCD TVs handle motion by introducing sets that use 120 Hz technology; simply put, the set’s circuitry doubles the number of video frames, smoothing out the motion.

Some manufacturers have gone a step further, introducing 240 Hz TVs that quadruple the number of frames.

Can most people see the difference? Unless you’re buying a gigantic TV, probably not, according to executives at the top TV manufacturers. But it makes for a nice marketing strategy. Before you pay extra to buy a 240 Hz set, watch a favorite DVD on TVs that use that and the less-expensive 120 Hz technology, and see if you can tell the difference.

SCREEN RESOLUTION While 1080p TVs have become almost standard issue, if you’re on a tight budget you can still save money by buying a lower-resolution 720p or 1080i resolution set.

Whether you can see the difference in screen sharpness depends in part on how far you sit from the set. If you’re watching a 30-inch HDTV screen from 20 feet away, they’ll all look the same.

Various charts are available to show you how far you should sit from a particular size screen in order to maximize the perceived resolution.

THIN AND THINNER Today’s flat TVs have slimmed down, with some plasma and LCD sets not much more than an inch deep.

The thinner they are, the higher the price. And unless you’re planning on mounting the TV on the wall, thinner sets may give you bragging rights, but with their higher prices, they’ll also give you a thinner wallet.

Also, the thinner the set, the more difficult it is to get decent sound out of the speakers that generally need to face downward to conserve space. “Downward facing speakers do not work well,” said Gary Merson, owner of HDGuru.com. “They sound as if you’re speaking to someone while facing away from them.”

ARE YOU WELL-CONNECTED? Modern HDTVs, as well as the additional audio and video components you’ll join to them, use HDMI cables as the standard connection method. Unlike other cables, HDMI combines audio and video; Blu-ray signals will only pass through an HDMI plug.

Before you decide on your purchase, figure out how many HDMI inputs you’ll need on the TV. If you plan on connecting a Blu-ray or DVD player, an audio receiver, a digital video recorder and a video game console, that could be as many as four. Some manufacturers offer a side-mounted HDMI input, handy for the occasional times you want to plug in a digital video camcorder.

SURF’S UP Many new HDTVs from most manufacturers, including LG, Panasonic, Samsung, Sharp and Vizio, offer proprietary Web-based content, like news, weather, YouTube videos, the Picasa photo site and access to certain movies and TV shows from Netflix and Amazon’s online download services.

To receive it, you’ll need an HDTV that has an Ethernet connection. New models are beginning to appear that offer wireless connections, perfect for those whose Ethernet access is in another room.

Even if you’re not interested in accessing Web-based content on your TV, an Ethernet connection can prove useful when a manufacturer needs to upgrade the digital TV’s operating system to, for example, address incompatibilities between it and a set-top box.

Some day, manufacturers will be able to use your TV’s Internet connection to remotely diagnose any problems with the set.

Technicians from the electronics maker Sharp can already remotely adjust picture quality over the Internet.

Shock Waves Posted By Bethany Vaccaro On June 1, 2009 @ 2:46 pm In Article, Cover Story, Summer 2009 | Comments Disabled

Shock Waves
Posted By Bethany Vaccaro On June 1, 2009 @ 2:46 pm In Article, Cover Story, Summer 2009 | Comments Disabled

Going to war brings with it the very real possibility of dying. When my brother Robert left for Iraq in September 2006, our family feared that his commitment might demand what is often called the highest price. Before he left, I imagined what it might be like as the sister of a dead soldier to tell everyone that he had laid down his life in such a contentious struggle. I pictured the flag-draped coffin, the article in our local newspaper, the murmuring friends and neighbors filing through to praise the dead hero. Always a realist, I prepared myself for his death as the worst possible outcome. I failed to conceive of any scenario that could rival the bitter finality of his dying.

I soon discovered that giving one’s life can come in more than one form. For my brother, his life as he knew it was taken on January 14, 2007, in Baghdad, when an EFP—an explosively formed projectile device—detonated outside his Army Humvee, sending a shock wave through his brain, severely injuring him without leaving a mark on his body. Robert escaped death, but has paid a price almost as high. Today, he is back from war, 25 years old, brain-injured, and disabled. My brother accepted this risk when he signed his military contract in 2002 through the ROTC program at the University of Rhode Island. Although my family didn’t sign an agreement or contract, we have discovered that we are as bound to his commitment as he is himself. Before my brother’s injury, the phrase traumatic brain injury, or TBI, meant very little to my family. Now it defines our daily existence. The ongoing process of rehabilitation since his injury has tenaciously enmeshed each one of us, altering our plans, our family structure and interactions, our ideas about life and sacrifice, and most resolutely our belief that if he would only make it back home, everything would be okay.

My brother’s injury occurred in the early hours of the morning in Baghdad, as his platoon was finishing a 10-hour shift of route clearing. He was a mechanical engineer and a second lieutenant, in charge of 25 men. Their assignment was to find and dismantle or detonate IEDs (improvised explosive devices) and other explosives that litter the roadways in Iraq. His convoy was nearing an Iraqi checkpoint when his vehicle, the third in line, was targeted by an EFP. The explosion catapulted the vehicle into the side of a building. The force of it blew a hole in the side of the armored Humvee, sending a chunk of metal into the driver’s head, killing him almost instantly. My brother was in the passenger seat, and it was the force of the explosion rather than metal that penetrated his head.

