The Value of Health Care Experiments

Atul Gawande has a lengthy piece in the latest New Yorker on attempts to control medical expenditures by targeting the costliest, at-risk patients.  Unfortunately, it's not out from behind the pay wall, but I recommend buying the magazine--it's a sobering, but often inspiring, read.

Perhaps it mirrors our general outlook on health care that for Ezra Klein, the article seems to be a beacon of hope, while for me, it's ultimately pretty depressing.  Ezra sees these as the beginnings of the sort of experimentation that is going to allow us to figure out what works, and thereby control health care costs.  I see them as admirable local efforts that are unlikely to go anywhere.

The history of social science--very much including public health studies--is littered with exciting programs that promised to both significantly improve the lives of the targeted populations, and to save money.  Yet you will notice that spending on things like health care and education is still going up, while the major reforms that have succeeded in either changing lives or controlling costs have been extraordinarily blunt: things like the EITC, where we just give poor people money; or welfare reform, where we stop doing so.

Why don't we have more revolutions in human affairs?  For starters, because these revolutionary studies are usually working with a pretty small number of patients.  This means that there's going to be a lot of variance--some will, by chance, show good results; some will, by chance, seem like disasters.  The programs with "good results" will survive and get written up by social science journals and people like Atul Gawande; the programs that end up costing money will collapse and disappear into a welter of administrative embarassment.  Note that I don't say that this is what has happened in the case of these particular programs.  The problem is, with small programs like this, it always has to be at the back of your mind.  That's one of the major reasons why promising pilot programs are so rarely replicated successfully. 

But not the only reason. Even the programs that genuinely work have a lot of things going for them that a broader program won't.  They have a crack team of highly educated experts who are extremely excited about the program, and understand the ideas behind it backwards and forwards.  They work in a controlled environment, and usually have a decent amount of administrative support for their efforts.  They are time limited, which matters--people are willing to endure lots of things for a limited, known duration that they wouldn't do permanently. They are often offering bonuses for participation.

Then they get implemented in the real world, with ordinary people who don't particularly want to change the way they've always done things, don't really care about the noble ideas behind your program, and don't see any end to it.  And the effects disappear.  

Ezra writes "We don't really know if his success can be replicated. But somebody's can be."  I'm not really so sure. These aren't medical problems; they're social problems.  And there hasn't actually been a lot of inspiring progress on the social problem front in the last hundred years.  "Give poor people more money" is mostly as far as we've gotten.  It works for problems that mostly stem from not having enough money--like malnutrition, or lack of adequate clothing.  But it's the opposite of the problem we're trying to solve now.