Taking the Wand from Gawande

While I liked Atul Gawande's healthcare article in the NY'er, I think his Times op-ed today is an airy and fatuous summary. The takeaway message of the NY'er article, to my mind, was that deep cultural shit -- matters that had to do with initial conditions -- had a great deal to do with whether healthcare ended up being cheap or expensive in a given region. The upshot of the article is that if doctors would behave decently, and not act on the perverse incentives the system offers them, everything would work fine. (In all fairness, Gawande also talks about local community meetings -- sort of a healthcare version of a PTA -- keeping the doctors in line. But he can't be serious about that.) The problem is that he just sort of waves his magic wand instead of suggesting a concrete institutional framework to keep the doctors in line.

To my mind the important finding of Gawande's work is that there is in fact a lot of waste in the system: that the rising cost of healthcare includes the substantial cost of medical profiteering. The problem is that solutions like this -- "a unified local system focused on quality of care" -- are terribly unsustainable, as Gawande acknowledges at the end of the NY'er piece. Why would anyone care about giving patients just the right amount of care if they could make a ton of money by ordering unnecessary procedures instead? (Competition is apparently empirically not an answer; if it were, then one would have better healthcare in towns that weren't dominated by large monopolies like the Mayo Clinic, as people can't as a rule choose to go to the ER in the next town. Per Gawande this is not the case.)