An Argument for Pilot Programs

This is Atul Gawande, writing about the Senate health bill in The New Yorker:

Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.

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. … 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.

And how many models of excellence have been created by pilot programs? Exactly none.

Comments (9)

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  1. Michael Kirsch, M.D. says:

    Speaker Pelosi has proposed some toothless ‘pilot programs’ to pursue tort reform. This will have the same fate as you suggested in your post. Interestingly, her view of tort reform, which is written in the House legislation is that caps against non-economic damages cannot be addressed nor can attorneys’ fees be adjusted. Sounds like landmark legislation.

  2. Ken says:

    I like your last line. There is no way we are going to get meaningful reform with pilot programs.

  3. Larry C. says:

    Agree with Ken. Pilot progams are no substitute for real markets.

  4. John Stuart Mill says:

    This is a dishonest post. It gives the impression Gawande is critical of the proposed healthcare legislation when, in fact, he thinks it is absolutely right-on.

    Gawande’s point is that pilot programs are preferable to a “master plan” because they enable us to learn by trial-and error. In his long piece, he argues that is how U.S. agricultural production became the envy of the world.

  5. Devon Herrick says:

    Gawande makes some interesting points, but he’s ignoring the fact that small farmers operate in a (nearly) perfectly competitive business. Therefore, they have an incentive to boost productivity and efficiency because the result is higher profit. The health care marketplace is not competitive. In health care, there is no incentive to boost efficiency when becoming more efficient actually costs the provider money. Because providers are paid by task, inefficiency often pays better if by being inefficient we mean ordering unnecessary tests and marginal treatments.

  6. Dan S says:

    The New Yorker has always been a world leader in publishing fiction. Non-fiction is another matter. I read the Gawande piece until I couldn’t control my nausea any longer. To compare a commodity production business like agriculture with a professional service business like medicine is the ultimate apples and oranges fallacy. Do we need “pilot programs” to re-structure the legal profession? It’s not a big stretch to make the argument in education, but that is still a by-rote kind of operation and, let’s face it, kids can be home schooled with excellent results. Corporate wonks are always wanting to make medicine just like a widget factory, but the widgets we are striving to help behave the way they want to when they leave the office, we can’t throw away defective or old models and we can’t replace parts of an airplane when it’s at 35,000 feet without suffering a crash.

  7. John Goodman says:

    John Stuart Mill: The indented material is from Gawande. The nonindented comments are mine. I think it is reasonably clear that Gwande supports the pilot programs approach to reform in the bill and I do not.

  8. Linda Gorman says:

    All proposals like this do is turn health care into education. We have paid for innumerable pilot programs in education. Curricula are studied and changed year in and year out. Fads come and go.

    Models of excellence created by them? None.

    Improvements in education occur when private individuals come up with new models that succeed or fail in the educational marketplace. This includes charter schools that have to succeed by pulling kids away from existing public schools, new homeschooling curricula, and new models of adult education.

  9. Michael Kirsch, M.D. says:

    Too many pilot programs are not done as an honest experiments. They are done as stalling maneuvers, to avoid doing what should be done. If the pilot approach is optimal, let Speaker Pelosi raise taxes in her district alone as a ‘pilot program’. Then, after a few years, we can evaluate the benefits before making the project a national effort.