After he was wounded, Robert’s brain began to swell and the pressure inside his skull skyrocketed. He was taken into surgery as quickly as possible, where a large part of the skull on the right side of his head was removed to allow his brain to expand unencumbered. The pressure continued to rise, and a second surgery to remove even more of the skull was necessary before he left Iraq. It was almost a week before he was stable enough to be moved to the Landstuhl Regional Medical Center in Germany. During this time, my family did little besides sit together and pace around the house, waiting for the phone to ring with an update on his condition. We didn’t fully grasp the severity of his injury. We weren’t told at the time that he was awarded his Purple Heart in the middle of the night after he was wounded, because doctors feared he wouldn’t live until the next day.

Once Robert was in Germany, the Army flew my father out to be with him. It was only then that we understood the gravity of the situation. As his body began to awaken, my brother was kept in an induced coma, allowing his brain to rest. When they finally tried to bring him out of it, he would not wake up.

I am one of five children spanning 14 years. Robert, the eldest, and I were lumped together for much of our childhood, being the closest in age to each other. Although he is 18 months older, I have always acted like the eldest. My mother says he didn’t talk until I did. I distinctly remember explaining to him how to pronounce “Hallelujah.” Because we were homeschooled, much of our schoolwork was done together. We did our English and history lessons as a pair, as well as all of our science projects—I dictated the steps of the scientific method while he scribbled ferociously into a notebook that would later prove indecipherable. We didn’t stay particularly close. He moved into his own sphere when he joined ROTC in college, while I studied philosophy and kept to myself. I could tell he relished being in the traditionally masculine world of the military, where he could perform and deliver, unlike at our university, where he struggled to get through his required courses. Occasionally, he would let me go out with him and his ROTC buddies. I would sit back with my pint of beer and listen to their rapid banter, chuckling where I thought it was appropriate, as they fired movie quotes at each other. I liked watching him laugh and gesticulate. Like our father, Robert would laugh until his eyes watered—with an exuberance that seemed a long time coming after the hesitations of his childhood.

My parents have organized their lives around their children, creating a force field that continually draws us home even as we have grown up. The night we learned of Robert’s injury, the rest of us were at our house in Kingston, Rhode Island, where we had spent most of our lives. We were sitting on the floor of the kitchen tie-dyeing T-shirts when the phone rang. A crackly voice told us he had been in an explosion and was going into surgery for head trauma. They would call again in two hours to let us know how it had gone. We gathered in our living room, stunned and unsure of what to do with ourselves. My father stood in the center of the room, slowly rocking back and forth on his feet. When he moved, the imprint of his shoes was chiseled into the carpet as clearly as if he had been standing on clay. He finally sat down, dragging an armchair tight into the circle of chairs and couches. It was not a time for sitting on the other side of the room. I knew my parents were praying, clinging to their lifelong faith, but I only waited for events to unfold and eventually sat at the kitchen table coloring fairies and dragons with my siblings to pass the hours. Every instant seemed like it could be the magical moment—surely now he is gone, or now all is well.

The phrase head trauma meant very little to me that night. I wondered to myself if my brother had perhaps lost an ear or an eye. The possibility of cognitive changes never crossed my mind. I was only vaguely aware of traumatic brain injury as the so-called “signature” wound of the Iraq war, something that is largely due to the increasing sophistication of the explosive devices used by the insurgency. I learned later that the Defense and Veterans Brain Injury Center, which operates out of Walter Reed Army Medical Center, had treated 1,803 cases of TBI stemming from the Afghanistan and Iraq conflicts as of November 2008, while cumulatively their sites had recorded 9,100 cases of this injury. I was completely unaware of the large advocacy and support networks, such as the Wounded Warrior Project, that exist to rally for the treatment of severely injured service men and women, the influx of whom our government has proven sadly unequipped to handle. I didn’t know that it is still an uphill battle for many families to receive the kind of care that this incredibly complex injury needs in order to maximize recovery. This was the world we were about to enter that night, although we couldn’t have been more ignorant of its existence.

As soon as my brother was moved to Bethesda Naval Hospital in Maryland, my parents began the arduous task of attending to him. I never saw a hint of hesitation in them, even through the long months of care, as everything else in their lives took a distant second place. They were unflinchingly proud of Robert, as they had been when he joined the Army, decided to volunteer for deployment, and ultimately left for Iraq. My parents saw his wartime role in crisp black and white. They were not angry, like I was. Any political context for his actions and what had happened to him collapsed into the overarching fact that he is their son and was in need.

The day my mother prepared to leave for Bethesda, she told us she might stay the whole week. She was sure we could mind each other (two of my brothers were still being homeschooled), the house, and our grandmother for that amount of time. It would be hardest on my nine-year-old brother, who had never been separated from both his parents at once. But we were all eager to rally and pitch in, snapping into an automatic mode that propelled us through our daily routines. My mother was gone for the better part of four months, my father for six months. They would rotate, depending on my father’s university work schedule, and were often not home for more than three days at a time. But even when they were home, my parents were present in Rhode Island only in body. Their minds and all their energies were concentrated on a single hospital bed hundreds of miles away.




