Friday, December 18, 2009

Health Care is not like Agriculture

Atul Gawande is an excellent writer and has a lot to say about the practice of medicine. His columns in the New Yorker have been very educational, and his observations about what some doctors do to make medicine safer and more effective are really incisive. His June article on the difference in costs of providing approximately equivalent services across the country caught a lot of people's attention. He has continued to explore issues related to health care reform, but I'm afraid his most recent article misses the mark.

In December's New Yorker, Dr. Gawande describes how the US Department of Agriculture spread information about the practice of farming by hiring extension agents who convinced local farmers to try out pilot projects to demonstrate the benefits of scientific farming, and where they had successes, recruiting additional farmers by the power of example. Gawande seems to think that most of the improvement in American farm productivity is due to the work of the USDA. He then proposes that this approach is hidden in the draft health care bills, and that it is likely to work as well for health care as it did for agriculture.

I'm very doubtful, and the reason is that everything the USDA did was voluntary. That's why they got volunteers to run pilot projects--they needed to show that the ideas worked, and they couldn't force anyone to go along with it. And voluntarism is one thing you can be sure will be missing from the pilot projects (disguised as targetted programs for particular districts) included in the health care bill. The ideas may well be tried out in one local area at a time, but I'd bet each pilot will be mandatory for some set of doctors, clinics, or insurers. The kinds of approaches that could be made to work if practitioners were allowed to try them are very different from the kinds that might work when practitioners are forced to follow them. The big problem in health care is that there's already way too much regulation. Adding more layers of regulation, and more requirements, won't give any of the participants in this industry any incentive to improve results or lower prices.

A solution would have to include finding ways to make more of medicine look like lasek surgery, or any other competitive industry, but nothing like that is on the table. The Cato institute has been pushing for opening up insterstate competition in various ways, but I don't get the impression that anyone with the ability to influence outcomes is listening to them.

1 comment:

Robert said...

My first contact with Gawande was a few weeks ago, when libertarians took a different New Yorker article apart, pointing out that Gawande does not understand the concept of "the market". (He rejected patient-interest in medical costs on the grounds that patients were not about to bargain "like they were in a souk" with a surgeon.)
This New Yorker article shows his bias toward "businessmen are stupid, government is wise". He explicitly rejects the Reagan-ism that the government can be the problem. I disagree.
My current medical group is indeed in the dark ages when it comes to everyday high-tech. Surely the Palo Alto Medical Foundation, in the heart of Silicon Valley, should know about email? Why indeed they do. Why do they not conduct part of their medical practice via email? I bet it is because "Government Medicare and government-regulated insurance companies won't pay for it."