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Most Objectivist thinkers are ‘little known’ outside of Objectivist circles so I will post a list of the ones I know.Objectivist Intellectual’s Biographies (85) last updated 10/14/18 (not complete)Amesh AdaljaMD, 2002, American University of the CaribbeanDr. Adalja, a board-certified physician in infectious disease, critical care medicine, emergency medicine and internal medicine, specializes in the intersection of national security with catastrophic health events. He publishes and lectures on bio-terrorism, pandemic preparedness and emerging infectious diseases. He has been a guest on national radio and television programs.John AllisonMBA, Management, 1974, Duke UniversityMr. Allison is president and CEO of the Cato Institute. He was previously chairman and CEO of BB&T Corporation, the 10th-largest financial services holding company headquartered in the United States. During Allison’s tenure as CEO from 1989 to 2008, BB&T grew from $4.5 billion to $152 billion in assets.Carl BarneyCarl Barney is a businessman who, among other business activities, owns and manages several private business colleges.Rituparna BasuBS, Biology, 2010, Pennsylvania State UniversityMs. Basu is a health care policy analyst at ARI. Her work has appeared in publications such as Forbes and The Daily Caller, and she has been interviewed on radio and TV programs, internationally. Ms. Basu has briefed congressional staffers and speaks regularly at university campuses, including Georgetown, Emory and Temple.Ben BayerPhD, Philosophy, 2007, University of Illinois at Urbana-ChampaignDr. Bayer teaches philosophy at Loyola University New Orleans. His research focuses primarily on questions about the foundations of knowledge and the freedom of the will.Robert BegleyRobert Begley is a writer for The Objective Standard. He is the founder and president of the NY Heroes Society, an organization dedicated to promoting heroism in the culture. Robert is also a judge in Anthem, The Fountainhead and Atlas Shrugged essay contests. He was the host and producer for the Manhattan Cable TV program, The Voice of Reason. Robert is currently writing a book about the history of New York heroes.Michael S. BerlinerPhD, Philosophy, 1970, Boston UniversityDr. Berliner is the founding executive director of the Ayn Rand Institute and served as co-chairman of ARI’s board of directors. He is editor of "Letters of Ayn Rand", "Understanding Objectivism" and a recent biography of operetta composer Emmerich Kálmán. Dr. Berliner taught philosophy and philosophy of education for many years at California State University, Northridge.ANDREW BERNSTEINPhD, Philosophy, 1986, City University of New YorkAndrew Bernstein holds a Ph.D. in Philosophy from the Graduate School of the City University of New York. He has taught at Hunter College, the New School for Social Research, Pace University and Marymount College, where he was chosen Outstanding Faculty Member for 1995. He currently teaches at the State University of New York at Purchase, where he was selected Outstanding Faculty Member for 2004.Dr. Bernstein has lectured at universities across the United States, including at Harvard, Yale, Stanford, the United States Military Academy at West Point and many others; and at philosophical conferences both in America and abroad. He is the author of The Capitalist Manifesto: The Historic, Economic and Philosophic Case for Laissez-Faire, to be published in the spring of 2005 by University Press of America. His first novel, Heart of a Pagan, was released in 2002. He is currently writing Objectivism in One Lesson, an introduction to the philosophy of Ayn Rand. His website is Andrew Bernstein | Philosopher and TeacherDr. Bernstein is the author of "The Capitalist Manifesto" (2005), "Objectivism in One Lesson" (2008), "Capitalism Unbound" (2010), "Capitalist Solutions" (2011), and of numerous essays. He is currently writing “Heroes and Hero Worship” for the Clemson Institute for the Study of Capitalism. Dr. Bernstein lectures widely on Ayn Rand’s novels and Objectivism.DAVID BERRYD.M.A., Composition, 2002, University of South CarolinaDavid Berry is an associate professor of music. He teaches courses across a wide range of historical and theoretical musical subjects including film music. He is a recorded and published (BMI) composer with performances of his music in America and Europe in both fine art and popular music genres.CRAIG BIDDLEB.A., Fine Arts, 1988, Virginia Commonwealth UniversityCraig Biddle is the author of Loving Life: The Morality of Self-Interest and the Facts That Support It and is currently writing another book, Good Thinking for Good Living: The Science of Being Selfish. In addition to writing, he lectures on the Objectivist ethics and teaches workshops on thinking in principles. Editor and Publisher of “The Objective Standard”Specialties: Ethics, ObjectivismHARRY BINSWANGERPh.D., Philosophy, 1973, Columbia UniversityDr. Binswanger is the author of The Biological Basis of Teleological Concepts, the editor of The Ayn Rand Lexicon and co-editor of the second edition of Ayn Rand’s Introduction to Objectivist Epistemology. Dr. Binswanger is a professor of philosophy at the Ayn Rand Institute’s Objectivist Academic Center and is a member of ARI’s board of directors. He is currently working on a book on the nature of consciousness.Dr. Binswanger is the author of "How We Know" and "The Biological Basis of Teleological Concepts", the editor of "The Ayn Rand Lexicon" and co-editor of the second edition of Ayn Rand’s "Introduction to Objectivist Epistemology". He is an instructor of philosophy at the Ayn Rand Institute’s Objectivist Academic Center and a member of ARI’s board of directors.TORE BOECKMANNWriterMr. Boeckmann has written and lectured extensively on Ayn Rand’s fiction and philosophy of esthetics. He edited for publication Rand’s The Art of Fiction. His own fiction has been published in Ellery Queen’s Mystery Magazine and Alfred Hitchcock’s Mystery Magazine. He is currently writing a book on Romantic literature.Thomas A. BowdenSpecialties: Legal issues, physician-assisted suicide, abortion rights, mandatory community service.Mr. Bowden, an attorney in private practice in Baltimore, Maryland, taught at the University Of Baltimore School Of Law from 1988 to 1994. Author of a booklet against multiculturalism, “The Enemies of Christopher Columbus,” he has also published op-eds in the Fort Lauderdale Sun-Sentinel, Philadelphia Inquirer, Portland Oregonian, Los Angeles Daily News, Minneapolis Star Tribune, and Charlotte Observer. He is a former member of the board of directors of The Association for Objective Law, a non-profit group whose purpose is to advance Objectivism, the philosophy of Ayn Rand, as the basis of a proper legal system. In that connection, Mr. Bowden has filed amicus curiae briefs in the U.S. Circuit Courts of Appeal for the Second and Third Circuits, challenging mandatory community service for high school students on legal and moral grounds.YARON BROOKPh.D., Finance, 1994, University of Texas at AustinDr. Brook is president and executive director of the Ayn Rand Institute. A former finance professor, he has published in academic as well as popular publications, and is frequently interviewed in the media. He has appeared on CNN, Fox News Channel and PBS among others. On college campuses across America and in the boardrooms of large corporations, he has lectured on Objectivism, business ethics and foreign policy.Dr. Brook is executive director of the Ayn Rand Institute. He is the coauthor of the national best-seller “Free Market Revolution: How Ayn Rand’s Ideas Can End Big Government” and a contributing author to both “Neoconservatism: An Obituary for an Idea” and “Winning the Unwinnable War: America’s Self-Crippled Response to Islamic Totalitarianism.”ANDY CLARKSONMBA University of MarylandMr. Clarkson is a decades-long Objectivist He has focused on researching the history of ideas and published The Impact of Aristotle Upon Christian, Islamic, and Jewish Cultures : A Compilation of Notes and Quotes From A Variety of Sources Plus Commentary, published in December 2016.PAT CORVINIPh.D., Electrical Engineering, 1995, University of California at Santa BarbaraDr. Corvini recently left a twenty-year career in semiconductor optoelectronics to work full time in the history of science and mathematics. She lectured on Archimedes at the 2003 Objectivist Summer Conference.SUSAN CRAWFORDB.S.N, Nursing, 1982, Marymount College, VirginiaSusan Crawford is a registered nurse. She has given two parenting courses and wrote the pamphlet “The Reading Habit/Money Management.” Susan is married to Jack Crawford and the mother of two sons, Jason and DavidERIC DANIELSPh.D., American History, 2001, University of WisconsinDr. Daniels is a visiting assistant professor of history at Duke University’s Program on Values and Ethics in the Marketplace. He has lectured at summer conferences and to numerous Objectivist community groups. He is an alumnus of ARI’s Objectivist Graduate Center (precursor to the Objectivist Academic Center). A contributor to the Oxford Companion to United States History, he is currently working on a book about American politics andDr. Daniels works at LePort Schools, teaching science and history, and as a curriculum developer. Previously, he was a professor at Clemson, Duke and Georgetown Universities. Dr. Daniels has published book chapters and articles on antitrust, individualism and economic freedom.John DennisPhD, Psychology, 2010, University of Texas at AustinDr. Dennis teaches at Catholic University in Milan, University of Perugia and University of Alberta. His research on motivation is funded by the EU and Templeton Foundation. He is a licensed psychologist trained in CBT. In 2013 Dr. Dennis started Melioravit, a scientific communication company that helps researchers get funded, published and cited.Robert van DortmondMSc in Applied Physics, Delft University of Technology; Executive Program, Stanford Graduate SchoolMr. van Dortmond teaches entrepreneurship at the University of Amsterdam/The Amsterdam Centre for Entrepreneurship. He is an active mentor, shareholder and board member of various startups. He speaks on Ayn Rand’s ideas and is an advisory board member of ARI Europe of which he was one of the initiators.Dianne DuranteSpecialties: Esthetics, painting, sculpture, homeschooling.Dr. Durante is a freelance writer on art and current events. She has lectured on painting and sculpture at Objectivist conferences; several of these lectures are available on tape from the Ayn Rand Bookstore. She has also just finished a book on New York sculpture, Forgotten Delights: The Producers. Dr. Durante and her husband homeschool their daughter in Brooklyn, NY.Alex EpsteinSpecialties: Current Affairs, racism, and moral defense of businessmen.Alex Epstein is an Objectivist speaker and writer living in Richmond, VA. His Op-Eds have been published in dozens of newspapers around the country, including The Houston Chronicle, The Atlanta Journal-Constitution, The Miami Herald, The Philadelphia Inquirer, and The Washington Times. He is also a regular contributor to The Intellectual Activist, a monthly magazine analyzing political and cultural issues from an Objectivist perspective. Mr. Epstein holds a BA in philosophy from Duke University, where he was editor and publisher of The Duke Review for two years.STUART MARK FELDMANM.A., Art, 1975, Rowan University, New JerseyStuart Feldman works in bronze, stone and wood, creating sculptures of the human figure expressing man’s most noble and inspiring qualities. A former instructor at the Pennsylvania Academy of Fine Art, he is cofounder of the Schuylkill Academy of Fine Art, in Philadelphia. His sculptures are held in private collections, and he has created a number of commissioned pieces.ROBERT GARMONGPh.D., Philosophy, 2002; University of Texas at AustinDr. Garmong is a graduate of the Objectivist Graduate Center, and has lectured on philosophy at many Objectivist conferences. He is the author of “J.S. Mill’s Re-Conceptualization of Liberty,” currently under submission to publishers. Dr. Garmong teaches philosophy at Texas A&M University and at Texas State University.MARILYN (GEORGE) GRAYB.S., Child Development, 1961, Iowa State UniversityMarilyn George is a retired Montessori teacher, school owner and administrator. She holds teaching certificates from both the American Montessori Society and the International Association of Progressive Montessorians and was a Montessori teacher for twenty-five years. She owned, administered and taught for ten years in her own school, which had an international reputation for excellence. She taught Montessori courses at Seattle University for more than ten years and has consulted for schools nationwide. Marilyn has been ballroom dancing since she met Ted Gray at a conference in 1989, at her first lesson, and today they compete at the Silver level.Debi GhateLLB, Law, University of Calgary, 1995Ms. Ghate is vice president of Education and Research at the Ayn Rand Institute, where she heads up a variety of educational and policy-related programs. She is also director of the Anthem Foundation for Objectivist Scholarship, an organization that supports academic scholarship based on Ayn Rand’s work.Onkar GhatePhD, Philosophy, 1996, University of CalgaryDr. Ghate is senior fellow and chief content officer at the Ayn Rand Institute. He specializes in Rand’s philosophy, Objectivism, and is ARI’s senior instructor and editor. He publishes and lectures on Rand’s philosophy and fiction, including application of Objectivism in the culture, and has been a guest on national radio and television