In all of my conversations, people know that I often go back to one basic principle: Follow the Money. It’s amazing how often that explains various behaviors, market dynamics, or trying to understand the why of something that seems unexplainable. However, in healthcare I find this is often dramatically more complicated than people realize. The number of people and organizations that profit off the dysfunction of healthcare is troubling to say the least.
I thought of this when Gabe Charbonneau, MD shared one of his favorite quotes:
All of us employed by healthcare corporations need help to assess our blindspots we don’t know we have. I’m reminded of one of my favorite quotes by Upton Sinclair:
It is difficult to get a man to understand something when his salary depends upon his not understanding it.
— Gabe Charbonneau, MD 🇺🇸 (@gabrieldane) August 9, 2022
This is so terribly true in healthcare. There are all sorts of blind spots where people’s salaries depends on ignoring something that would otherwise feel wrong. I call them perverse incentives and they seem to be all over healthcare.
This is the same thing I think about when I hear someone offers a stat about how much of US GDP goes to healthcare and then proudly declares that this growth in healthcare costs is “unsustainable.” They probably hate me for it, but I usually respond with “Why is it not?” and/or “What’s going to stop it?”
Their point is actually a different one. Their point is that we’re going to pay a hefty price if we don’t figure out a way to stem the costs of healthcare (insert fun graph/rankings of the US having bad healthcare and spending so much more than most nations). I agree with them on this. The costs of healthcare is a problem, but one person’s problem is another person’s livelihood.
To illustrate the magnitude of this “problem”, just look at a number of major cities where the dominant health system is the number one employer. It always bothers me when a health system is proud to be one of or even the top employer in a city. Shouldn’t we want our healthcare smaller? Reminds me of Michael J. Fox saying his goal was to put his foundation out of business. Unfortunately, that same sentiment doesn’t exist in healthcare. Instead, we create blind spots to things cause so many people’s salaries depend on us not understanding it.
This problem leaks into politics too. It’s bad politics to do something that will cut revenue to an industry that is the largest employer in your area. Yet, that’s kind of what we’re saying we want politicians to do when we say that healthcare costs are unsustainable and they need to lower those costs. A politician that cuts the costs of healthcare means that many people are going to lose jobs or at least take home less money. If you have a healthcare cost cutting plan that doesn’t do this, I’d love to see it since I haven’t seen one yet.
The closest I’ve seen to hope in this regard is value based contracts. It’s amazing how many of these perverse incentives change under a value based contract. It doesn’t solve everything and it’s not clear to me how we fully shift to value based care when we’re addicted to the free flowing fee for service world. However, I’m hopeful that the right mix of data will help us finally get there and reward those that are able to save money and improve health.
