Friday, March 20, 2009

Should medical reforms be comprehensive or incremental?

469 words

A fundamental problem for medical reformers is to decide whether needed changes should be introduced as a package deal, one major piece of legislation, or by means of a series of smaller changes, taking one step at a time.

In organization theory this issue is stated in terms of “comprehensive rationality” versus “incrementalism” (or, more graphically, “muddling through.”)

There are both advantages and disadvantages to both of these approaches to major reforms, and proponents of major medical system reforms need to be aware of them. A single major package offers the possibility of a certain neatness and elegance and appears to allow designing a medical system that makes sense when seen as a whole. It also offers the prospect of getting the job done much faster than a series of incremental changes would allow.

A series of incremental changes, on the other hand, allows for a more experimental approach,. It is easier to back out of smaller changes if they do not work as expected. In a country like the U.S., some changes can be tried at the state level and then imitated at the national level if they work out well----the “laboratory of federalism” idea.

A major problem with reforming in a single big step is that it is very hard, perhaps impossible, to predict the consequences when we make a major change in a highly complex social system. And there is no doubt that the American medical care system, accounting for about one sixth of the total economy, is extremely complex.

A series of small changes, on the other hand, may take too long and may move the overall situation into a blind alley from which it is difficult to escape. And they can produce such a complex medical system, even more so than today’s, that the average person cannot figure out how to use it.

It is politically difficult to achieve major changes because perspectives on all proposals will differ greatly, and opponents of any particular change can always argue plausibly that it will not work and will produce disastrous consequences. And all of the vested interests that will be harmed by the change can join together and form a powerful bloc against it. Smaller changes, which will injure fewer vested interests, may therefore be more politically feasible.

In the former Soviet empire, a similar argument took place between advocates of “shock therapy,” (who argued that you cannot step across the Grand Canyon in two or more steps), and those who wanted to move to a private-enterprise economy more gradually. Just which approach worked better in those countries is hard to say.

In actual practice, these two approaches to change are often combined, and that is what I expect will happen as we seek improvements in the American medical care system.

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