I’m not sure when I realized that the shock wave that penetrated my brother’s brain continued across continents and seas, engulfing my parents, my siblings, and me. Our lives were transformed rapidly, and it was months before I explicitly acknowledged the extent of the change. I had graduated from college three weeks before my brother’s injury and was working at a restaurant while I plotted my next move. But without my parents at home, the bulk of the housework, cooking, homeschooling, and grandmother care fell on my shoulders, giving me the unusual opportunity at the age of 22 to experience the life of a middle-aged married woman with children. My head became filled with grocery lists, grade school lessons, the appointment calendar, a barrage of daily details that had nothing to do with my own life plans or preparations. I quit my job, and life narrowed to my siblings, my family’s needs, and trying to keep everyone afloat. On a rare night out with one of my friends, I explained that my siblings had asked me to be home by 10. I wasn’t sure which was more bizarre—the fact that I had readily assented to this curfew or the fact that I thought it was a fair compromise for being “allowed” to go out. Even as I told myself that I was on the moral high ground, resentment began to fester within me as the sacrifices, the hurt feelings, and the hardships began to pile up.

As my family’s reality continued to revolve around my brother, I began to realize that every family member of someone with TBI becomes enslaved by the condition of their loved one. But while the tedium of this sometimes threatened to overwhelm me with self-pity, the tautness of the real tragedy was continually re-framed and re-focused. Despite all of the changes to my life, my attention went again and again to my brother, who languished at the upheaval’s epicenter, suffering at a level that could not be compared to ours.

The first time I saw Robert, three weeks after his injury, he was still being kept in an induced coma. I flew down to Washington, D.C., with my sister Anna for the weekend. We were giddy and giggly in a bleary haze of extreme nervousness. When we asked what to expect, our father said that nothing could prepare us to see the devastation that was our brother. Outside of his room in the intensive care unit, we donned yellow gowns, masks, and gloves. We could see the end of his bed from the door. His feet were clad in gray socks and listing outward in extreme lassitude. We could already hear all the hospital noises, the beeps and whirs, the heavy whoosh of his ventilator. I wasn’t brave enough to walk right in and confront my brother, so I peeked around the corner with one eye. Recoiling, I whispered to my sister that I wasn’t sure if I could do this.

Robert was swollen and bloated; his skin was puffy and enamel white. He looked worse than dead and somehow a bit reptilian, more cadaver than creature. The violent rise and fall of his chest with each pull of the ventilator looked painful, as if the machine were assaulting him. His eyes were fluttering a bit. When they were open, his pupils sometimes rolled around, not entirely in synch with one another. The right side of his head where the skull had been removed had a cavernous dent, the skin sinking in because there was nothing to hold it up. Mucus had built up around his nostrils, his lips looked extraordinarily thick, and his face was damp. He looked strained, far from peace, and barely human.

Anna and I crept to each side of Robert’s bed. It took a tremendous effort to grasp his hand in mine, and even more to begin speaking. As we each held one of his cold, bloated hands and began talking to him in shaky voices, I found it hard to regulate the volume of my speech; it came out dreadfully squeaky. “It’s us,” we said over and over again. It was worse than talking to a corpse. I felt there was no way to reach him and that my words would only emphasize this chasm between where he was and where I was. “We never thought we would have a reason to come to Maryland,” my sister whispered. She seemed unsure of who to look at, me or our brother.

It was awkward, but as the wildness of the initial shock wore off, we gradually remembered some of the things we had decided to say on this first visit. A nurse lowered the level of his sedation, hoping that he would become more aware of us, and we chattered about how much we had wanted to come. Our sentences tumbled out rapidly, blurring together at their edges. “You did everything right, your men are safe,” we said repeatedly, like a mantra. “We’re so proud of you.” We told him to come home soon, because our other brother was already driving his car and had taken his leather jacket. His eyes wandered. In my distress, I wanted to lean down and shake him. He hovered below the surface of some great torpor, and I felt that if only I could break through its glassy layers, I could pull him out to be with us. It was all I could do to keep from yelling, “Robert, this way!” Yet despite my desperation, he remained remote, as if he were hearing the echoes of my voice in the wind but could not tell which direction to turn. His mouth began twitching, its corners turning down. A teardrop slowly came out of one eye. “He’s crying,” my mother croaked.

Today, two years into his injury, Robert lives in an apartment next door to our family home. My parents care for him and help him with daily tasks, managing his affairs, cooking his meals, cleaning his apartment, doing his laundry, cutting his fingernails, cajoling him to do what he needs to do, and cheering him up when it all gets to be too much. He has become their child all over again and their full-time job. His neurological signals remain “markedly abnormal,” and he goes to occupational and physical therapy three times a week to work on his limitations. He is still unable to use his left hand and arm very much, and it curls against his side like a fractured wing, the white, cold fingers curved into a lifeless ball. He sometimes stretches it out, displaying his hard-won ability to part the fingers and lift the arm above his head. But then it pulls back into its bent, wounded position and languishes there with an extraneous air, flopping about as he walks with his uneven and heavy gait.

The oddities of traumatic brain injury become more apparent to us every day. It is a cruel fate that allowed him to come so close to being normal, and yet miss it altogether. Outsiders are sometimes amazed by how well he functions. But we who live with him and care for him would find it exceedingly difficult to characterize him as anything resembling a typical 25-year-old man. Robert was certainly not a saint before his injury, as few men his age are. He could be angry, violent, indignant, ungrateful, and rude. Now that he is living with TBI, we have noticed that many of his less-desirable character traits, noticeable yet controlled before his injury, have been amplified or twisted into a puerile caricature of adult emotion. Even my parents acknowledge that their son has become an uncomfortable mix of a child and a man. He “lives on his own,” yet once pitched a temper tantrum because he needed to make a phone call and my father would not do it for him. He is often petulant and capricious, self-centered and unreasonable. One night he loves chicken Parmesan, the next night he insists he has hated it his whole life. If he is physically uncomfortable, he is crabby and will snap at whoever is near him. Sometimes when he is exhausted and overwhelmed after his day of therapy, he will sink into a teary sulk, rubbing his red eyes and sharply demanding food or something else that he needs. Even his voice enhances his juvenility, being a little squeakier and more slurred than it used to be.

