SCAPP

What Is Healthcare? In the winter of 2011, I took my television show to the Mayo Clinic in Rochester, Minnesota. Washington was arguing about how to pay for healthcare. I wanted to look at the care. I met Kevin Bennett, Mayo’s chief of engineering. He described a hospital where a doctor could bring other doctors, nurses and engineers into a patient’s case as part of the ordinary working day. The patient’s doctor conducted the effort. Consultation was on the schedule. Bennett told me about a pair of conjoined twins who shared a liver. Before the surgeons operated, Mayo’s engineers made a full-size model of the organ. The team sat with it and worked out where to cut so each child would have a functioning liver. I kept thinking about the model. Nobody could bill the patient for a healthier liver because the doctors had sat together and thought harder before making the first cut. Yet that meeting might be the most valuable work they did. Bennett explained the part that made it possible. Mayo paid its doctors salaries. A doctor could spend time on another doctor’s case without watching his own income disappear. Outside that arrangement, the arithmetic was different. A procedure produced a fee. A meeting with a colleague might produce nothing. The doctor who stayed in his office and performed another procedure got paid. The doctor who walked down the hall to help solve a difficult case could lose money for that hour. You can give speeches about collaboration all day. The payment system is giving instructions too. In Greedy Bastards, I reported a study of elderly Medicare patients near the end of life. Spending at Mayo was roughly half what it was at nearby providers in Rochester. That comparison did not prove every hospital could cut every bill in half. It did show something Washington’s argument kept missing: excellent care and higher spending were not the same thing. The trip changed the question I was asking. Why are we fighting so fiercely over who will pay the bill without examining why the bill is so high? Why does the debate begin with preserving every payment and every institution already in place? I had expected to find a shortage of solutions. I found a working example. The difficult part was changing the rules that paid for the old way of doing things. And the rules had defenders. Every payment went somewhere. A redundant procedure was revenue to somebody. The organizations built around that revenue employed people, hired lobbyists and financed campaigns. They had a place in the room when government decided what healthcare would pay for next. The patient had no comparable seat at that table. Neither did the doctor trying to organize better care for less money. I left Rochester with a picture of what renewal could look like. People with different skills gathered around a real problem. They had the time and the incentive to do the work well. The result mattered more than the number of billable steps it took to get there. That should have been the starting point for a national argument about healthcare. Instead, we kept asking how to finance the system we already had. Subscribe: dylanratigan.substack.com