Rapidly rising health care costs over recent decades have prompted the application of business practices to medicine, with the goals of improving efficiency, restraining expenses, and increasing quality. In the wake of the current economic crisis and the advent of a new presidential administration, even more attention will be focused on containing costs in the health care system. Price tags are being applied to every aspect of a doctor's day, creating an acute awareness of costs and reimbursement. Physicians are now routinely provided with profit-and-loss reports reflecting their activity, and metrics are calculated to measure the cost-effectiveness of their work. Many business managers believe that clinicians will change their behavior to meet the imperatives of increased efficiency, cost containment, and improved quality only by increasing their focus on the flow of money in their work environment.
But are there unintended consequences of applying a business mindset to medicine? Results from studies in behavioral economics and psychology suggest that there may be. Assigning a monetary value to every aspect of a physician's time and effort may actually reduce productivity, impair the quality of performance, and thereby even increase costs.
Not long ago, we overheard two colleagues talking in the hall. One physician asked the other for his thoughts on a complex case; despite a busy schedule, he did not hesitate to stop and engage in thoughtful discussion. Now, imagine that they had just left a departmental meeting where the divisional budget was reviewed and goals for individual relative value units (RVUs, the monetary metric of physicians' time and effort) were presented. Would their interaction be different?
Studies have shown that even the suggestion of money promotes behavior marked by selfishness and lack of collegiality.1 In one experiment, a control group performed a series of tasks, such as unscrambling phrases, in a “neutral” environment, whereas another group was “primed” through the inclusion of the concept of money in the scrambled phrases and the placement of play money within their visual periphery during the exercise. After the assignment was completed, a researcher posing as a subject entered the room and said that she was confused about the instructions for a certain task. According to the study results, control subjects spent twice as much time helping this “confused” peer as did those who had been primed with money. “Apparently,” the researchers concluded, “participants who were primed with money believed that [the researcher posing as subject] should figure out on her own how to perform the task, as a self-sufficient person would do.” In a series of such experiments, money-primed subjects were consistently less willing to extend themselves to those in need of assistance. The authors concluded, “Relative to people not reminded of money, people reminded of money reliably performed independent but socially insensitive actions.”
Now imagine that the first doctor in our scenario had said to the other, “I know it takes extra time and effort for you to discuss this case, so here is 50 cents.” How would the offer of compensation affect their interaction? A recent experiment, involving 614 undergraduates, assessed the willingness of passersby to move a sofa onto a truck.2,3 The control group was asked to do it as a favor (without monetary compensation), whereas another group was offered 50 cents to help. The controls were significantly more willing to assist. When students were offered a piece of candy to help, there was no difference in willingness relative to the control group. But when the cost of the candy was mentioned (“a 50-cent candy”), willingness declined significantly, to the same low level as with the offer of 50 cents. Only by offering a substantially larger amount of money (10 times as much) did the cash group reach the same level of willingness to help as the control group. How could 50 cents be worth less as a motivator than no money at all?
The answer may lie in the difference between “social” or “communal” interactions and “market” or “exchange” interactions. Researchers have described two types of relationships that involve giving a benefit to someone else.4 In a market relationship, when you provide goods or services, you expect to receive cash or bartered goods of similar value in return. In a communal relationship, you are expected to help when there is a need, irrespective of payment. Such relationships are most familiar among family members and friends, who willingly give time and labor without obliging anyone to pay them. Medicine involves both kinds of interactions. It has marketplace elements that are inherent in any business — a physician receives payment for services. But there is also a communal relationship, an expectation and obligation to help when assistance is needed. We believe that in the current environment, the balance has tipped toward market exchanges at the expense of medicine's communal or social dimension.
Many physicians we know are so alienated and angered by the relentless pricing of their day that they wind up having no desire to do more than the minimum required for the financial bottom line. In our view, this cultural shift risks destroying some essential aspects of the medical profession that contribute to high-quality health care, including pride in profession, sense of duty, altruism, and collegiality. Extending oneself to patients, families, trainees, and colleagues not only is a traditional element of medicine but translates into more effective care. “Quality” as currently defined by insurers involves giving an aspirin or a beta-blocker to a patient with heart disease or making sure a child wears a bicycle helmet. These are important interventions, but is tracking their use the best way to assess the quality of care? In the new business model there is no metric for the quality that derives from the communal dimension of medicine.
The shift toward market norms also seems evident in the career choices made by medical students. More and more young doctors are selecting specialties that are lucrative and can be practiced during regular, limited work hours, such as anesthesiology, radiology, and ophthalmology. These specialties have always paid well, but only recently have students flocked to them in such large numbers. Certainly, these disciplines offer intellectual challenges and are essential components of medicine. But as many experts acknowledge, the new generation of graduates often does not choose these fields for such reasons. Students constantly hear their mentors, as well as the media, discuss the monetary aspect of medicine; it permeates the training environment. Although money has always been part of medicine, it has never been so prominent, and it has not been the primary motivator of most doctors' practices. Today's medical students are being inducted into a culture in which their profession is seen increasingly in financial terms. Add in such pressures as the need to pay off enormous debts, and it is not surprising that students' choices are dictated by the desire to maximize income and minimize work time.
Some established primary care physicians are also making career choices in response to this new culture and fleeing to concierge practices, often citing their desire to escape the constant pricing of every aspect of their day. Since concierge practices collect yearly premiums from patients, such doctors may ironically be less “primed” by money at each encounter and may avoid feeling “nickeled and dimed” by insurers. This arrangement creates an environment that can foster social interaction more than it does market exchange. But concierge medicine is unaffordable for most Americans, and it drives much-needed primary care providers away from the larger population.
How can we restore the balance between communal and market exchange in medicine in the current economic environment, given the imperative to cut costs? One answer may lie in an experimental new paradigm in primary care termed the “patient-centered medical home.” The term itself suggests an emphasis on the social exchange that exists in a family rather than the market exchange of a business. The medical home is envisioned as a “compassionate partnership”5 of primary care providers and patients, with coordinated care for patients' ongoing problems and increased attention to preventive measures. The insurer would pay a set fee for each patient cared for in the medical home to cover what is now nonreimbursed time. Substantial cost savings are expected to result from coordination of care. As policymakers refine this model and extend it to include medical specialists, they should take into account the lessons of behavioral economics. Caregivers should be appropriately reimbursed but should not be constantly primed by money. Success in such a model will require collegiality, cooperation, and teamwork — precisely the behaviors that are predictably eroded by a marketplace environment.
No potential conflict of interest relevant to this article was reported.
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Dr. Hartzband is an endocrinologist at Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School, and Dr. Groopman is a hematologist–oncologist at Beth Israel Deaconess Medical Center and a professor of medicine at Harvard Medical School — both in Boston.
Money and the Changing Culture of Medicine
11:30 | January 2009, NEJM 2009, NEJM 360 with 0 comments »
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