My brother’s childlikeness can bring a degree of awkwardness into our interactions with him. His new demeanor is more often characterized by excessive giggliness than by anger. He will frequently prattle away with a wide-eyed seriousness and then collapse into silly laughter that is sweet and uninhibited but also a bit sad coming from a 25-year-old man. He finds it especially funny when he baffles us with some strange observation like “So you want to put on those pants and walk down that path?” When the response is a perplexed stare, Robert will gleefully chortle away at his wittiness. Although he fully knows who we are, my brother calls my sister “Albert Hanesworth” and addresses me as “Edward Hackinson.” He will laugh outrageously at our protests and never seems to tire of the joke, if indeed that’s what it is.

Sometimes Robert’s contributions to our conversations don’t quite make sense, yet often they are witty or even insightful. When Anna was discussing a poem she had talked about in class at the University of Rhode Island, she read it aloud and inquired what we thought it meant. My previously liberal-arts-phobic brother immediately responded, “The anonymity of strangers,” which upon a second reading, seemed to be the very thing the poem was talking about. In defiance of his previous distaste for research, our brother sometimes tells us of his “unquenchable thirst for the elixir of knowledge,” which often leaves him unable to sleep in the middle of the night until he has powered up his computer and researched some burning question, such as who Adonis was or why we sometimes get “brain freeze” when biting into something cold.



In a way, Robert is more endearing than before. Yet there are barriers that inhibit his desire and ability to interact with people outside his family who might sincerely enjoy his company. My brother’s language is sometimes slightly garbled, due to the diffuse nature of his brain injury. He once was trying to say, “Typical, typical,” but instead said, “Pitacal, pitacal,” and continued on without noticing his error. He often recounts stories from his therapy sessions or explains how he is feeling with an undeniable element of theatricality, brandishing his arms and using archaic or overblown language. He uses words like “whither,” “thus,” and “thence,” and consistently says “nay” instead of “no.” He also takes delight in the kind of pranks a 10-year-old might pull, such as bopping someone on the head as they come around a corner. He can be extremely rude when out in public, completely ignoring an old friend or a formerly familiar passerby who is asking about his health.

It can be difficult to console my brother during the times he explicitly or tacitly laments his lost abilities. He can no longer play baseball or basketball with his friends, and this makes it hard for him to participate in the sports nights they used to enjoy together. He cannot go shooting with them or play paintball. He cannot play the bass for hours at a time anymore. Because of his medications and the risk of seizure associated with the crainoplasty that restored the missing part of his skull, he cannot drink alcohol. An ardent sports fan, who spent countless nights watching football and drinking beer with his friends, he now rarely goes out with them to a bar or sports parties. Robert has neglected these relationships and, in turn, has been neglected by many of his friends. It is difficult for them to know how to respond to the way he is now. My brother does have one friend who takes the bus down from Providence on Thursday nights to play video games with him. They sit on the couch in his apartment, eating Skittles and laughing hysterically at their memories of the old days. My brother looks forward to these evenings with unabashed joy. We are extraordinarily grateful for the dedication that compels this friend to return again and again.

As my brother recovered in Bethesda and later in Tampa, he knew he was in rehab with the specific purpose of getting stronger and becoming well; he was a recuperating soldier. When he returned home, many people assumed it meant that he had been patched up and put back together again. They often greeted him with a pat on the back, saying, “So do you feel like yourself again?” My brother would nod with the wide-eyed and complaisant face he sometimes assumes when talking to people outside the family and mumble something like, “Yeah, yeah.” At such moments I would try to remind him that he had never stopped being himself. The last thing I want him to think is that his injury has taken away whatever made him himself, especially since most of its effects will not go away for as long as he lives.

But there is more kindness than logic in what I tell him. The parts of his personality and his life that he has lost have been carved out with a heavy hand. It is not hard to think that the Robert we knew is gone. My brother is a paradox. We insist that he has survived, that his essential self has been retained. We have not mourned the loss of someone we love. I cannot compare what he or my family has been through to the anguish caused by death in war. We are unquestioningly happy that he is indeed still here, but something—some part of him—clearly came to an end that morning in Baghdad.

Robert still loves to throw out snatches of movie lines. He loves guns and dogs and watching sports just like he used to. But he is no longer the person who, for 23 years, I thought of as “my brother.” His quirky mind, his narrow focus, his slurred speech, and his physical difficulties all suggest another person to me. My brother is alive, but transformed to such a degree that I separate who he is now from the person I once knew as if they were entirely different individuals. This is subconsciously reflected in the way we address him. Before his injury, he went by “Rob.” My family now often calls him “Bob,” as if he is someone other than the “Rob” we knew for so many years.

