The Power of Pilot Programs

The always-enlightening Atul Gawande evaluates the new health-care bill’s efforts (or lack thereof) to control runaway health-care costs. The bill, which has been widely criticized for its lack of significant cost reductions, proposes a few small pilot programs aimed at cost containment. As Gawande writes: “[W]here we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet — here’s the interesting thing — history suggests otherwise.” He goes on to compare health care reform to the agricultural reform that transformed the nation (and the world) in the early 1900’s and was implemented piecemeal in a series of small experimental programs. Gawande concludes on a hopeful note: “[I]f we’re willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity. We’ve done it before.” [%comments]


Pilot programs beat the Great Leap Forward.

Kevin H

I'm a bit skeptical. If the pilot programs are really so great. Why not just have the pilot programs and scrap the rest? It would be a cheap, quick bill that probably would have wide, if not enthusiastic, support.


"The bill ,,, has been widely criticized for its lack of significant cost reductions."

Really? I thought rather the opposite was true. The Republicans are complaining no end about cost reductions to Medicare.


Yes, agricultural policy in the U.S. is such a resounding success.

Just what I want: Massive, politically motivated, endless, market-distorting subsidies for healtcare as well as for agriculture.

Oh wait, State and Federal Governments already do that to healthcare, which is the main reason why healthcare is such a mess, followed closely by trial lawyers.

And to think that some doctors will get paid to not treat patients in order to keep prices high, just like farmers are paid to not grow crops.


Eric M. Jones

That's how the military does it-- Invade small weak countries frequently to practice for wars with big ones.


It's worth noting that the state of agriculture in our country--specifically, large-scale production considerations and profit-driven processing--are arguably responsible for the healthcare epidemic (obesity, diabetes, heart disease) currently elevating our health costs.


Jeez, I would take a million small pilot programs over the single giant experiment the Obama administration seems bent on launching us all on.


I really wonder what portion of increased ag production came from the USDA and what part came from technology. The 2 aren't completely independent, but the current system of crazy ag subsidies isn't something I want for health care.

Marshall Sashkin

Dr. Gawande is, unfortunately, wrong. These pilots, like so many others (especially in education, but in other areas as well) will fail because they do not incorporate basic knowledge of the diffusion of innovation. The great agricultural pilot Dr. Gawande cites worked because the extension agent to be was extremely smart and enlisted an "opinion leader" who agreed to try out the various innovations (when promised there would be no risk to him). Others copied him because they had, in the past, watched this farmer to see what his "best practices" were, or even gone to him (usually informally) for advice. The agent Dr. Gawande mentions was not only smart enough to see this, but applied the lesson to the eventually-developed Agricultural Extension Service. Agents are not just academics but are usually farmers. They know who the local opinion leaders are, who to go to with new ideas. (This same pattern has been used extensively by drug companies who track physicians who are "opinion leaders," who other doctors emulate in prescribing new drugs. These are the physicians the "detail men"--who are now as or more often women--are most anxious to connect with in pushing a new drug.) None of this knowledge--which has been academically developed by Dr. Everett Rogers, the best-known modern scholar of innovation diffusion--is used in planning the many government pilot programs in the bill.


not necessarily science minded, but definately personal

I cannot help but begin once more to wonder about the healthcare business. Here's the context. I went with a family member to the doctor this week For a second opinion . Thus far, the previous doctor recommended taking pills as if that would solve a physical problem that, as it seems, will not go away. So I thought, ok, let's see if the problem can be solved through diet or by natural means. New doctor- same old approach except this one seemed as if he were going to push taking not one pill, but two long term. Recommended a blood test and that we come back in a week or so. I came away (several hundred dollars later) thinking-- one more pill pushing, money grabbing doctor. Perhaps I was too quick to judge- but that was my sense of this guy. What's a person to do who cares about a loved one. Well, I plan to go to the library and figure out what to do myself because frankly, I suspect that with the exception of a certain few (that if I am lucky, I might come across byu chance) I am unlikely to find a doctor who really practices medecine. Instead, I will hear the same story line over and over again as if every case is exactly the same. That is not medecine as it was practiced in the past-- it's mass produced pill pushing and a health business for the benefit of doctors and the insurance industry they serve. We don't need more insurance companies involved in our business of health care, we need real doctors and frankly, at the moment, I only know of one. His specialty is quite limited and he does not take insurance. I don't blame him. So what's this business of being forced to buy insurance? Whose interest does that serve? Again, I say regulate health insurance and make it in the interest of doctors to want to go back to practicing medicine instead of public mass marketing.



Pilot programs only will be copied if they're cost effective AND not ignored. When you have massive governmental impediments (artificially high malpractice insurance, over-regulated health insurance, pharmaceutical company lobbying, etc.), even wildly successful pilots will be pushed aside because they rock the boat. The health care problem is an endemic "corruption" problem, not one of having no idea what to do.


This "pilot program" idea sounds good. I suggest three steps for implementation:

1. Divide the country into 13, or even 50 completely independent pilot programs, which are allowed to subdivide as they see fit.

2. Prohibit the federal government from interfering with these programs, since ideas which are good enough get adopted without being forced from above, and since even good ideas benefit from having experimental "control groups" to compare against.

3. Identify Congressmen and Presidents who try to ignore step 2, vote them out of office, and spit on them when encountering them on the sidewalk.

The Constitution did a pretty good job with steps 1 and 2, so we're 66% of the way there...

Mekhong Kurt

The piece is right; pilot programs can work, and work well. But as another contributor to these comments notes, to be adopted on a wide scale, if the intitial effort is a small pilot program, it's critical that opinion leaders be involved.

Think of the Green Revolution several decades ago, when agriculture in Third World countries advanced by leaps and bounds, especially in the areas of disease resistance and crop yield. (I'm drawing a blank on name of the recently deceased scientist who was a leader in this.) That's how he went about it, as I understand it.

I grew up on a small farm that evolved into a ranch in Texas, and while I was in high school, I raised pigs for an agricultural class. I had an excellent teacher at hand: my Father. He recommended I raised the same breed he had, a time point at which to sell, what to feed them, and so on. (He had moved into industry by that point, but kept the ranch.) There was one other local who raised the same breed, though his selling strategy was different; even so, he was an invaluable source of more information. Finally, the extension agent and my teacher wanted me to try some new things no one in the area had tried.

People remembered my Dad's successes, and new of the other guys, and learned of mine. Next thing you new, that particularly breed -- rare in the area at the time -- had been adopted my many pig farmers, and many of them adopted various best practices from my Dad, the other guy, and even me. Then later, they adopted each other's.

So, that wasn't a government pilot program, but it involved many of the same principles. I was amazed when middle-aged and older men came to me, a mere teenager, for advice!


Eric M. Jones

@12- roystgnr:

I'm not sure we're 66% there. We had that messy business of the Civil War, ya know....


"These pilots, like so many others (especially in education, but in other areas as well) will fail because they do not incorporate basic knowledge of the diffusion of innovation"

This doesn't make sense to me; the point of the pilots is to find out what works. Then the *next* step is to take the successful ones and figure out how to encourage diffusion.

Diffusion doesn't have to be part of the pilot design, its part of what comes after that.


Mekhong Kurt:

You're thinking of Norman Borlaug.