We were pleased to read this essay in Modern Healthcare by David L. Brown, M.D., chief executive and co-founder of Curadux, a healthcare decision-support firm that’s partnering with Cambridge Management Group in some projects.
Americans dealing with advanced illness are at risk of overtreatment and undertreatment of their conditions because powerful and silent incentives are often driving their healthcare, rather than their own unique values and goals. After 38 years of practicing medicine inside the world’s elite healthcare institutions, and as a survivor of my own advanced illness, this is my foremost concern for current and future generations of patients and their families.
For those serving inside modern medical institutions, these risks are well known. As one caregiver recently told the Institute of Medicine, “When you take the time to find out what’s most important to patients and families, they make very reasonable choices. The challenge is that our healthcare system does not encourage these conversations, our professional providers frequently do not have the time or training, and treatment measures default to those that are health system centered.”
Healthcare is not always patient-centered because our third-party payer system disrupts the normal buyer-seller relationship we often take for granted. In healthcare, for reasons of public policy, the consumer isn’t always the paying customer for the services they consume, which distorts incentive structures throughout healthcare (and not always for the patient’s benefit).
Overtreatment — treatment that is unnecessary or futile for improving a person’s quality of life—is the dominant problem today. It may cause unwanted, invasive and expensive care, as well as unnecessarily prolonged and painful deaths. Health systems are subtly incentivized to overtreat patients because they generate more revenue based on the volume of services provided. Physicians are incentivized to recommend more services because they want to minimize perceived risks to patients and their own legal liability. Without clear guidance to the contrary, physicians default to treating a condition, often no matter how futile or painful for the patient.
Undertreatment — the lack of necessary treatment for improving a person’s quality of life — is the emerging problem. Policymakers are seeking ways to control healthcare costs as governments bear more financial responsibility for healthcare due to an aging population, the expansion of government programs, and increased consumption of healthcare by individuals. Since policymakers can’t change demographics and since a policy decision has been made to expand programs and subsidies, the primary option left for policymakers is to limit consumption of services.
Like most service industries, healthcare providers have traditionally been paid fees for the services they provide. Healthcare is unique, however, because the third-party payer system eliminates the natural market mechanism for limiting consumer demand and optimizing the quality and quantity of services around the perceived value to the consumer. At present, without a meaningful limit on consumer demand, providers act in their self-interest and deliver higher volume of services, which generates more revenue and increases costs.
To control costs, whether wise or unwise, policymakers opted against moving toward a market-based model whereby consumers assume more responsibility for healthcare and, instead, expanded the current system. They are now testing an artificial mechanism for controlling demand by simply capping payments to providers through population-health concepts. While this may reduce costs, it creates the risk that providers may discourage healthcare services for people who may legitimately benefit from them.
To permanently realign healthcare incentives around the individual would require overhauling the entire system so market forces could naturally optimize consumption. This is unlikely because of legitimate public policy issues and the practical difficulty of overhauling established commercial, financial, and regulatory frameworks in a polarized political environment.
Today, patients must educate themselves and stay actively involved in aligning their values and goals with their healthcare decisions. Primary-care physicians traditionally led this process through end-of-life conversations, but as clinical production pressures and demands have increased, physicians have less time to thoroughly discuss and analyze each patient’s unique values and goals. Instead, physicians now often rely more on other staff to perform this function. While these staff can be useful, the rich expertise provided by experienced physicians is often lost. True patient-centered care for patients and families facing an advanced illness is clearly ready for further innovation.
Dr. David L. Brown has practiced medicine for 38 years. He recently retired as chairman of the Anesthesiology Institute at the Cleveland Clinic. He has also led the anesthesiology departments at the University of Texas M.D. Anderson Cancer Center, University of Iowa Hospital and Clinics, and Virginia Mason Medical Center, as well as serving as professor of anesthesiology at the Mayo Clinic.