Reassessing the value of care for chronic health conditions

Surgeon Atul Gawande says we need to reconsider health care’s focus on generously rewarding physicians who practice heroic interventions, rather than those who practice incremental medicine for chronic conditions. Gawande talks with William Brangham about the value of that kind of care, and the potential effects of a Republican repeal of the Affordable Care Act.

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    Finally tonight, a conversation about changing the way we think about health care.

    In an article in the latest issue of The New Yorker, Dr. Atul Gawande, a surgeon and author, makes the case for the value of what he calls incremental medicine to deal with chronic conditions. It's the kind of medicine less heralded than that using heroic measures.

    William Brangham spoke with Dr. Gawande recently and asked him how health care is changing.

  • DR. ATUL GAWANDE, The New Yorker:

    When you think about the future of health care and where we're going at this moment of debate, there's a transformation going on that involves a recognition that our focus in medicine has been on heroic interventions, like the kind that I do now as a surgeon.

    But the biggest gains are coming right now from incremental medicine, from a commitment to the kind of steady, overtime management of complex problems like chronic illnesses that can add years to people's lives. But that's work done by some of the people with the least resources in our health care system.


    So, who practices incremental medicine in our health care system today?


    Well, good examples, just look at the list of who the lowest-paid people are.

    Pediatricians are at the bottom. You would also look at internists. You would look at psychiatrists. You would look at family physicians, HIV specialists. People who take care of chronic illnesses by seeing people carefully over time, those are the people who get the least money.

    The people who have the most are people like orthopedic surgeons, interventional cardiologists. And my point isn't that — you know, that we're — that there is something wrong with heroism.

    My own son has a congenital heart condition, where his life was saved by a cardiac surgeon stepping in at 11 days of life to save his life. But he is now 21 years old because of constant monitoring and working with him with a primary care physician and people who controlled his blood pressure, recognized problems before they arose, dealt with learning issues that were related to his condition.

    And that's the only reason now that he's getting to live a long and healthy life. That's what we're not rewarding. They don't have the kind of resources and commitment that we are giving to people like me. I have millions of dollars of equipment available to me when I go to work every day in an operating room.

    The clinicians who keep my son going are lucky if they can have a nurse.


    So, if that care is so valuable, why are the incentives seemingly going in the opposite direction?


    It's mainly because our health system was built at a time when we couldn't really do this kind of work.

    Go back to the '30s, '40s, '50s, and it was the discovery of heroic interventions, the ability to cure people with penicillin or do an operation to stop disease that was what saved the day. Primary care physicians couldn't do all that much that really demonstrated a difference.

    Now we have had the data to track people for a long time, the computational power that recognized, you know what, high blood pressure, which we didn't even know was a huge problem, we discovered that it afflicts a third of all Americans, and it's our biggest killer, that years down in the future, that that is our cause of everything from not only heart disease, but dementia and of kidney disease.

    So, you know, the people who control and work with you to control your blood pressure, they're not rewarded for doing that or to be innovative about doing that. So, the result is half of Americans have uncontrolled high blood pressure, despite seeing clinicians.


    The Affordable Care Act tried to move the needle in this direction, to put more incentives towards the exact kind of care that you're talking about. How successful has that been, that effort been?


    Here's what I would describe it as.

    We now have 30 percent, for example, of Medicare patients who are seeing doctors who are rewarded for doing this kind of work, which is a dramatic change from six or seven years ago. So, the Affordable Care Act has pushed this direction down the road.

    It has also offered protections that allow for preexisting conditions, as people know, that if you have preexisting conditions like my son does, that you're provided coverage and you can maintain steady coverage. And that's an important part of being able to stay in care and do better over the long run.


    So, do you think — if the Republicans and president-elect Trump go forward and repeal this, do you think that some of these incentives will stay in it? Or what do you fear coming down the road?


    My biggest fear — so, first of all, where we are right now, 27 percent of Americans under 65 have an existing health condition that, without the protections of the ACA, would mean they would — could be automatically excluded from insurance coverage.

    Before the ACA, they wouldn't have been able to get insurance coverage on the individual market, you know, if you're a freelancer or if you had a small business or the like.


    Because of preexisting conditions?


    Now that — because of preexisting conditions. So, the first thing is that the ACA protections have to be preserved, or those people get pitched out.

    But the big thing that's happened is, in the time since the ACA has been going on, our medical science has been advancing. We have now genomic data. We have the power of big data about what your living patterns are, what's happening in your body. Even your smartphone can collect data about your walking or your pulse or other things that could be incredibly meaningful in being able to predict whether you have disease coming in the future and help avert those problems.

    That is the transformation that's coming. But one of the consequences of if the ACA is repealed, is that all of us now are at risk of being a preexisting — of having a preexisting condition waiting to happen. Life, increasingly, is a preexisting condition waiting to happen, now that we have more and more of this data available.


    All right, Dr. Atul Gawande of The New Yorker magazine, thank you so much.


    Thank you.

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