It may be possible that receiving life instead of death can become its own kind of torment. Robert must negotiate his “new” life in the face of bitter and permanent alteration. It is incredibly sad when I catch an occasional glimpse of his frustration and bewilderment at his new dependency. His moments of seeming oblivion are interlaced with times of an acute sense of loss and extreme self-consciousness—about his appearance, his disabilities, his difficulties in following rapid conversations. It is hard to know how to respond when he refuses to eat out at a restaurant with us, because it is too embarrassing to be seen having someone help him with his food and implements.

My brother was not characterized by timidity or reluctance during his brief military career. Robert volunteered to go to Iraq and was placed with a new unit that was just deploying. His work there of removing roadside bombs and IEDs probably saved hundreds of lives in a country that has seen too much sadness already. His men said he was like a father to them, though many of them were older than he. They said he did everything right. They said he was the only person they wanted to trust with their lives. For Robert, an identity defined by disability must seem a poor trade, especially as he had so recently found his way to flourish.

Robert still occasionally insists that all he wants to do is re-join the military and be an engineer. He took a vocational test as part of his rehabilitative therapy and scored highest in these two areas, a cruel jab at his inability to now follow his “calling.” His physical and cognitive limitations have trapped him in a sphere of himself that doesn’t contain the parts that he always liked the most about himself. What do you do with yourself when all you ever wanted to do is resolutely out of your reach? Since my brother’s injury, I have often struggled with the despair that this line of thinking brings. In weariness, I succumb to believing that this harsh fate will rival any death stroke. My brother may always remain a hero for what he has been through. But a hero who is unable to open a jar or spread the cream cheese on his own bagel may grow weary and contemptuous of life very quickly.

Every time I see my brother’s curved, flaccid fingers or run my own able fingers along the baby skin of the huge scars that cross his head, I wish fervently that this had never happened. To serve his country, my brother sacrificed a promising future as a leader in the military. I fear that all he is becoming instead is a guy scratching at himself as he sits on the sofa with his computer watching Internet porn, living on his military disability pay and Social Security.

But this is not the possibility that my family must choose to dwell on as we vacillate each day between despair and hope. Not every disabled person becomes tired of life. There is always dignity, pleasure, and meaning to be found in existing. Science and medical research continually hold the promise of alleviating Robert’s symptoms. With the therapies that he is undergoing, he has a fighting chance to regain a little more function. We must never forget how much we have already received. My brother has been given back to us multiple times: from death, from a vegetative state, and from an enfeebled condition. Surely this can be seen as an encouraging trend.

Robert escaped death by two feet, living while the driver sitting next to him, a young man from Washington named James, died. Before each mission, the two of them would clasp arms and tell each other, “No fear on earth.” I understand that what these two soldiers were saying to each other was that acting as if you are unafraid is how to function in a volatile and perilous world. It is this grim determination that repels the terror and discouragement that unfairness and absurdity can engender.

I no longer have the illusion that soon my family will be able to clap my brother on the back and say, “Phew, that’s over. We made it through.” Robert is never going to be cured. But the possibility of our continual enslavement—my brother’s to his injury, my parents’ to their son, and mine to my family—is something I do not want for us. This tragedy may not disappear or even lessen much in severity, but the virtue of being alive and not dead is that we can respond actively and creatively to even this situation. So while my brother treks across our parents’ yard every morning, following the dusty path that his feet have worn in the grass, to sit in the kitchen and wait for someone to make his oatmeal and coffee before resuming his position on the sloping, brown couch in his apartment, I have booked a plane ticket to New Zealand and am preparing to fulfill my post-graduation plans, which will be two years overdue by the time I embark.

The persistence that it takes to adapt to change is a daily concatenation of choices. Although I choose to be hopeful for both myself and my brother, hope can never assuage the heartbreak for what he and my family have gone through. But I am resolved to believe that just as my brother set in motion the conditions for enslavement, I can set in motion those for freedom. Maybe now he will follow my voice, as he was unable to do as I stood over his bloated and tremulous body many months ago in the ICU. It is telling him that enduring change means bearing sadness, anger, regret, and pain. But if I can find a way to spite the despair, so can he.

Article printed from The American Scholar: http://www.theamericanscholar.org

URL to article: http://www.theamericanscholar.org/shock-waves/

What a Texas town can teach us about health care. by Atul Gawande June 1, 2009

Annals of Medicine
The Cost Conundrum
What a Texas town can teach us about health care. by Atul Gawande June 1, 2009

Text Size:
Small Text
Medium Text
Large Text

Print E-Mail Feeds
Costlier care is often worse care. Photograph by Phillip Toledano.

Costlier care is often worse care. Photograph by Phillip Toledano.

Related Links
Audio: An interview with Atul Gawande.
Who pays the price when patients sue doctors?

Keywords
Health Care;
McAllen, Texas;
Mayo Clinic;
Doctors;
Medicare;
Doctors Hospital at Renaissance;
Grand Junction, Colorado

It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it's a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. "Lonesome Dove" was set around here.

McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country's health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It's also devouring our government. "The greatest threat to America's fiscal health is not Social Security," President Barack Obama said in a March speech at the White House. "It's not the investments that we've made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation's balance sheet is the skyrocketing cost of health care. It's not even close."

The question we're now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.

From the moment I arrived, I asked almost everyone I encountered about McAllen's health costs—a businessman I met at the five-gate McAllen-Miller International Airport, the desk clerks at the Embassy Suites Hotel, a police-academy cadet at McDonald's. Most weren't surprised to hear that McAllen was an outlier. "Just look around," the cadet said. "People are not healthy here." McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.

