McAllen, Texas, Evidence-Based Medicine, and President Obama

Abstract

INTRODUCTION In April we traveled to McAllen, Texas, to present an evidence-based medicine (EBM) seminar to the faculty of the University of Texas Pan American (UTPA) PA Program in nearby Edinburg. On our route to the UTPA campus, we drove by what seemed to be a plethora of medical facilities ranging from family medical clinics and those focusing on pediatrics and women’s health to subspecialty clinics. There were numerous ambulatory surgical facilities and at least four home health businesses. The hospitals we stumbled across seemed, from the road, to be modern and attractively designed. We agreed that the number of health care facilities seemed out of proportion to what we perceived to be average for a community of McAllen’s size. To our knowledge, McAllen and its suburbs were not known as a research or tertiary care center that would create the need for health care organizations in greater-than-expected numbers. We did not think much more about this as we were focused on effectively delivering our presentation and not getting lost on the way to UTPA. The 21⁄2-day EBM seminar went well and we were impressed with a dynamic UTPA faculty, supported by visionary leadership. As is often the case, we returned home with a number of ideas from our attendees that will likely improve our own curriculum. Shortly after our return I (DK) received an email from a health policy and access listserve that I belong to about the June 1, 2009, New Yorker magazine article1 by staff writer Atul Gawande, MD. Dr. Gawande is on the medical staff at Brigham and Women’s Hospital in Boston and has been a writer for the New Yorker since 1998. What drew me to the article was not only my interest in health policy, but also the fact that it focused on McAllen, Texas. Dr. Gawande’s article compared McAllen to El Paso, Texas, and found what he termed “overutilization” of health care services. This was consistent with our decidedly nonsystematic observation that there was an overrepresentation of health facilities in McAllen. Intrigued, I read the article and have since followed the ensuing debate about the factual foundation of his reporting. Dr. Gawande’s finding that McAllen’s 2006 Medicare costs per enrollee of $14,946 were double those of its northern neighbor, El Paso ($7,504), was central to his thesis that current incentives in our health insurance system can lead to overutilization of services when profits rather than outcomes are a prime motive. Of particular interest to Dr. Gawande was the proliferation of physician-owned diagnostic facilities that, in his mind, explained much of the asymmetry of Medicare costs in this south Texas city. The fact that health outcomes were no better — and in some cases worse — in McAllen compared to El Paso suggests that his concern might have merit. The article caught my eye because it underlines the fact that under our current system of health care, incentives are centered on maxThe intent of this feature is to present a forum for PA educators to share their approaches to teaching EBM. Areas of interest might include reviews of EBM resources; mini-tutorials in areas such as statistics, epidemiology, and study design; ethical, historical, or philosophical perspectives of EBM; and discussion of practice or technological tools that enhance application of EBM. Prospective authors are encouraged to contact the feature editors to receive approval of topics in advance. Authors desiring to contribute to EvidenceBased Medicine should forward submissions to: