Atul Gawande, MD is an accomplished surgeon at Brigham & Women’s, a Rhodes scholar and recipient of a MacArthur “genius” grant, and a writer with two well-received books that are collections of essays he has written for The New Yorker.

He recently published one of these essays called The Cost Conundrum about health care reform, quality and the costs of health care. And I am happy to see more and more brain power, like Gawande’s, spent on the topic. As President Obama recently said, “The greatest threat to America’s fiscal health is not Social Security, though that’s a significant challenge. 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.”

Looking at Medicare data on how much is spent per enrollee, in specific areas around the country, he travelled to McAllen, TX to see what made that market the most expensive place in the country when it comes to Medicare expenditures. He talked to the physicians there and researched the quality of care provided there. He compared McAllen, TX to places like Mayo Clinic and Grand Junction, CO, which provide superior care at 1/3′rd the cost.

He did not find McAllen’s costs to be higher because doctors and hospital’s were profitting inappropriately, or due to higher malpractice insurance costs, or because the doctors there are providing extraordinarily good medicine. His conclusion will likely make physicians AND patients squirm a little: the source of the difference in health care spending is “overuse of medicine” by hospitals and physicians alike. When it comes to ordering expensive tests and procedures, more is definitely not better. “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,” writes Gawande.

Gawande’s argument is that simply achieving universal insurance – whether it’s a public single payer plan or a mix of private and public programs – will not be enough. Costs will continue to run amok, and quality will decline, if we don’t foster carefully researched and coordinated care for populations instead of giving physicians incentives to flog (or reward) patients with unnecessary and tests and treatments. Here’s Gawande’s final paragraph:

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.

(As a follow-up to this essay The New Yorker has also published the text of Dr. Gawande’s recent commencement speech at the University of Chicago Medical School, which further addresses the subject, in a truly elegant way.)