One day, I went on rounds with Lester Dyke, a weather-beaten, ranch-owning fifty-three-year-old cardiac surgeon who grew up in Austin, did his surgical training with the Army all over the country, and settled into practice in Hidalgo County. He has not lacked for business: in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it. I walked around with him as he checked in on ten or so of his patients who were recuperating at the three hospitals where he operates. It was easy to see what had landed them under his knife. They were nearly all obese or diabetic or both. Many had a family history of heart disease. Few were taking preventive measures, such as cholesterol-lowering drugs, which, studies indicate, would have obviated surgery for up to half of them.

* from the issue
* cartoon bank
* e-mail this

Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn't possibly be the reason that McAllen's health-care costs are so high. (Or the reason that America's are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)

Was the explanation, then, that McAllen was providing unusually good health care? I took a walk through Doctors Hospital at Renaissance, in Edinburg, one of the towns in the McAllen metropolitan area, with Robert Alleyn, a Houston-trained general surgeon who had grown up here and returned home to practice. The hospital campus sprawled across two city blocks, with a series of three- and four-story stucco buildings separated by golfing-green lawns and black asphalt parking lots. He pointed out the sights—the cancer center is over here, the heart center is over there, now we're coming to the imaging center. We went inside the surgery building. It was sleek and modern, with recessed lighting, classical music piped into the waiting areas, and nurses moving from patient to patient behind rolling black computer pods. We changed into scrubs and Alleyn took me through the sixteen operating rooms to show me the laparoscopy suite, with its flat-screen video monitors, the hybrid operating room with built-in imaging equipment, the surgical robot for minimally invasive robotic surgery.

I was impressed. The place had virtually all the technology that you'd find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don't. But that rule doesn't hold for health care.

At McAllen Medical Center, I saw an orthopedic surgeon work under an operating microscope to remove a tumor that had wrapped around the spinal cord of a fourteen-year-old. At a home-health agency, I spoke to a nurse who could provide intravenous-drug therapy for patients with congestive heart failure. At McAllen Heart Hospital, I watched Dyke and a team of six do a coronary-artery bypass using technologies that didn't exist a few years ago. At Renaissance, I talked with a neonatologist who trained at my hospital, in Boston, and brought McAllen new skills and technologies for premature babies. "I've had nurses come up to me and say, 'I never knew these babies could survive,' " he said.

And yet there's no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.

Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen's five largest hospitals performed worse, on average, than El Paso's. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it's delivering better health care.

One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.

Some were dubious when I told them that McAllen was the country's most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen's health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

"Maybe the service is better here," the cardiologist suggested. People can be seen faster and get their tests more readily, he said.

Others were skeptical. "I don't think that explains the costs he's talking about," the general surgeon said.

"It's malpractice," a family physician who had practiced here for thirty-three years said.

"McAllen is legal hell," the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn't lawsuits go down?

"Practically to zero," the cardiologist admitted.

"Come on," the general surgeon finally said. "We all know these arguments are bullshit. There is overutilization here, pure and simple." Doctors, he said, were racking up charges with extra tests, services, and procedures.

The surgeon came to McAllen in the mid-nineties, and since then, he said, "the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about 'How much will you benefit?' "

Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. "But young doctors don't think anymore," the family physician said.

The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren't any complications—and there usually aren't—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.

Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn't going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.

I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?

Send her home, they said. Maybe get a stress test to confirm that there's no issue, but even that might be overkill.

And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.

"Oh, she's definitely getting a cath," the internist said, laughing grimly.

To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth's Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare's data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.

The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine.

This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state's quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.

In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.

That's because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.

To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.

In an odd way, this news is reassuring. Universal coverage won't be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with. So the idea that there's plenty of fat in the system is proving deeply attractive. "Nearly thirty per cent of Medicare's costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas," Peter Orszag, the President's budget director, has stated.

Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare's problems (indeed, almost all the federal government's budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.

I had what I considered to be a reasonable plan for finding out what was going on in McAllen. I would call on the heads of its hospitals, in their swanky, decorator-designed, churrigueresco offices, and I'd ask them.

The first hospital I visited, McAllen Heart Hospital, is owned by Universal Health Services, a for-profit hospital chain with headquarters in King of Prussia, Pennsylvania, and revenues of five billion dollars last year. I went to see the hospital's chief operating officer, Gilda Romero. Truth be told, her office seemed less churrigueresco than Office Depot. She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience. And when I inquired, "What is going on in this place?" she looked surprised.

Is McAllen really that expensive? she asked.

I described the data, including the numbers indicating that heart operations and catheter procedures and pacemakers were being performed in McAllen at double the usual rate.

"That is interesting," she said, by which she did not mean, "Uh-oh, you've caught us" but, rather, "That is actually interesting." The problem of McAllen's outlandish costs was new to her. She puzzled over the numbers. She was certain that her doctors performed surgery only when it was necessary. It had to be one of the other hospitals. And she had one in mind—Doctors Hospital at Renaissance, the hospital in Edinburg that I had toured.

She wasn't the only person to mention Renaissance. It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital's profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) Romero and others argued that this gives physicians an unholy temptation to overorder.

Such an arrangement can make physician investors rich. But it can't be the whole explanation. The hospital gets barely a sixth of the patients in the region; its margins are no bigger than the other hospitals'—whether for profit or not for profit—and it didn't have much of a presence until 2004 at the earliest, a full decade after the cost explosion in McAllen began.

