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"This is such a terrific model," says Henry Aaron. "It costs less and gives better results. In a Darwinian business system, you have to wonder why it doesn't spread." Only about 33% of Americans get their health care through organizations like Geisinger. But the model is becoming more popular, encouraged by the Centers for Medicare and Medicaid Services (CMS), which has run hundreds of pilot projects over the past six years. "If you're a group practice that joins one of the CMS pilots and prove you can improve service while cutting Medicare costs, you get to keep a portion of the savings," says Fisher. Much of the savings projected for the Affordable Care Act--Obamacare--would come from a broader application of his model.
But that's going to be a big fight and difficult to win: most doctors don't like the Mayo-Geisinger way of doing business. The culture of fee-for-service medicine, which features each doctor as the captain of his or her own ship, is incredibly powerful. "What you hear from doctors who don't like our system," says Steele, "is 'We don't want to be robots run by your computers.' But we encourage innovation if it really works." Devan says that while Geisinger doctors don't have to worry about the business hassles of running a fee-for-service practice, it isn't exactly natural for doctors to have their work under constant scrutiny by their peers. "We have monthly meetings where each patient is reviewed," she tells me. "That's a major cultural shift for most doctors."
The shortcomings of fee-for-service medicine are well known, especially when it comes to Medicare. At the age of 80, my mother insisted on having a heart-valve operation to fix a murmur she'd had since birth. "It's getting worse," she said. "I'm feeling more tired than I used to." The going rate for such operations was more than $100,000, and Medicare paid for hers. The current system is rife with such unnecessary expenditures--"We're having a national epidemic of wrong patient operations," Fisher says--and it seems clear that a model like Geisinger's, in which doctors aren't rewarded for performing extraneous tests and operations, would be the best way to reduce the costs of Medicare. It also seems clear that asking people like my parents to make market decisions about their health care--the sort of system that Congressman Paul Ryan and other Republicans support--would be an act of cruelty and an unnecessary one at that. In the end, changing the way health care is provided rather than the way it is sold may be the most efficient way to generate savings.