Testing, Testing

February 27, 2010 3:25 PM

Atul Gawande offers a way for health care to be improved through experimentation and pilot programs, much as agriculture was in 20th century
posted by reenum (24 comments total)

It's funny, I almost posted this myself. It's a great article. I'm not involved in medicine in any capacity, but I try to read everything Gawande writes. He's one of my favorite writers, by far.
posted by HighTechUnderpants at 3:48 PM on February 27, 2010

Here are two responses to Gawande's recent output from Physicians for a National Health Program.
posted by RogerB at 3:52 PM on February 27, 2010 [2 favorites]

I guess we need experiments because we are unwilling to look at all the other civilized countries in the world that have perfectly functional national health programs?
posted by DU at 4:31 PM on February 27, 2010 [7 favorites]

...perfectly functional national health programs?

Out of true ignorance here, but what countries are these?
posted by cjorgensen at 4:53 PM on February 27, 2010

Out of true ignorance here, but what countries are these?

Throw a dart at Western Europe or Scandinavia.
posted by Davenhill at 5:22 PM on February 27, 2010 [6 favorites]

Sorry, I didn't mean "perfectly functional" in the sense of "functioning perfectly" but in the sense of them being "perfectly good". Like "I know crunchy PB isn't your favorite, but eat this sandwich anyway--it's perfectly good!"
posted by DU at 5:23 PM on February 27, 2010 [1 favorite]

Wow, I couldn't even get pass the first page. Thought I was gonna make it through it. But when I got to the part where I was told to "turn to page 621" of the current health care bill, my head exploded.

I'm dying to know though, does the article really try to compare the US agriculture industry in the early 1900s to the current US healthcare industry?

And I would love to know his suggested solution--sounds like the dude has got it all figured out. Fix the government-run Medicare and Medicaid, reducing costs, and then implement another government program that is successful. Fix the problems and implement a successful solution! Genius.
posted by stevenstevo at 5:32 PM on February 27, 2010

To be fair, DU, each of those health care systems evolved in a different environment than our own. Because our health care system is different, it's entirely possible (I would think even likely) that the best option for getting inclusive, cost-effective care in the US may be quite different than in any of those other countries.

Frankly, I think it's a pretty good thing that these pilot programs will exist. I like the idea of taking a 'throw stuff against a wall, see what sticks' approach.
posted by HighTechUnderpants at 5:35 PM on February 27, 2010

I like the idea of taking the expressed will of the people seriously.
posted by DU at 5:45 PM on February 27, 2010

Ref comments by DU and Hightechunderpants :

Human centered design approach versus spaghetti on the wall approach
posted by infini at 6:01 PM on February 27, 2010

This kind of experimentation is good, and should HCR pass, I expect it will help to lower costs. But improving agricultural productivity was much more amenable to this kind of approach because it was fundamentally a technical problem, while health care reform is a political one.

Lowering the amount of money spent on health care isn't conceptually very hard- there are only two ways to do it. Reduce the amount of health care provided, or reduce the cost per unit of health care. We could use some of both in the U.S., but the biggest problem is the cost per unit, as these graphs show. If you keep actual treatments the same and simply adjust our treatments costs to be equal to Canada's, health care spending falls by roughly 50%. But in order to do this, you have to take money away from doctors, or hospitals, or drug companies, or device manufacturers.

This is a very different kind of challenge from figuring out the best soil preparation or grazing techniques, whose improvements hurt no one. That doesn't mean that our health care system isn't amenable to experimentation- it's just that this is really a political science experiment, not a medical or economic one. The people running these pilot programs are going to be trying to find ways to reduce income to health care providers that won't cause the public or legislators to interfere.
posted by Gnarly Buttons at 6:35 PM on February 27, 2010 [4 favorites]

Gawande got at least 3 shout outs during the health reform summit on Thursday, from BOTH sides of the isle.

I like a lot of his ideas, especially the checklist idea for health delivery, although its applicability to ALL of medicine may prove more difficult. Checklists are great for procedures, operations, or other standardized situations, but it becomes more difficult to see the parallels to the office environment or a chaotic emergency room.
posted by i less than three nsima at 6:37 PM on February 27, 2010

To be fair, DU, each of those health care systems evolved in a different environment than our own. Because our health care system is different, it's entirely possible (I would think even likely) that the best option for getting inclusive, cost-effective care in the US may be quite different than in any of those other countries.

That really doesn't make much sense. The whole point of HCR is to change the system into another one. A change obviously entails some transition costs, some labor pains, but when it's done. And we have the new system.

I like the idea of taking the expressed will of the people seriously.

So we should scrap HCR? That seems to be what the polls say now, even though most of the individual components of the bill poll well. Oh and they also want to cut spending without cutting any of the major extant budget items (Medicare, Social Security, education, the millitary, etc)
posted by delmoi at 7:09 PM on February 27, 2010 [1 favorite]

Checklists are great for procedures, operations, or other standardized situations, but it becomes more difficult to see the parallels to the office environment or a chaotic emergency room.

I actually disagree. Anywhere where there are common mistake made, a checklist could theoretically help. And it might help to reduce the Chaos in said chaotic emergency room. It might not be needed in an office environment, but I think doing more things in an office using checklist like software could speed things up.
posted by delmoi at 7:14 PM on February 27, 2010

Because our health care system is different, it's entirely possible (I would think even likely) that the best option for getting inclusive, cost-effective care in the US may be quite different than in any of those other countries.

Yes, because Europeans and Scandinavians have easily upgradeable, external, modular vital organs; just rack in the new heart, twist a few dials, and reboot. Cheap and easy.