"Those are good points," Romero said. She couldn't explain what was going on.

The following afternoon, I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined "Opinions from an Unrelenting Conservative Spirit." He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let's-get-this-over-with.

So I asked him why McAllen's health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. "The people in charge of the purse strings don't know what they're doing." (2) If anything, government insurance programs like Medicare don't pay enough. "I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays." (3) Government programs are full of waste. "Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste." (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, "are providing necessary, essential health care," Gelman said. "We don't invent patients."

Then why do hospitals in McAllen order so much more surgery and scans and tests than hospitals in El Paso and elsewhere?

In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.

"Do we provide better health care than El Paso?" Gelman asked. "I would bet you two to one that we do."

It was a depressing conversation—not because I thought the executives were being evasive but because they weren't being evasive. The data on McAllen's costs were clearly new to them. They were defending McAllen reflexively. But they really didn't know the big picture of what was happening.

And, I realized, few people in their position do. Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn't what they are responsible or accountable for.

Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor's pen. And, as a rule, hospital executives don't own the pen caps. Doctors do.

If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.

Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and "adequate health insurance to cover tests and medications." Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.

Why? Some of it could reflect differences in training. I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I'd been trained. But the doctor in Alexandria was going to send Walker home. That was how he'd been trained. Suppose things change for the worse? I asked him. It's extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.

There was no sign, however, that McAllen's doctors as a group were trained any differently from El Paso's. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.

"In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine," he said. But in McAllen, the administrator thought, that percentage would be a lot less.

He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had "entrepreneurial spirit," he said. They were innovative and aggressive in finding ways to increase revenues from patient care. "There's no lack of work ethic," he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. "It's a machine, my friend," one surgeon explained.

No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.

Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.

Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don't miss their mammograms and pap smears and colonoscopies.

Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don't pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients' scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

In every community, you'll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.

In a few cases, the hospital executive told me, he'd seen the behavior cross over into what seemed like outright fraud. "I've had doctors here come up to me and say, 'You want me to admit patients to your hospital, you're going to have to pay me.' "

"How much?" I asked.

"The amounts—all of them were over a hundred thousand dollars per year," he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.

He didn't pay any of them, he said: "I mean, I gotta sleep at night." And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.

Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it's a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.

Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as "medical directors," for steering business in their direction. Doctors came to expect a share of the revenue stream.

Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.

"I explained the rules and regulations and the anti-kickback law, and told them no," she said of her dealings with such doctors. "Does it hurt my business?" She paused. "I'm O.K. working only with ethical physicians," she finally said.

About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.

The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It's why El Paso isn't like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.

"I'll be there," the cardiologist said.

Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.

The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn't pay. The time required just to organize the system wouldn't pay.

The core tenet of the Mayo Clinic is "The needs of the patient come first"—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

"It's not easy," he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors' goal in patient care couldn't be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.

"When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing," Cortese told me.

Skeptics saw the Mayo model as a local phenomenon that wouldn't carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo's collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.

The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare's highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors' group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.

Grand Junction's medical community was not following anyone else's recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs 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.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country's best electrician on the job (he trained at Harvard, somebody tells you) isn't going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here's how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some "skin in the game," and then they'll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.

One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.

"Medicine has become a pig trough here," he muttered.

Dyke is among the few vocal critics of what's happened in McAllen. "We took a wrong turn when doctors stopped being doctors and became businessmen," he said.

We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.

"I don't have a problem with it," he said. "But it won't make a difference." In McAllen, government payers already predominate—not many people have jobs with private insurance.

How about doing the opposite and increasing the role of big insurance companies?

"What good would that do?" Dyke asked.

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."

Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don't form these organizations.

This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.

Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can't do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.

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. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don't see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen's lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, "some of the doctors are beginning to complain about 'leaving money on the table.' "

As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don't, McAllen won't be an outlier. It will be our future. ♦
McAllen, Texas and the high cost of health care : The New Yorker (26 December 2009)
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all
http://snipurl.com/tuyc5

You’ve Got Voice Mail, but Do You Care? By JILL COLVIN

April 2, 2009
You’ve Got Voice Mail, but Do You Care? By JILL COLVIN
WHEN Steve Hamrick left his last job as manager at a software corporation, he had at least 25 unheard messages in his office voice mailbox. And that’s not counting the unreturned calls on his cellphone or landline at home.

It’s not that he doesn’t like to talk. But with the cascade of messages he receives by e-mail, texting and on Facebook, Mr. Hamrick, 29, a self-described “voice mail phobic” from Cupertino, Calif., said he’d found better ways to keep in touch.

“I had to give up something and that, for me, was voice mail,” he said. “It’s cutting out some forms of communication to make room for the others.”

When it was introduced in the early 1980s, voice mail was hailed as a miracle invention — a boon to office productivity and a godsend to busy households. Hollywood screenwriters incorporated it into plotlines: Distraught heroine comes home, sees blinking red light, listens as desperate suitor begs for another chance to make it all right. Beep!

But in an age of instant information gratification, the burden of having to hit the playback button — or worse, dial in to a mailbox and enter a pass code — and sit through “ums” and “ahs” can seem too much to bear.

Many dread the process or, like Mr. Hamrick, avoid it altogether, raising the question: is voice mail on its way to becoming obsolete?

