As a clinical ethics consultant and bioethics professor for many years, it still amazes me that one of the most common problematic features of our healthcare system is the tendency to over treat patients to the point of causing harm and wasting financial resources. The question is, why?
The question, why do physicians generally over treat patients in the U.S., must be approached in light of the fact that we spend more per capita and more overall, about 16% of GDP, on healthcare and get far worse outcomes than do countries like Canada and Western European countries who spend far less of their GDP on healthcare. But to be fair, before we blame physicians entirely for making poor judgments about treatment options, it is important to keep in mind that the U.S. is big, diverse nation with complex social and economic issues where creating efficient systems of healthcare is both practically and politically challenging. Also the U.S. spends more on medical research than most other countries, which still benefits patients everywhere. But what is most uniquely American is an economic system designed by politicians first and foremost for creating wealth for investors and that provides, generally speaking, efficient markets for consumer goods and services. But, whatever the virtues of American capitalism in creating efficient markets, it does not hold true for healthcare.
It has been known for sometime that a large portion, perhaps up to 1/3 of what we spend on healthcare, does not improve the quality of care for patients. The central reason that is often given to explain this pattern is the way physicians get reimbursed for providing services—the more procedures they perform, the more revenue they generate. This basic feature of how providers are paid to perform services is complicated by a system in which the economic stakeholders of healthcare, such as physicians, including specialists, hospitals and facilities, insurers, including the federal government, pharmaceutical companies, are each protecting their own economic interests, often at the expense of the overall system. For example, though it may be a loss to insurance companies to spend tens and maybe hundreds of thousands of dollars to continue to over treat a dying patient in the ICU, it may be economically favorable to the individual hospital. So there may be incentives that reflect the self-interests of the individual stakeholder but are contrary to the interests of society and to the larger healthcare system. The result is a system of incentives where individual stakeholders are motivated to fend for themselves while the healthcare system as a whole, one that is uniquely American, continues to be bloated and inefficient. To make it worse, each of these stakeholders has their own lobbying or advocacy group defending the status quo and claiming that any changes in the system would be injurious to patients. When people are making lots of money from the status quo, reform is hard, as was evident since 2009 with the passage of the ACA.
Two factors that add to the momentum to over treat are often seen in clinical ethics consultations. One is patients and families request to “do everything” at all cost. Interestingly since most people have little stake in the direct cost of services, to request more rarely adds more personal financial burden. Instead consumers of healthcare are most often insulated from the financial burdens, which are absorbed into an impersonal system. The tendency to request “everything” is exacerbated by a cultural tendency, and often misguided, to view added medical and technological interventions as a sign of how much we care about the patient. The second factor is the tendency for American physicians to excessively follow patient and surrogate requests for desired treatment, even if it makes little sense or provides only marginal benefits. The apparent motivation for such physician acquiescence is the fear of law suits, which many of us feel is exaggerated. Studies have shown that physicians get sued more for poor communication and callous behavior than compassionately and understandingly saying, “I’m sorry but what you are asking me to do is not medically indicated.” There is no question but that the system would be better off if physicians provided more guidance in many difficult situations for patients and families. And also patients clearly would be better off since they would receive less burdensome, non-beneficial care, and at a low cost.
The good news is that there are solutions to these problems. Quality medical care is the right amount of treatment based on available scientific evidence. Quality care is also having the courage to offer treatment options to patients and families that are viable medical options and to decline to provide those that are not medically indicated. But before this will happen, physicians need to be rewarded for providing sound medical care and accomplishing important health outcomes rather than by performing more and more procedures, and generated more and more revenue, regardless of whether or not they add to quality care. This approach would both improve the quality of medical care for all patients and it will also be less costly. But such change will also be disruptive to the financial interests to those faring well in the current system. The real question is, how long those players can hold out before reforms can be made, or the system itself implodes?
The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.