programs.GENA GORLINPhD, Clinical Psychology, 2012, University of VirginiaMs. Gorlin has two years of experience conducting individual psychotherapy with anxious and depressed young adults. Her research has been published in highly regarded academic journals. She is also a graduate of the Objectivist Academic Center and a former board member of The Undercurrent, a national campus publication.Allan Gotthelf (deceased)Specialties: Love, self-esteem, happiness, Objectivism, AristotleAllan Gotthelf is emeritus professor of philosophy at The College of New Jersey. He is an internationally recognized authority on the philosophy of Aristotle, with many scholarly publications. He has lectured on Objectivism and Aristotle — including their views on love and sex, self-esteem, and individual happiness — throughout North America and in Europe and Japan. He has been a visiting professor at Swarthmore College, Georgetown University, Oxford University, Tokyo Metropolitan University, and most recently, the University of Texas at Austin. In 1987, Dr. Gotthelf was one of the founders of the Ayn Rand Society; a professional organization affiliated with the American Philosophical Association, Eastern Division, and has headed it since 1990. He enters his second year as Visiting Professor of Historyand Philosophy of Science (HPS) at the University of Pittsburgh. Prof. Gotthelf holds the Pitt Fellowship for the Study of Objectivism, funded by the Anthem Foundation and he will be working throughout the year on various projects in connection with his Fellowship. He is the author of On Ayn Rand (Wadsworth Publishing, 2000), the best-selling book in the Wadsworth Philosophers Series.4-19-2007 from his website:Visiting Professor, under the university's new Fellowship for the Study of Objectivism (Member: Classics, Philosophy and Ancient Science Program). A specialist on Aristotle's biology and philosophy, and on the philosophy of Ayn Rand, Gotthelf is emeritus professor of philosophy at The College of New Jersey, and has taught on a visiting basis at Swarthmore, Oxford, Georgetown, Tokyo Metropolitan, and the University of Texas at Austin. He is a life member of Clare Hall Cambridge, and was a visiting member of the Institute for Advanced Study, Princeton. Gotthelf is author of On Ayn Rand (Wadsworth Philosophers Series, 2000); co-editor of Philosophical Issues in Aristotle's Biology (Cambridge 1987); editor of Aristotle on Nature and Living Things (Pittsburgh 1985); and has prepared for publication D.M. Balme's posthumous editions of Aristotle's Historia Animalium (Cambridge 2002, Cambridge MA 1991). His collected Aristotle papers will by published next year by Oxford University Press, under the title: Teleology, Scientific Method, and Substance: Essays on Aristotle's Biological Enterprise. He is currently working on several Aristotle projects and an extended study of Rand's theory of concepts, essences, and objectivity.TED GRAYB.S., Mechanical Engineering, 1965, Northeastern University;M.S., Mechanical Engineering, 1971, Brooklyn Polytechnic InstituteTed Gray, an engineer, has been dancing since his teens. They both consider dancing primarily a social and romantic activity. Occasionally, they enter amateur dance competitions. As a couple they have given many formal and informal group lessons—at home, at conferences and on a cruise ship. Ted is a mechanical engineer with forty years experience in design and analysis of structures, and prevention of vibration. He is an amateur student of history, enjoying especially the biographies of great Americans and the history of technology. He has been a student of Objectivism for thirty-eight years.Hannes HackerSpecialties: history and politics of the space program, science and technology.Mr. Hacker graduated from the University of Notre Dame with a BS degree in aerospace engineering in May 1988. He earned a MS degree in aerospace engineering at the University of Texas at Austin December 1990. He has eleven years of space-flight operations experience including work on the space shuttle, international space station and commercial communications satellites.DAVID HARRIMANB.S., Physics, 1979, University of California at Berkeley;M.S., Physics, 1982, University of Maryland;M.A., Philosophy, 1995, Claremont Graduate University, CaliforniaDavid Harriman is the editor of Journals of Ayn Rand and a senior writer for the Ayn Rand Institute. He has lectured extensively on the history and philosophy of physics. He is currently developing the physical science curriculum at VanDamme Academy and working on two books: one demonstrating the influence of philosophy on modern physics (The Anti-Copernican Revolution) and the other presenting Leonard Peikoff’s theory of induction (Induction in Physics and Philosophy).David HolcbergSpecialties: Environmentalism, science, capitalism. David Holcberg holds a degree in civil engineering and is a senior writer for the Ayn Rand Institute.JONATHAN HOENIGCommunications and Philosophy, 1999, Northwestern UniversityMr. Hoenig manages Capitalistpig Hedge Fund, LLC. A former floor trader, his first book, Greed Is Good, was published by HarperCollins. Mr. Hoenig has written for publications including The Wall Street Journal, Wired andMarketWatch: Stock Market News - Financial News. He was named one of Crain’s Forty Under Forty and appears regularly on Fox News Channel.Gary HullSpecialties: Philosophy, multiculturalism, business ethics, education.Dr. Hull is director of the Program on Values and Ethics in the Marketplace at Duke University. His op-eds have been published in numerous newspapers, including the Los Angeles Times, the San Francisco Chronicle, the Orange County Register, the Philadelphia Inquirer, and the Chicago Tribune. He has made numerous television and radio appearances to discuss Ayn Rand’s philosophy, multiculturalism, affirmative action, the Elian Gonzalez affair, sex, ethics, politics. He has lectured on Ayn Rand’s philosophy at conferences around the world and, as a member of the Ayn Rand Institute’s Speakers Bureau, has spoken at universities across the country, including Harvard, Michigan at Ann Arbor, Wisconsin at Madison, Texas at Austin. Dr. Hull is the author of A Study Guide to Leonard Peikoff’s book Objectivism: the Philosophy of Ayn Rand, and is co-editor of The Ayn Rand Reader (Penguin/Plume, 1999), a collection of fiction and non-fiction writings by Ayn Rand.MARTIN F JOHANSENMS, Computer Science, 2009, University of OsloMr. Johansen is a PhD research fellow at SINTEF, the largest independent research institute in Scandinavia. He is currently completing his PhD studies at the University of Oslo as part of an international research project on software testing.Elan JournoBA, Philosophy, 1997, King's College, LondonMr. Journo, director of policy research at ARI, is completing a book on American policy toward the