The significant problems we face cannot be solved at the same level of thinking we were at when we created them. — Albert Einstein
In my book, “Modern Health Care Delivery: Deliverance or Debacle,” I outlined some of the critical drivers of the high cost of medical care in the US. These included waste as exemplified by the performance of unnecessary services, the fee-for-service payment model, the practice of defensive medicine, and the excessive administrative costs associated with its delivery.
Is there any potential redress to these devitalizing monetary black holes? While previously discussed separately, in reality these drivers of cost are inexorably interlaced, and as such, any potential solution to one will have requisite effects upon the others.
…For at least the first three of the above drivers, an obligatory change in behavior by one or more parties will be necessary for the success of any proposed solution. A basic tenet of behavioral psychology is, “Never expect anyone to engage in a behavior that serves your values, unless you give that individual(s) adequate reason to do so.” Its corollary is similar: “To affect change, it is necessary to convince others that the behavior you seek to influence is the best action in which they can engage in the service of their values.” Assuming these statements to be incontrovertible, we can now ask ourselves an even more elementary question, “Why do people do what they do?”
…Many, if not all, actions are motivated by three basic considerations: first, quid pro quo* which also includes deferred gratification; second, loss of value satisfaction, for example use of fear, coercion, intimidation or threat (i.e., punitive measures to change someone’s behavior) and third, the moral good or imperative of Western ethics. The latter can be thought of as a principle originating inside a person’s mind—perhaps in “conscience”—that compels a person to act in a certain manner.
…Two other apriorisms are needed before examining the specifics of some potential interventions. First, the physician or alternative provider is the gatekeeper of healthcare resources that ultimately result in downstream healthcare costs. While hospitals may provide the needed infrastructure and insurance companies and healthcare organizations the needed administrative support, it is the physician or alternative healthcare provider who serves as gatekeeper for the patients’ entry into the healthcare system. Without the healthcare provider, there can be no healthcare delivery, no use of healthcare resources, no healthcare outcomes, and of course, no healthcare costs. Second, for an intervention to succeed, all parties: patient, provider, hospital, healthcare organization, and payer must have “skin in the game.”
How many times in your life have you attempted to change someone’s conduct, only to find that until financial consequence somehow got baked in, no lasting behavioral change ever took place. Put more bluntly, until you hit someone in the pocketbook, you might as well accede to the “moral imperative”—beneficent, but today perhaps more so than ever, hopelessly inadequate to accomplish what needs to be done.