Pity McAllen, Texas. In May, the town came to symbolize almost everything that's wrong with American health care after Dr. Atul Gawande, a medical journalist, described it in the New Yorker as a city with a glut of specialists too eager to perform expensive procedures and tests, the kind of place that demonstrates why medical costs keep spiraling upward nationwide. Gawande's article made such a convincing case against McAllen's medical culture—and against the profit motives that drive much of the health-care system—that the president made it required reading for his staff. One of the town's largest medical groups also just paid $27.5 million to settle allegations that it was giving doctors kickbacks so they would refer patients to its hospitals.
Now, the Allergy and Asthma Foundation of America has named its Fall Allergy Capitals, "the 100 most challenging places to live with allergies" in the country. The absolute worst town on the list? Yep, McAllen again.
The city's double thrashing was not politically motivated. Mike Tringale, the AAFA's director of external affairs, hadn't read the Gawande article until last week, when I sent it to him. And some of the reasons McAllen landed on the bad-allergy list have nothing to do with the health-policy concerns in Gawande's piece—for instance, the fact that the city, at the southern tip of Texas, has lots of pollen, high humidity, and almost no freezing weather.
But there's at least one odd way in which the AAFA's take on medicine in McAllen seems at first glance to contradict Gawande's—and there's a lesson in it for people looking to cut down on health-care costs. According to the AAFA (which is a nonprofit patient group, not a doctor lobby), one of the reasons the city is so hard on allergy sufferers is its lack of board-certified allergists. Is McAllen, the city of too much medicine, somehow also suffering from too few doctors?
Not quite. For the most part, the AAFA report doesn't contradict Gawande's findings about a pervasive culture of overtreatment. If anything, it bolsters them. Take, for instance, Gawande's point that "compared with patients in El Paso and nationwide, patients in McAllen [get] more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care." They get more allergy drugs too, according to the AAFA. "In McAllen, patients are overmedicated for allergies. Their use is off the charts," says Tringale. "They're completely dissatisfied with single solutions. They'll take a prescription medication, an over-the-counter medication, and an eyedrop all at the same time."
But what about McAllen's missing allergists? There's no question that the town is lacking specialists in the field; this local news article says there's only one allergist in all of greater McAllen. How can a town with virtually no allergists be dramatically overtreating its patients' allergies?
The answer is that a lack of specialists in a field doesn't always mean a lack of treatment in that field. In fact, sometimes having fewer specialists can actually cause overtreatment.
If patients with runny noses and hay fever can't get appointments with local allergists, they don't necessarily decide to suck it up and buy some Kleenex. Those with milder cases—who might not have bothered to see allergists in the first place—medicate themselves with the huge array of drugs available over the counter.
Patients with more serious symptoms don't give up, either. They seek out other docs who can prescribe something stronger than the OTC stuff. "A lot of allergy care is delivered by primary-care physicians," says Tringale. "Maybe even more than half." Patients who get their allergy treatment from primary-care providers are more likely to overuse beta-agonists than patients who see allergists—largely, says Tringale, because allergists are "better able pinpoint the best treatment for their patients the first time." It's also pretty easy to find an otolaryngologist who can prescribe allergy drugs in McAllen; this Web site lists nine. In other words, if you're an allergy sufferer in McAllen and you want to join the ranks of the overtreated, you don't need an allergist to get there.
In the larger health-care debate, it's common to hear that an easy way to reduce costs is to limit patients' access to specialists. Send them to primary-care docs instead, the thinking goes, and they'll get more preventive care and fewer pricey treatments. That's true if you're talking about an illness that responds to cheap preventive measures and is only treated by specialists.
But McAllen's allergy problem isn't as simple as that. The issue here isn't that specialists are writing unnecessary prescriptions. It's that unnecessary prescriptions get written at all. And if it's happening here, chances are that patients nationwide are demanding what amounts to overtreatment. And if they can't find the appropriate specialist to give it to them, they may just find someone else who can.