HealthLawProf Blog

Editor: Katharine Van Tassel
Concordia University School of Law

Wednesday, December 1, 2004

New Yorker Article by Atul Gawande

041129_newyorker For those fans of the New Yorker Magazine, and specifically Atul Gawande, the December 6th issue has a terrific article on the many difficulties faced by current efforts to measure and to improve the quality of health care.  Dr. Gawande's article, "The Bell Curve," addresses the variations that exist in healthcare and specifically examines whether these variations in care matter.  He argues that these variations in care may have a profound impact on the type of care a person receives.   As the name of the article suggests, Dr. Gawande finds that  the variations in care tend to fall into a bell curve with a number of doctors with poor outcomes for their patients, a handful with remarkably good results, and a great undistinguished middle. 

After a discussion which examines the difficulty in measuring quality of care, the article then focuses on Dr. Don Berwick, CEO of the Institute for Healthcare Improvement (a small nonprofit organization), and his mission to "improve health care by promoting candid communication among doctors, hospitals, and patients about the shortcomings of a hospital's program, and its plans for improvement." Mr. Berwick states that he believes "openness would drive improvement, if simply through embarrassment."  One of the hospitals that has adopted his approach is Cincinnati Children's Hospital.  They report that their new honesty policy has increased rather than decreased patients' faith in the care that they receive from the hospital and its medical staff.  The article acknowledges that "the bell curve isn't going away," and thus addresses potential medical liability issues such as, "Will being in the bottom half [of the bell curve] be used against doctors in lawsuits?"  The answer, according to the article, is most likely yes.

"The Bell Curve" is available on-line at the New Yorker website, as is a companion interview with Atul Gawande, discussing his search for better quality of care in medicine.  I found both pieces very informative and enjoyable to read.   If you like the article, Atul Gawande also has a wonderful book, Complications:  A Surgeon's Notes on an Imperfect Science, which was a 2002 National Book Award Finalist.

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If you are interested in information flows in medical markets, please have a look at a style of ‘auction’ that I have invented (though its hard to believe others wouldn't have thought of it before this) which seems to me to solve a range of incentive problems which are unleashed by the collection and publication of data. In essence, one lets the person or medical unit that is having its quality measured, predict in advance their success rate. Their predicted success rate is progressively compared with their results to produce a moderating factor. When corrected by the moderating factor predictions then become unbiased predictions of results. The merits of such an approach are several-fold.

o It produces simple numbers which generate important information about quality.

o Those numbers can be used by medical administrators, and by patients to select the medical service that best meets their needs.

o It disciplines medical service providers to make predictions. In itself this process is likely to be beneficial in helping them to understand better a range of factors influencing success

o There is never any incentive for medical service providers to turn someone away because they fear they will harm their rating. They simply make a bid that reflects their assessment of the relative risk of their patients.

The idea is written up in a more general context in an article accessible at The article is available at Article.pdf. The relevant material begins on p 96. and what I call ‘prognostic auctions’ are outlined on p. 97. They are also illustrated in some slides which outline the idea and reinvigorating reform.pdf.

Anyone interested in the animated slides which illustrate how things work should contact me at

Posted by: Nicholas Gruen | Dec 10, 2004 6:11:47 PM

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