The American Medical System is in a difficult and dangerous place right now. Healthcare services have become incredibly expensive, and the entire system has become so complex that few people fully understand it and even fewer can successfully navigate the system to get appropriate care that they can reasonably afford. My experience is that many people don’t see value in much of the care they receive or with many of the actors connected with their care. They know they need insurance to afford their care, but they really can’t see what value their insurance provides – it often appears to be more of a frustration than something most people appreciate. The same can be true for primary care, anesthesiologists, and the variety of healthcare benefits that employers may offer to their patients. There seem to be lots of people ready to profit from healthcare, but not a lot of people ready to provide real value to the people who need it.
These sentiments are all generalizations, and of course many people really do see value in at least some of their healthcare and are grateful for the care they receive. However, the complexity, the lack of transparency, and the ever climbing costs of care have people questioning the entire system, especially at a moral and ethical level. I think a great deal of support for Medicare for All, or universal healthcare coverage, comes from people thinking that profit within medicine may be unethical and from a lack of trust that stems from an inability to see anything other than a profit motive in many healthcare actors and services.
Gerd Gigerenzer writes about this idea in his book Risk Savvy. In the book he doesn’t look at healthcare specifically, but uses healthcare to show the importance of being risk literate in today’s complex world. Medical health screening in particular is a good space to demonstrate the harms that can come from misinformed patients and doctors. A failure to understand and communicate risk can harm patients, and it can actually create perverse incentives for healthcare systems by providing them the opportunity to profit from uninformed patients. Gigerenzer quotes Dr. Otis Brawley who had been Director of the Georgia Cancer Center at Emory in Atlanta.
In Dr. Brawley’s quote, he discusses how Emory could have screened 1,000 men at a mall for prostate cancer and how the hospital could have made $4.9 million in billing for the tests. Additionally the hospital would have profited from future services when men returned for other unrelated healthcare concerns as established patients. In Dr. Brawley’s experience, the hospital could tell him how much they could profit from the tests, but could not tell him whether screening 1,000 men early for prostate cancer would have actually saved any lives among the 1,000 men screened. Dr. Brawley knew that screening many men would lead to false positive tests, and unnecessary stress and further medical diagnostic care for those false positives – again medical care that Emory would profit from. The screenings would also identify men with prostate cancer that was unlikely to impact their future health, but would nevertheless lead to treatment that would make the men impotent or potentially incontinent. The hospital would profit, but their patients would be worse off than if they had not been screened. Dr. Brawley’s experience was that the hospital could identify avenues for profit, but could not identify avenues to provide real value in the healthcare services they offer.
Gigerenzer found this deeply troubling. A failure to understand and communicate the risks of prostate cancer (which is more complex than I can write about here) presents an opportunity for healthcare providers to profit by pushing unnecessary medical screening and treatment onto patients. Gigerenzer also notes that profiting from uninformed patients is not just limited to cancer screening. Doctors who are not risk literate cannot adequately explain risks and benefits of treatment to patients, and their patients cannot make the best decisions for themselves. This is a situation that needs to change if hospitals want to keep the trust of their patients and avoid being a hated entity that fails to demonstrate value. They will go the way of health insurance companies, with frustrated patients wanting to eliminate them altogether.
Wrapping up the quote from Dr. Brawley, Gigerenzer writes, “profiting from uninformed patients is unethical. medicine should not be a money game.” I believe that Gigerenzer and Dr. Brawley are right, and I think that all healthcare actors need to clearly demonstrate their value, otherwise any profits they earn will make them look like money-first enterprises and not patient-first enterprises, frustrating the public and leading to distrust in the medical field. In the end, this is going to be harmful for everyone involved. Demonstrating real value in healthcare is crucial, and profiting from uniformed patients will diminish the value provided and hurt trust, making the entire healthcare system in our country even worse.