Medicine’s Tragedy of OR

Thanks to Dr. Paul Wiseman for sharing the NY Times op-ed article,  How Medical Care Is Being Corrupted, via LinkedIn this afternoon. Article authors Pamela Hartzband and Jerome Groopmannov are on the faculty of Harvard Medical School and co-authors of Your Medical Mind: How to Decide What is Right for You.

The article deals with an old nemesis in healthcare policy: individual incentives. More particularly, how the misalignment of individual incentives can often be the Trojan horse befalling well-intended policy initiatives.

Idealistically, as patients we we want our doctors to have our best interests in mind at every touch point of our experience with them. And fortunately, I believe that continues to by and large hold true. But the forces pushing against physicians to maintain that altruistic objectivity and autonomy on our behalves is being vehemently tested by what the authors describe as, “financial forces largely hidden from the public [that] are beginning to corrupt care and undermine the bond of trust between doctors and patients.”

Though coming from different sources the common thread is the push toward value-based payments. I have written here in the past on value and value-based healthcare. The theory is market-based sound logic: value = outcomes/cost. The challenge, as I have written before, starts within a few nanoseconds after you start to contemplate how to objectively assess outcomes and whose value are we talking about?

As Hartzband and Groopmannov importantly note, there is a challenging conflict between what is perceived as valuable for population health (i.e., in the aggregate) versus what is valuable for individual health. Physician payment incentives are increasingly being created based upon broad public health metrics (e.g., incidence of hypertension and hyperlipidemia, which are both often treated with medications that can be very effective – but also have significant side effects that can vary significantly from one individual to the next).

So it doesn’t take too many connected dots to imagine the potential conflict of interest between wanting to hit the metrics versus doing what’s in the best interest of the patient. And the challenges are compounded when it’s not just the rewards that are in play – but the potential punishment for not following prescribed protocols from third parties – e.g., poor ratings publications and/or loss of base payments. That’s what is known in the non-scientific world as getting it coming and going.

So what the authors propose is the establishment of legislation that would make public information available on, “the hidden coercive forces” that could be at the root of physician-patient incentive misalignment due to the aforementioned consequences of well-intended policies. That may not be enough, but it’s an important recognition that the policies may not work as intended. I note, however, that they do not recommend going backwards to the past era of, “paternalism, where doctors imposed their views on the patient.”

Progress often means a couple of steps forward and a few back. Trying, learning and adjusting. This is a fundamental difference in  thinking among healthcare policy types that believe we just have to give Adam Smith’s invisible hand wider breadth. Way back in 1995, Jim Collins (Good to Great) wrote an article, (Building Companies to Last), in which among other areas of recognition – that even back then noting that relying on lessons of the past would not suit us well in a world of transformational change – he discusses embracing the genius of the “and.” This is a theme that has pervaded much of his work since.

Too often those critical of policy initiatives jump for self-satisfactory joy whenever they come across fair and objective criticism of those initiatives. But such criticism, if you can get by the politics (yeah, I know), doesn’t have to be viewed through the prism of the Tranny of Or. It can be viewed as an opportunity to learn and work toward the Genius of And.

Cheers,
  ~ Sparky

Photo Credit: Alex Merto