Drive toward containing health care costs could have consequences for health care delivery

The drive toward containing health care costs could have the unintended consequence of reducing physician productivity, impairing quality and perhaps even increasing costs, two Beth Israel Deaconess Medical Center physicians suggest in a New England Journal of Medicine "Perspective."

Citing studies in behavioral economics and psychology, Pamela Hartzband, MD and Jerome Groopman MD, express the fear that assigning a monetary value to every aspect of a physician's time could prove to be self-defeating.

"There is also a communal relationship, an expectation and obligation to help when assistance is needed," Hartzband and Groopman write in NEJM 's Jan. 8, 2009 edition. "We believe that in the current environment, the balance has tipped toward market exchanges at the expense of medicine's communal or social dimensions."

The physicians, an endocrinologist and hematologist-oncologist respectively, note the environment in which they work has long been one where a colleague would not hesitate to stop in a corridor and offer a colleague his or her thoughts on a complex case.

"Now imagine that they had just left a departmental meeting where a 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?"

The physicians cite studies that suggest the answer is yes. Experiments found money-primed subjects were consistently less willing to extend themselves to those who needed help.

In one study, a control group asked to do a favor without compensation was significantly more willing to help move a sofa than those offered a token payment.

These experiments have a greater meaning in a profession where marketplace and communal relationships live side by side.

"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,'" they write. "In our view, this cultural shift risks destroying some essential aspects of the medical profession that contribute to high quality health care, including pride of profession, sense of duty, altruism and collegiality.

"Extending oneself to patients, families, trainees and colleagues not only is a traditional element of care, but translates into more effective care."

Hartzband and Groopman suggest that new trends in primary care may offer an opportunity to restore balance. The "patient-centered medical home" is being envisioned as a "compassionate partnership" between caregivers and patients, with compensation for what is now unreimbursed time.

"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."

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