Israeli/Palestinian conflict. His 2009 book, “Winning the Unwinnable War,” analyzes post-9/11 U.S. foreign policy. His writing has appeared in “Foreign Policy,” “Journal of International Security Affairs” and “Middle East Quarterly.”ELLEN KENNERPh.D., Clinical Psychology, 1992, University of Rhode IslandDr. Kenner, a clinical psychologist, has taught university courses in introductory psychology, abnormal psychology and theories of personality. She gives talks on romance, self-improvement, psychological self-defense, parenting and communication skills. She is in her eighth year as host of the nationally syndicated radio talk show The Rational Basis of Happiness®.Ryan KrausePhD, Strategic Management and Organization Theory, 2013, Indiana UniversityDr. Krause is an assistant professor at Texas Christian University’s Neeley School of Business. He researches corporate governance and has published in “Academy of Management Journal,” “Strategic Management Journal” and “Journal of Management.” His research has been covered by the “Wall Street Journal,” “USA Today,” “Businessweek” and Fox Business Network.Andrew LaymanAndrew Layman is a Senior Program Manager at Microsoft where he works on Internet and database technologies. Prior to joining Microsoft in 1992, he was a Vice President of Symantec Corporation and original author of the Time Line project management program.Peter LePort, M.D.Specialties: Medicine, free market reform of healthcare, medical savings accountsDr. LePort, a full-time surgeon, lectures nationwide on free market reform in healthcare, particularly on the benefits of medical savings accounts. He is a member of the board of directors of Americans for Free Choice in Medicine. He co-wrote a healthcare reform proposal that discusses voluntary, tax-free medical savings accounts and high-deductible personal health insurance and which includes a method to privatize Medicare. He earned his medical degree from Downstate Medical Center, Brooklyn, New York, and is a former assistant professor of surgery at that institution. He is a member of the Faculty of the American College of Surgeons and of the Orange County Surgical Society.Andrew LewisPostgraduate Diploma of Philosophy, 1994, University of Melbourne, AustraliaMr. Lewis has studied philosophy at the Objectivist Academic Center, the University of Melbourne and the University of Southern California. He worked with Leonard Peikoff on his radio show, has lectured at Objectivist conferences, and is principal at VanDamme Academy, where he teaches a three-year history curriculum covering ancient, European and American history.JOHN LEWIS (deceased)Ph.D., Classics, 2001, University of CambridgeDr. Lewis is assistant professor of history at Ashland University, where he holds an Anthem Fellowship for Objectivist Scholarship. He is Assistant Professor of History in the Department of History and Political Science. He has published in several professional journals, and has been a visiting scholar at Rice University and Bowling Green State UniversityEDWIN A. LOCKEPh.D., Industrial Organizational Psychology, 1964, Cornell University.Dr. Locke is Dean’s Professor of Leadership and Motivation (Emeritus) at the Robert H. Smith School of Business at the University of Maryland, College Park. He is internationally known for his research and writings on work motivation, leadership and related topics, including the application of Objectivism to psychology and management. He is a senior writer for the Ayn Rand Institute and has published numerous op-eds.Keith LockitchPhD, Physics, 1999, University of Wisconsin at MilwaukeeDr. Lockitch is an ARI fellow and director of advanced training. In addition to speaking and writing for ARI on issues related to energy, climate and environmentalism, he teaches writing for the OAC and has developed courses on Ayn Rand’s ideas and novels for a variety of audiences.ROBERT MAYHEWPh.D., Philosophy, 1991, Georgetown UniversityDr. Mayhew is associate professor of philosophy at Seton Hall University. He is the author of Aristotle’s Criticism of Plato’s Republic and The Female in Aristotle’s Biology and the editor of Ayn Rand’s Marginalia, Ayn Rand’s The Art of Nonfiction, Essays on Ayn Rand’s “We the Living” and (forthcoming) Ayn Rand’s Q & A. He has completed a book on Ayn Rand’s HUAC testimony and is preparing for publication a collection of essays on Ayn Rand’s Anthem.Arline MannArline Mann is an attorney. She is vice president and associate general counsel of Goldman, Sachs & Co.John P. McCaskey, Ph.D. in history, is the founder and chairman of the Anthem Foundation for Objectivist Scholarship. He spent twenty years in the computer business, most recently as founder of Epiphany, Inc., before returning to academia in 2001. He studies and teaches history and philosophy of science at Stanford University.Scott McConnellSpecialties: Volunteerism, Communism in America, Ayn Rand's life. Mr. McConnell is a former literature teacher and high school English teacher. He has a BA in behavioral sciences and worked in Hollywood as a script reader. He has given several lectures on Ayn Rand's life.Shoshana MilgramPhD, Comparative Literature, 1978, Stanford UniversityDr. Milgram, associate professor of English at Virginia Tech, specializes in narrative fiction and film. She has lectured on Ayn Rand at Objectivist and academic conferences and has published on Ayn Rand, Hugo and Dostoevsky. Dr. Milgram is editing the draft of her book-length study of Ayn Rand’s life (to 1957).Ken Moelis. Mr. Moelis is founder and chief executive officer of Moelis & Company, a global investment bank that provides financial advisory, capital raising and asset management services to a broad client base including corporations, institutions and governments. Mr. Moelis has over thirty years of investment banking experience. Prior to founding Moelis & Company, he worked at UBS from 2001 to 2007, where he was most recently president of UBS Investment Bank and, previously, Joint Global Head of Investment Banking. Mr. Moelis serves on the University of Pennsylvania Board of Trustees, the Wharton Board of Overseers, the Board of the Tourette Syndrome Association, and the Board of Governors of Cedars Sinai Hospital.Jean MoroneyCertificate, 1996, Objectivist Graduate Center, Ayn Rand Institute;MS, Psychology, 1994, Carnegie Mellon University;MS, Electrical Engineering, 1986, Massachusetts Institute of TechnologyMs. Moroney is president of Thinking Directions, a business that develops and teaches methods in applied psycho-epistemology. She has given her flagship course, Thinking Tactics, to corporate and public audiences across North America. She is writing a book titled “Smarter: How to Achieve Your Goals When Nothing Goes as Planned.”Adam Mossoff is Professor of Law at George Mason University School of Law. He is also Co-Director of Academic Programs and a