Modern medicine is pretty much only a century old. Bodies are the same everywhere, medicine is pretty much the same (sure, their are regional centers of excellence, but there are also "medical tourists" who go to India to get the same treatment cheaper than at the prices available in the US).

The difference isn't the health care system: it's the legal, regulatory, and most importantly medical finance systems that are different in the US -- different and worse than any other First World country.

And that difference is all about making absolutely sure that the Plaintiff Bar, Big Pharma, and Big Insurance can and will get rich off our suffering and dying.
posted by orthogonality at 7:56 PM on February 27, 2010 [9 favorites]

Wow, I couldn't even get pass [sic] the first page. ... I'm dying to know though, does the article really try to compare the US agriculture industry in the early 1900s to the current US healthcare industry?

I guess you'll never know. And the Republicans love you for it.

Perhaps this is more suitable for you.
posted by neuron at 9:53 PM on February 27, 2010 [5 favorites]

Harsh, but fair.
posted by orthogonality at 9:55 PM on February 27, 2010

Interestingly enough, a similar case (for using small pilot projects and extending them to larger spheres) has been made for improving Canadian health care in the book "Prescription for Excellence," (free at the link), by Michael Rachlis. It seems that so much in the world of medicine works along the lines of "this is how we do it because this is how it's always been done," and so much is open to improvement just by looking at how things run and tinkering a little bit.
posted by greatgefilte at 9:57 PM on February 27, 2010

Also keep in mind how poorly the US ranks in basic public health metrics. Infant mortality is a good yardstick. You don't need expensive drugs and fancy machines to reduce infant mortality. Food assistance and a couple of doctor visits will seriously improve a country's stats. You just need to make basic low-tech medical care available to those who need it.

But here we are, one of the richest, most advanced countries in the world and we rank 46^th in infant mortality. We're behind Italy. Slovenia kicks our ass. Our infant mortality rate is double that of the top-ranking countries like Singapore, Japan, and the Nordic countries.
posted by ryanrs at 10:23 PM on February 27, 2010

This is a very different kind of challenge from figuring out the best soil preparation or grazing techniques, whose improvements hurt no one.

The article says that from 1900 to 1930 a quarter of the entire US workforce was displaced from the agricultural sector. Do you think that was a painless transition?
posted by peeedro at 11:04 PM on February 27, 2010

Did anyone else notice that Gawande compared single-payer to Stalinist farm collectivization?
posted by indubitable at 6:22 AM on February 28, 2010

I caught that. Given that vehemence of rejection of a public option correlates really well with being content to rubber stamp Bush appointees who made Trofim Lysenko look like Erwin Chargaff, it's a pretty ballsy statement.
posted by Kid Charlemagne at 7:33 AM on February 28, 2010

That's an interesting link, Buttons. Without disputing the underlying point that costs are inflated in the US, I do want to point out that it's misleading to compare costs between the US and other countries on the basis of gross providers charges, since the US system is unique in the degree to which net reimbursement is decoupled from notional charges. After backing out contractual discounts to payors, denied charges, charity care and prompt pay discounts on patient balances and bad debts, a hospital might see less than 50 cents on the dollar in their charges actually reimbursed; though that figure will vary wildly based on the hospital's payor mix and charge structure.

What's more, most of that money will be reimbursed in a way that's not price-sensitive at all, as it will be reimbursed prospectively (for example, according to the Ambulatory Payment Classification fee schedule for outpatient care to Medicare beneficiaries), according to a set fee schedule without reference to the provider's charges. When a provider raises their charges, they'd be lucky to see ten cents in increased reimbursement for every dollar in price increases.

It's illustrative that when we look at the Medicare reimbursement amounts from the graphs you link to (which are more illustrative of actual reimbursement, though lower than what a commercial insurance plan would typically pay), the fees look to be more in line with those in industrialized countries, though still at the high end of the range.

Of course, I would argue that this Rube Goldberg reimbursement environment is in its own right one of the most significant drivers of the inflated costs of care in the US, both directly from the armies of billing office staff and expensive software and consultants that providers need to cope with their revenue cycle, and indirectly from things like cost-shifting and perverse incentives that make providing expensive and technologically complicated acute-care interventions more profitable than basic primary care and case management.

Incrementalist approaches like Gawande's leave me pretty cold because they tend to amount to slapping another layer of complexity on a system that's already too complicated as it is.
posted by strangely stunted trees at 2:16 PM on February 28, 2010

Also keep in mind how poorly the US ranks in basic public health metrics. Infant mortality is a good yardstick. You don't need expensive drugs and fancy machines to reduce infant mortality. Food assistance and a couple of doctor visits will seriously improve a country's stats. You just need to make basic low-tech medical care available to those who need it.

But here we are, one of the richest, most advanced countries in the world and we rank 46th in infant mortality. We're behind Italy. Slovenia kicks our ass. Our infant mortality rate is double that of the top-ranking countries like Singapore, Japan, and the Nordic countries.

African-American infants die at something around 600%-800% the rate of white infants. I'm sure it's just a coincidence that the states who not so long ago opposed equal education for black kids, who most favor executions (of disproportionately black prison populations), who most actively oppose Affirmative-Action, also happen to be the states who most oppose providing the kinds of medical assistance to poor families that would help eliminate this gigantic disparity in infant mortality rates for African-American infants.

Or maybe eugenics isn't a bug so much as a feature?

(Oh, I know, that's terribly unfair. That was a long time ago)
posted by Davenhill at 5:25 PM on February 28, 2010