“Once upon a time, voice mail was useful,” said Yen Cheong, 32, a book publicist in New York who has transitioned almost entirely to e-mail and text messaging. According to her calculation, it takes 7 to 10 steps to check a voice mail message versus zero to 3 for an e-mail.

“If you left a message, I have to dial in, dial in my code,” Ms. Cheong said. “Then I mess up and redial. Then once I hear the message, I need the phone number. I try to write it down, and then I have to rewind the message to hear it again,” she added, feigning exhaustion.

Tim Kassouf from Baltimore, 24, who calls himself “a certified voice mail hater,” said he had 68 messages, 62 of them unheard, in his cellphone mail box. Scott Taylor, 41, a senior manager at an e-commerce company in Phoenix, said voice mail was “just totally an ineffective communication method, almost ancient now.”

Like many others, Mr. Taylor advises callers on his outgoing message to try his cellphone or to send an e-mail message if they need to reach him right away.

It is good advice. Research shows that people take longer to reply to voice messages than other types of communication. Data from uReach Technologies, which operates the voice messaging systems of Verizon Wireless and other cellphone carriers, shows that over 30 percent of voice messages linger unheard for three days or longer and that more than 20 percent of people with messages in their mailboxes “rarely even dial in” to check them, said Saul Einbinder, senior vice president for marketing and business development for uReach, in an e-mail message.

By contrast, 91 percent of people under 30 respond to text messages within an hour, and they are four times more likely to respond to texts than to voice messages within minutes, according to a 2008 study for Sprint conducted by the Opinion Research Corporation. Even adults 30 and older are twice as likely to respond within minutes to a text than to a voice message, the study found.

There are no definitive studies of how many voice mail messages American leave compared with earlier periods, but if the technology is heading toward obsolescence — as many communication experts suspect — the trend is being driven by young people. Again and again, people under 25 recount returning calls from older colleagues and family members without bothering to listen to messages first. Thanks to cellphone technology, they can see who called and hit the Send button to reply without calling their voice mail box. “Didn’t you get my message?” parents ask. “No,” their children reply, “but I saw that you called.”

Jack Cathey, 20, a college student in Lewisburg, Tenn., said his parents and grandparents continued trying to leave him voice messages despite his objections. “Do you know your voice mail’s full?” a family member asked him recently, failing to comprehend that, for his generation, that might not be a problem.

To cater to those with no patience for voice mail, wireless providers are busy rolling out a new generation of text-based alternatives that promise to make communication faster and more efficient.

The most popular is Visual Voicemail, which comes standard on the iPhone and is available on other smart phones, including the Samsung Instinct and the BlackBerry Storm. The application displays messages in a visual in-box, just like e-mail, and allows users to listen to messages one by one, in any order, so important calls can be returned first and others saved.

Other companies have taken a bolder approach, eliminating the need to listen to messages altogether.

Frustrated by missing important calls while stuck in meetings, James Siminoff founded PhoneTag, now one of a handful of companies that offer voice-to-text transcription services. For a monthly or per-message fee, subscribers’ messages are converted into typed texts, which are then automatically delivered to phones or e-mail in-boxes.

“Voice mails are totally trapped info,” Mr. Siminoff said. Because the average person can read at least twice as quickly as he or she can speak, and text messages require no log-ins or waiting, Mr. Siminoff estimates that textual voice messaging is about 15 to 20 times faster than traditional voice mail.

Services like PhoneTag are about to be jolted by Google, which plans to introduce a competing free service, Google Voice, in a matter of weeks. The service will ring each phone a person uses at once — cell, home, office — and centralize all the messages received. Most important for the voice-mail-averse, Google Voice will also transcribe voice mails at no cost.

“Voice mail feels like it was a technology that was created to fill a gap — until something better came along,” Piers Fawkes, 34, a trend tracker, wrote on his company’s popular trend-tracking site, PSFK.com. “And now it has.”

Those in the industry expect voice-to-text messaging service to be standard in as little as a year or two down the line.

“Text is the future of voice mail,” Mr. Fawkes said.

But not everyone thinks that voice mail is going the way of the floppy disk. Richard Kelleher, 59, from Phoenix, who worked at AT&T when voice mail was developed, said he was still a loyal user and wondered why young people were shunning the technology.

“What does it take, 10 seconds to leave a message?” he said. “I can do that faster than Twittering.”

Yet many see the shift away from voice mail as part of a generational divide, in which younger people are substituting text for talk, while older folks yammer on.

Text messaging has increased more than tenfold over the last three years, according to CTIA — the Wireless Association, the trade group representing the industry. Young people have overwhelmingly been the most enthusiastic adopters. According to Nielsen Mobile, users 13 to 17 now send or receive an average of 1,742 text messages a month, versus 231 cellphone calls, and they spend nearly the same amount of time on their phones texting as talking.

For Charlie Park, 30, a Web developer in Williamsburg, Va., a text message is more efficient and — equally important — more respectful of the recipient’s time.

“You never send an e-mail that says, ‘Hey, e-mail me back!’ You’re always sending information,” he said.

But even Mr. Park admits that sometimes, there is value in voice.

When his eldest daughter, Lucy, now 5, was learning to talk, he had to take a business trip. While away, she left him a message: “I love you daddy. I miss you. Come home soon.”

Mr. Park said he kept the message for several years and would replay it again and again.

“There is something nice about hearing people’s voices,” he said.

Thankfully, she kept it brief.

Jill Colvin is a reporter for the Columbia News Service.