It is impossible to deny a political agenda in Gawande's article considering its tone and timing of release. If the cost of medical care in McAllen is indeed one of the highest in the nation is not because of overutilization of resources but instead because of having to take care of a sicker and older population. 

He implies that overutilization is done for financial gain because "doctors have an echo machine, nuclear medicine and even CTA in their offices". Self referral is not a sin as long as it is used judiciously.

There are specific aspects that must be controlled: overspending in home health is one of them. Electronic medical records will help avoid redundancy in medical tests.

As Dr. Terstein rightfully states, if a lay person reads this paper the obvious conclusion will be that all doctors in McAllen are crooks. As in any other medical society we have had our share of bad apples that have been appropriately fined, marginalized, suspended or even incarcerated because of actions started by their own peers.

I take offense by Dr. Topol's comments about seeking medical care in McAllen. According to US & News Report and Thompson data, Doctors Hospital at Renaissance in McAllen was considered among the five best hospital for cardiovascular care in Texas.

Sometimes I jockingly tell my students that for some people their only role in life may be to serve as a bad example. Please do not use us in McAllen as such in order to advance your political agenda.

Just about all procedural based physicians require a hospital affiliation in order to utilize hospital facilities and pick up a patient base.

A system of reimbursement by third parties which break procedures down into professional, technical and global and in which the smallest reimbursement is for the professional component is a problem.

Motivation is for the physician to acquire equipment which will allow global billing. The physican then becomes a direct competitor with his/her hospital.

The hospital must maintain equipment for inpatients. The net result  is an oversupply of spect cameras, echo machines, x-ray, etc. While making GE, Phillips, Siemens, Toshiba happy, the system leads even the most dedicated evidence based follower into temptation. Net result: huge costs.

There are two ways to correct this problem:

1) Salaried providers who work for and utilize hospital equipment. With no bonuses given for referral of patient volume.

2) Reduction in reimbursement by CMS and insurances to make equipment purchase economically challanging. This is being promulgated for instance in echo.

One spin off that might be positive.........if we ever do drift towards the Canadian system of healthcare, there should be a surplus of equipment which would cut down waiting tmes.