Money and Finance

TESTING, TESTING - by Atul Gawande

Thanks to Farnam Street for passing Dr. Gawande’s latest piece along.

There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen. Problems of the second kind, by contrast, are never solved, exactly; they are managed. Reforming the agricultural system so that it serves the country’s needs has been a process, involving millions of farmers pursuing their individual interests. This could not happen by fiat. There was no one-time fix. The same goes for reforming the health-care system so that it serves the country’s needs. No nation has escaped the cost problem: the expenditure curves have outpaced inflation around the world. Nobody has found a master switch that you can flip to make the problem go away. If we want to start solving it, we first need to recognize that there is no technical solution.

Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. They want to provide good care, but they also measure their success by the amount of revenue they take in, and, as each pursues its individual interests, the net result has been disastrous. Our fee-for-service system, doling out separate payments for everything and everyone involved in a patient’s care, has all the wrong incentives: it rewards doing more over doing right, it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure.

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front. Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county. Transforming health care everywhere starts with transforming it somewhere. But how?

We have our models, to be sure. There are places like the Mayo Clinic, in Minnesota; Intermountain Healthcare, in Utah; the Kaiser Permanente health-care system in California; and Scott & White Healthcare, in Texas, that reliably deliver higher quality for lower costs than elsewhere. Yet they have had years to develop their organizations and institutional cultures. We don’t yet know how to replicate what they do. Even they have difficulties. Kaiser Permanente has struggled to bring California-calibre results to North Carolina, for instance. Each area has its own history and traditions, its own gaps in infrastructure, and its own distinctive patient population. To figure out how to transform medical communities, with all their diversity and complexity, is going to involve trial and error. And this will require pilot programs—a lot of them.

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None of this is as satisfying as a master plan. But there can’t be a master plan. That’s a crucial lesson of our agricultural experience. And there’s another: with problems that don’t have technical solutions, the struggle never ends.

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Related previous posts:

Dr. Atul Gawande - 2009 Commencement Speeches

A Lifesaving Checklist - By Atul Gawande

THE CHECKLIST - by Atul Gawande

Related link: The New Yorker: Video of Atul Gawande

Other recommended articles written by Dr. Gawande:

The Cost Conundrum

The Cost Conundrum Redux

- Atul Gawande And Charles Munger On Why More Health Care Isn't Better
Link to article: Atul Gawande And Charles Munger On Why More Health Care Isn't Better American health care is obsessed with more. But the industry is beginning to realize that more isn’t always what’s best for patients. Dr. Atul Gawande,...

- Interview With Atul Gawande - By Alex Howard
Found via Simoleon Sense. Dr. Atul Gawande (@Atul_Gawande) has been a bard in the health care world, straddling medicine, academia and the humanities as a practicing surgeon, medical school professor, best-selling author and staff writer at the New Yorker...

- Atul Gawande: Why The Uninsured Are Still Vulnerable
Tens of millions of Americans don’t have access to basic care for prevention and treatment of illness. For decades, there’s been wide support for universal health care. Finally, with the passage of Obamacare, two years ago, we did something about...

- Malcolm Gladwell Reviews Atul Gawande's Latest Book: The Checklist Manifesto
I can't wait to read this book! As Charlie Munger says: "Checklist routines avoid a lot of errors. You should have all this elementary [worldly] wisdom and then you should go through a mental checklist in order to use it. There is no other procedure...

- Dr. Atul Gawande - 2009 Commencement Speeches
Dr. Atul Gawande gave two commencement speeches in June. The first I found via the Farnam Street blog. (Below are some of excerpts. Click on the paragraphs for the entire speeches.) June 4, 2009 Speech at the HSPH Commencement 2009 We have arrived, I...

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