Gawande: A 'hodgepodge' of pilot programs may be the right approach to cut health costs

Legislation to overhaul the American health system lacks an overarching plan to curb the rising costs of medicine, according to Atul Gawande, the influential surgeon and writer, in an essay for the Dec. 14 issue of The New Yorker. "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," Gawande writes. "Instead, what it offers is . . . pilot programs."

But, he suggests, that's not necessarily a bad thing. Health care costs are a problem that is not "amenable to a technical solution." That type of problem is meant to be "managed," rather than solved, Gawande writes, through a process of trial and error, and ongoing reform. Gawande compares health reform to agricultural reform. "At the start of the twentieth century, another indispensable but unmanageably costly sector was strangling the country: agriculture." The country was confronted with a fragmented, inefficient agricultural system that ignored evidence that could improve outcomes and consumed huge resources. But, "The United States did not seek a grand solution. Private farms remained, along with the considerable advantages of individual initiative. Still, government was enlisted to help millions of farmers change the way they worked. The approach succeeded almost shockingly well" (Gawande, 12/7).