Senior Scholar at the Center for the Protection of Intellectual Property at George Mason, which he co-founded in 2012. He teaches and writes in the areas of patent law, trade secrets, trademark law, property law, and internet law. He has published extensively on the theory and history of how patents and other intellectual property rights are fundamental property rights. His article on the very first patent war, the Sewing Machine War of the 1850s, has been widely cited in today's public policy debates concerning patent litigation, patent licensing, and patent pools. He has testified before the Senate, and he has spoken at numerous congressional staff briefings, professional association conferences, and academic conferences, as well as at the PTO, the FTC, the DOJ, and the Smithsonian Institution. He is Co-Chairman of the Intellectual Property Committee of the IEEE-USA, and he is a member of the Amicus Committee of the American Intellectual Property Law Association, the Public Policy Committee of the Licensing Executives Society, and the Academic Advisory Board of the Copyright Alliance. ADAM MOSSOFF is an expert in patent law and property theory. He has published numerous law review articles and book reviews on topics in legal philosophy, patent law, and property law, including in law reviews at the University of Arizona and UC-Hastings, and in the interdisciplinary law journal, the University of Chicago Law School Roundtable. He was a visiting lecturer and John M. Olin Fellow in Law at Northwestern University School of Law, where he taught a seminar on property theory. Immediately prior to coming to MSU College of Law, he clerked for the Hon. Jacques L. Wiener, Jr., of the U.S. Court of Appeals for the Fifth Circuit. Professor Mossoff graduated from the University of Chicago Law School with honors in 2001. He has a M.A. in philosophy from Columbia University, where he specialized in legal and political philosophy, and a B.A. in philosophy from the University of Michigan, where he graduated magna cum laude and with high honors in philosophy. Hi is now an Associate Professor of Law at George Mason University School of LawSpecialties: Philosophy of Law, Constitutional Law, Intellectual Property Rights, Patent RightsJ. PATRICK MULLINS is a doctoral candidate in the history department of the University of Kentucky. He is in the last stages of writing his doctoral dissertation with the help of a generous grant from the Ayn Rand Institute.Travis NorsenSpecialties: Physics, science, history and philosophy of science, science education.Mr. Norsen is a physics and philosophy double-major at Harvey Mudd College in Claremont, CA. He is currently attending his final year of a PhD program in physics at the University of Washington in Seattle. Mr. Norsen is also a former adjunct instructor of physics at DigiPen Institute of Technology in Redmond, WA.JOHN E. OPFER, who still tops the list of Amazon Reviewers on the CyberNet Scoreboard, is Assistant Professor of Psychology at Ohio State University where he specializes in cognitive and developmental psychology. Nowadays he's too busy reviewing his research findings to review books. His work at OSU's Concepts and Learning Lab explores how young children form and change their concepts, such as concepts of living things and number. His website is at <Department of Psychology - John Opfer> where you will find links to several of his fascinating papers.Michael PaxtonMFA, 1984, New York UniversityMr. Paxton directed the world premiere of Ayn Rand’s Ideal (1989) and adapted and directed a dramatic presentation of Anthem (1991). His documentary, Ayn Rand: A Sense of Life, won an Academy Award nomination and a Golden Satellite Award for Best Feature Documentary. He teaches production design and film history at the Art Institute in Hollywood.Lee PiersonPhD, 1982, Psychology, Cornell UniversityDr. Pierson, director of the Thinking Skills Institute at Fairleigh Dickinson University, teaches students and business professionals how to keep any thought process moving toward its goal by activating the right knowledge as needed. He has a long-standing interest in and recently participated in life-extension research.AMY PEIKOFFJ.D., 1998, University of California, Los Angeles School of Law;Ph.D., Philosophy, 2003, University of Southern CaliforniaDr. Amy Peikoff is an Anthem fellow at the University of Texas at Austin, where she is teaching undergraduate courses in ethics and epistemology. Her writings on legal and philosophical issues have appeared in academic journals and leading newspapers. She has taught for the Objectivist Academic Center and lectured for Objectivist organizations and at conferences. Visiting Fellow at Chapman University’s Law School.Leonard PeikoffPh .D., Philosophy, 1964 New York UniversityFrom 1957 until 1973, Peikoff taught philosophy at Hunter College, Long Island University, New York University, the University of Denver and the Polytechnic Institute of Brooklyn.After that, he worked full-time on The Ominous Parallels (published 1982) and gave lectures across the country. He gave courses on Ayn Rand's philosophy regularly in New York City, which were taped and played to groups in some 100 cities in the U.S., Canada, and Europe. In addition, he spoke frequently before investment and financial conferences on the philosophic basis of capitalism.Dr. Peikoff, who is a naturalized American citizen, was born in Winnipeg, Canada, in 1933. His father was a surgeon and his mother, before marriage, was a band leader in Western Canada. He has been a contributor to Barron's and an associate editor, with Ayn Rand, of The Objectivist (1968-71) and The Ayn Rand Letter (1971-76).He is author of Objectivism: The Philosophy of Ayn Rand (Dutton, 1991), the definitive statement of Objectivism.Steve PlafkerJ.D., 1973 USCPh.D., Math, 1966 UNIVERSITY OF ILLINOISBS, MATH, MIT, 1961Dr. Plafker is a retired Los Angeles County deputy district attorney. His teaching experience includes teaching law to law students and to undergraduates. Before becoming a lawyer, he taught mathematics at Tulane University. He is a founder and member of the Board of Directors of The Association For Objective Law (TAFOL).Richard RalstonSpecialties: Ayn Rand’s life, Objectivism (General), Projects of the Ayn Rand Institute, Volunteerism, Foreign Policy, Journalism and MediaAfter serving seven years in the U.S. Army, Mr. Ralston completed an M.A. in International Relations at the University of Southern California in 1977. He then began a career in newspaper publishing and direct marketing. He has been the circulation director and publisher of The Christian Science Monitor, a radio producer, a national television news business manager, and a book publisher. As an independent direct marketing consultant, his clients included IBM, British Airways, CNN, and the Los Angeles Times. His book