Pizza Menus and Irrational Doctors.

A few days ago, Dan Ariely of Duke University, was on NPR to discuss his research on the way doctors make decisions, which mirrors the troubling ways consumers make decisions. If a pizza menu starts with the pie with everything, then descends into options with fewer and fewer toppings, people will order more toppings than if they're looking at a menu that puts the plain pie at the top.

"If you go to the hospital these days," Ariely says, "you will see that they have these electronic order forms. ... And sometimes these order forms are empty, nothing is selected for them. The default is nothing, and they have to pick what they want to order. And sometimes some tests are preselected for them." When they did an experiment on how these two options affected the choices doctors made, "in the empty set, physicians chose an average five tests. And in the full set, they chose an average 13 tests. ... And the difference was about $1,300 per patient."

What does this have to do with the health-care reform that might just finally pass soon?

The health-care reform bill that passed the Senate includes dozens of pilot programs and initiatives designed to test new ways of cutting costs without compromising care (and maybe even improving it). While there may not be a physician pizza menu pilot, as Atul Gawande wrote in December, "there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care."

And that only scratches the surface. There are demonstration projects for alternatives to litigation to resolve disputes over medical errors. There are projects to create and track quality measures in outcomes of particular diseases. There's a pilot program on "bundling," to explore a movement away from the fee-for-service system that is so expensive. There are programs meant to improve physician quality, and the efficiency of payment systems, and coordination of care (you can read about some of them here).

Individually, each of these programs cost only a little bit to implement -- a few million dollars here and there. And chances are that many if not most of them will turn out to have little impact. But there's also a good chance that among the pilots, a few will exceed expectations and produce real cost savings. We won't know until we start experimenting. It's one more thing to keep in mind when, once it passes, we start debating whether the reform glass is half full or half empty.

-- Paul Waldman

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