Communism: Its Rise and Fall in the 20th Century was published in 1991. Mr. Ralston is now Managing Director for the Ayn Rand Institute.JOHN RIDPATHPh.D., Economics, 1974, University of VirginiaDr. Ridpath (York University, retired) writes and speaks in defense of capitalism, and on the impact throughout Western history—including the American Founding era—of the ideas of the major philosophers. A recipient of numerous teaching awards, and nominee for Canadian Professor of the Year, he continues to lecture throughout Europe and North America.Jonathan Paul Rosman, MDSpecialties: Medicine, psychiatry.Dr. Rosman is a board certified psychiatrist, with additional qualifications in the subspecialties of addiction psychiatry and forensic psychiatry. Prior to entering full-time private practice in California in 1989 he was an assistant professor at Case Western Reserve University in Cleveland, Ohio. For several years, Dr. Rosman has been a psychiatric consultant to the City of Hope National Medical Center in Duarte, California, and is the psychiatric consultant to the Sleep Disorders Center at Huntington Memorial Hospital in Pasadena, California. He is also medical director for the Eating Disorder Center of California, a private, intensive outpatient clinic in Brentwood, California, devoted to the treatment of patients with anorexia and bulimia.Dr. Rosman is a published writer and lecturer on various aspects of psychiatry. Dr. Rosman's theoretical orientation is broad-based, drawing on and integrating aspects of cognitive-behavioral, short-term psychodynamic and biologic theories with Objectivist epistemological principles. He practices as both a psychotherapist and a psychopharmacologist.GREG SALMIERIB.A., Philosophy, 2001, The College of New JerseyPhD, Philosophy, 2008, University of PittsburghDr. Salmieri is a philosophy fellow at the Anthem Foundation and co-secretary of the Ayn Rand Society (a professional group affiliated with the American Philosophical Association). He teaches at Rutgers University. He has published and lectured on Aristotle and Ayn Rand and is co-editor of forthcoming books on both thinkers.Richard M. SalsmanSpecialties: Banking, free market economics, economic forecasting, capitalism, investmentsRichard M. Salsman is president and chief market strategist of InterMarket Forecasting, which provides quantitative research and forecasts of stocks, bonds, and currencies to guide the asset allocation decisions of institutional investment managers, mutual funds, and pension plans. He is the author of numerous books and articles on economics, banking, and forecasting from a free-market perspective, including Breaking the Banks: Central Banking Problems and Free Banking Solutions (American Institute for Economic Research, 1990) and Gold and Liberty (American Institute for Economic Research, 1995). Mr. Salsman’s work has appeared in The Intellectual Activist, the New York Times, Investor’s Business Daily, The Wall Street Journal, Forbes, and Barron’s. From 1993 to 1999, he was a senior vice president and senior economist at H. C. Wainwright & Co. Economics. Prior to that he was a banker at Citibank and the Bank of New York. Mr. Salsman is an adjunct fellow at the American Institute for Economic Research and the founder of The Association of Objectivist Businessmen.Lee Sandstead received his B.A. Philosophy/B.S. Mass Communication from Middle Tennessee State University in December 1996, when he was awarded the prestigious award for “Outstanding Magazine Journalism Graduate.” He has studied art history at the University of Memphis’ graduate program, and most recently, the art history doctoral program at the Graduate Center of the City University of New York, New York City. He is a popular writer/photographer/lecturer of art-historical subjects. He has delivered almost 50 keynote lecture-addresses to such prestigious institutions as: Yale, Duke, University of Michigan, Penn State, NYU and the Academy of Realist Art in Toronto. Articles of his have been published in numerous journals, and his photography has been seen in publications such as: The New York Times, Fortune, and Ms. Magazine. He currently teaches art history at Montclair State University and is author of the forthcoming book on American master-sculptor Evelyn Beatrice Longman (1874-1954DINA SCHEIN FEDERMAN (deceased) is completing her article on "Integrity in The Fountainhead_" for ROBERT MAYHEW's upcoming collection of essays. She will also be delivering two lectures at the European Objectivist conference in London this month. Her writing projects include severalarticles on Virtue Ethics, a movement in academic ethics.DANIEL SCHWARTZBA, Liberal Arts, 2006, St. John’s CollegeMr. Schwartz is a doctoral candidate in philosophy at UC San Diego, where he is working on a dissertation titled “Baconian Foundationalism and the Problem of Certainty.” He specializes in early modern philosophy and the history of the philosophy of science.PETER SCHWARTZM.A., Journalism, 1972, Syracuse UniversityPeter Schwartz is the founding editor and publisher of The Intellectual Activist. He is the editor and contributing author of Ayn Rand’s Return of the Primitive: The Anti-Industrial Revolution, and is chairman of the board of directors of the Ayn Rand Institute.Thomas ShoebothamMM, Orchestral Conducting, 1996, University of New MexicoMM, Cello Performance, 1992, Eastman School of MusicMr. Shoebotham is music director of the Palo Alto Philharmonic. Previous conducting engagements have included Berkeley Opera, Opera San José, Peninsula Symphony Orchestra and many other groups. He has lectured on music, taught in school music programs and performed numerous recitals as a cellist and pianist over the last twenty years.Stephen SiekPhD, Musicology, 1991, University of CincinnatiDr. Siek, professor emeritus at Wittenberg University, has recently publishedEngland’s Piano Sage: The Life and Teachings of Tobias Matthay. For many years he has lectured and written about the early work of Frank Lloyd Wright, including a scholarly study of Wright’s 1909 home for Burton Westcott in Springfield, Ohio.BRIAN P. SIMPSONPhD, Economics, 2000, George Mason UniversityDr. Simpson is a professor at National University in San Diego. He is author of the book Markets Don’t Fail! and he has a number of papers published in academic journals. He is currently working on another book titled “Money, Banking, and the Business Cycle,” which he hopes to publish soon.Steve SimpsonJD, 1994, New York Law SchoolMr. Simpson is director of legal studies at the Ayn Rand Institute. A former constitutional lawyer for the Institute for Justice, he writes and speaks on a wide variety of legal and constitutional issues, including free speech and campaign finance law, cronyism and government corruption, and the rule of law.Aaron SmithPhD, Philosophy, 2010, Johns Hopkins UniversityDr. Smith is an instructor at the Ayn Rand Institute where he teaches in the Objectivist Academic Center and the Summer Internship program. He lectures for ARI and develops educational content for the Institute’s e-learning programs.Tara SmithPhD, Philosophy, 1989, Johns Hopkins UniversityDr. Smith, professor of philosophy at the University of Texas, holds the BB&T Chair for the Study of Objectivism and the Anthem Foundation Fellowship. She has published books on values, virtues, and individual rights. Her latest, “Judicial Review in an Objective Legal System,” is forthcoming in fall 2015 (Cambridge University Press).MARY ANN SURESM.A., Art History, 1966, Hunter College, New YorkMary Ann Sures taught art history at Washington Square College of N.Y.U. and at Hunter College. She applied Objectivist esthetics to painting and sculpture in a ten-lecture course, “Esthetics of the Visual Arts,” which was written in consultation with Ayn Rand. Her philosophical approach to art history is presented in “Metaphysics in Marble” (The Objectivist, February/March, 1969). She is co-author with her (late) husband Charles of Facets of Ayn Rand (published by the Ayn Rand Institute), memoirs of their longtime friendship with Ayn Rand and her husband Frank O’Connor.C. BRADLEY THOMPSONPh.D., History, 1993, Brown UniversityC. Bradley Thompson is the BB&T Research Professor at Clemson University and the Executive Director of the Clemson Institute for the Study of Capitalism. He has also been a visiting fellow at Princeton and Harvard universities and at the University of London.Professor Thompson is the author of Neoconservatism: An Obituary for an Idea and the prize-winning book John Adams and the Spirit of Liberty. He has also edited The Revolutionary Writings of John Adams, Antislavery Political Writings, 1833-1860: A Reader, co-edited Freedom and School Choice in American Education, and was an associate editor of the four-volume Encyclopedia of the Enlightenment. His current book project is on the ideological origins of American constitutionalism.Dr. Thompson is also an occasional writer for The Times Literary Supplement of London. He has lectured around the country on education reform and the American Revolution, and his op-ed essays have appeared in scores of newspapers around the country and abroad. Dr. Thompson's lectures on the political thought of John Adams have twice appeared on C-SPAN television.LISA VANDAMMEB.A., Philosophy, 1994, University of Texas at AustinLisa VanDamme is the owner and director of VanDamme Academy, a private elementary and junior high school in Laguna Hills, California. She specializes in the application of Objectivism to educational theory. Her previous lectures on homeschooling, hierarchy and the teaching of values will be included in a forthcoming education anthology featuring Leonard Peikoff’s “Philosophy of Education.”Don WatkinsBA, Business Administration, 2005, Strayer UniversityMr. Watkins is a fellow at the Ayn Rand Institute. He is the author of “RooseveltCare: How Social Security Is Sabotaging the Land of Self-Reliance” and coauthor, along with Yaron Brook, of the national best-seller “Free Market Revolution: How Ayn Rand’s Ideas Can End Big Government.”KEITH WEINERPh.D., Economics, 2012, New Austrian School of Economics (non-accredited)Dr. Weiner is the founder and CEO of Monetary Metals, a company on a mission to pay interest on gold, and the president of the Gold Standard Institute USA.He makes the economic arguments, as well as the moral, for a free market in money and credit. There has never been an unadulterated gold standard in history, as all governments (including the U.S.) have regulated and interfered with banking, even when other enterprises were unshackled. Today our monetary system is failing, and Keith describes the mechanics in detail, why making the passionate case for gold as the money of free markets.He is also the founder of DiamondWare, a software company sold to Nortel in 2008.Glenn WoiceshynSpecialties: Education, ethics, environmentalism, science, politics.Mr. Woiceshyn is currently developing curriculum and teaching materials for grades 4 to 6 based on his understanding of Objectivism and his experience in "homeschooling" his son and other children. As a freelance writer, Mr. Woiceshyn's op-eds have appeared in numerous newspapers, including the Los Angeles Times, Houston Chronicle, Philadelphia Inquirer, Baltimore Sun and Miami Herald.JAANA WOICESHYNM.B.A., 1983, Helsinki School of Economics and Business Administration; Ph.D., Organization and Strategy, 1988, University of Pennsylvania (Wharton School)Dr. Woiceshyn is an associate professor at the Haskayne School of Business, University of Calgary. She has taught business ethics and strategic management to undergraduate, MBA and executive MBA students and to various business audiences since 1987.BARRY WOODPh.D., History of Art and Architecture, 2002, Harvard UniversityDr. Wood is curator of the Islamic Gallery Project at the Victoria & Albert Museum in London. He has lectured and published on subjects ranging from Persian poetry to Web design.Darryl WrightSpecialties: Ethics, political philosophy, ObjectivismDarryl Wright is associate professor of philosophy at Harvey Mudd College, a member of the Claremont Colleges consortium. He received his Ph.D. in philosophy from the University of Michigan in 1991, and his A.B. in philosophy from Princeton University in 1985. Dr. Wright has published scholarly articles and/or lectured on the history of ethics, early twentieth-century philosophy, value theory, coercion, and other topics in philosophy.

To the patients health, you mean? I think you need to be more specific with your question.Edited to reflect your comment:There are a lot of factors that make up the cost of healthcare, and certainly to an extent, the cost of patients seeing doctors unnecessarily for visits/tests certainly takes a share of that rising cost.Unfortunately I am unable to really answer this question as I have always worked at not for profit hospitals and healthcare systems and have taken a salary and not charged per patient/procedure.However, here is a great article in the New Yorker Magazine Annals of Medicine on the subject of unnecessary tests and rising healthcare costs which I think you might find interesting and useful.The cost conundrumWhat a Texas town can teach us about HealthcareWritten by Dr. Atul GawandeCostlier care is often worse care. Photograph by Phillip Toledano.It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. “The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.From the moment I arrived, I asked almost everyone I encountered about McAllen’s health costs—a businessman I met at the five-gate McAllen-Miller International Airport, the desk clerks at the Embassy Suites Hotel, a police-academy cadet at McDonald’s. Most weren’t surprised to hear that McAllen was an outlier. “Just look around,” the cadet said. “People are not healthy here.” McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.One day, I went on rounds with Lester Dyke, a weather-beaten, ranch-owning fifty-three-year-old cardiac surgeon who grew up in Austin, did his surgical training with the Army all over the country, and settled into practice in Hidalgo County. He has not lacked for business: in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it. I walked around with him as he checked in on ten or so of his patients who were recuperating at the three hospitals where he operates. It was easy to see what had landed them under his knife. They were nearly all obese or diabetic or both. Many had a family history of heart disease. Few were taking preventive measures, such as cholesterol-lowering drugs, which, studies indicate, would have obviated surgery for up to half of them.Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)Was the explanation, then, that McAllen was providing unusually good health care? I took a walk through Doctors Hospital at Renaissance, in Edinburg, one of the towns in the McAllen metropolitan area, with Robert Alleyn, a Houston-trained general surgeon who had grown up here and returned home to practice. The hospital campus sprawled across two city blocks, with a series of three- and four-story stucco buildings separated by golfing-green lawns and black asphalt parking lots. He pointed out the sights—the cancer center is over here, the heart center is over there, now we’re coming to the imaging center. We went inside the surgery building. It was sleek and modern, with recessed lighting, classical music piped into the waiting areas, and nurses moving from patient to patient behind rolling black computer pods. We changed into scrubs and Alleyn took me through the sixteen operating rooms to show me the laparoscopy suite, with its flat-screen video monitors, the hybrid operating room with built-in imaging equipment, the surgical robot for minimally invasive robotic surgery.I was impressed. The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don’t. But that rule doesn’t hold for health care.At McAllen Medical Center, I saw an orthopedic surgeon work under an operating microscope to remove a tumor that had wrapped around the spinal cord of a fourteen-year-old. At a home-health agency, I spoke to a nurse who could provide intravenous-drug therapy for patients with congestive heart failure. At McAllen Heart Hospital, I watched Dyke and a team of six do a coronary-artery bypass using technologies that didn’t exist a few years ago. At Renaissance, I talked with a neonatologist who trained at my hospital, in Boston, and brought McAllen new skills and technologies for premature babies. “I’ve had nurses come up to me and say, ‘I never knew these babies could survive,’ ” he said.And yet there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.“It’s malpractice,” a family physician who had practiced here for thirty-three years said.“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?“Practically to zero,” the cardiologist admitted.“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.In an odd way, this news is reassuring. Universal coverage won’t be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with. So the idea that there’s plenty of fat in the system is proving deeply attractive. “Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated.Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.I had what I considered to be a reasonable plan for finding out what was going on in McAllen. I would call on the heads of its hospitals, in their swanky, decorator-designed, churrigueresco offices, and I’d ask them.The first hospital I visited, McAllen Heart Hospital, is owned by Universal Health Services, a for-profit hospital chain with headquarters in King of Prussia, Pennsylvania, and revenues of five billion dollars last year. I went to see the hospital’s chief operating officer, Gilda Romero. Truth be told, her office seemed less churrigueresco than Office Depot. She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience. And when I inquired, “What is going on in this place?” she looked surprised.Is McAllen really that expensive? she asked.I described the data, including the numbers indicating that heart operations and catheter procedures and pacemakers were being performed in McAllen at double the usual rate.“That is interesting,” she said, by which she did not mean, “Uh-oh, you’ve caught us” but, rather, “That is actually interesting.” The problem of McAllen’s outlandish costs was new to her. She puzzled over the numbers. She was certain that her doctors performed surgery only when it was necessary. It had to be one of the other hospitals. And she had one in mind—Doctors Hospital at Renaissance, the hospital in Edinburg that I had toured.She wasn’t the only person to mention Renaissance. It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) Romero and others argued that this gives physicians an unholy temptation to overorder.Such an arrangement can make physician investors rich. But it can’t be the whole explanation. The hospital gets barely a sixth of the patients in the region; its margins are no bigger than the other hospitals’—whether for profit or not for profit—and it didn’t have much of a presence until 2004 at the earliest, a full decade after the cost explosion in McAllen began.“Those are good points,” Romero said. She couldn’t explain what was going on.The following afternoon, I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”Then why do hospitals in McAllen order so much more surgery and scans and tests than hospitals in El Paso and elsewhere?In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.“Do we provide better health care than El Paso?” Gelman asked. “I would bet you two to one that we do.”It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.And, I realized, few people in their position do. Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.Why? Some of it could reflect differences in training. I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I’d been trained. But the doctor in Alexandria was going to send Walker home. That was how he’d been trained. Suppose things change for the worse? I asked him. It’s extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”“How much?” I asked.“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.“I’ll be there,” the cardiologist said.Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.“Medicine has become a pig trough here,” he muttered.Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.How about doing the opposite and increasing the role of big insurance companies?“What good would that do?” Dyke asked.The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.Source: http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum