On The Opportunity To Profit From Uninformed Patients

On The Opportunity To Profit From Uninformed Patients

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.

The Value of Objects - Joe Abittan

The Value of Objects

My dad collected Hot Wheels toy cars. He had thousands of cars, all in their packaging, with limited editions and rare valuable cars all collected and organized together. It was a hobby, and an example of how much value an individual can attach to objects that don’t mean anything to other people.

 

On my wife’s side of the family, near-hoarding behavior is not uncommon. With my dad’s collection and my wife’s family’s saving everything just in case, we have both seen the excesses of placing too much value in objects. We try hard to think critically about the things we have in our lives, and try to avoid having too many things and giving them too much value. But still, it is hard to part with things, even when they are gifts that we never really wanted and even when we know that we don’t need it or could replace it easily.

 

In the book Nudge, Cass Sunstein and Richard Thaler write the following about the value of objects. “People do not assign specific values to objects. When they have to give something up, they are hurt more than they are pleased if they acquire the very same thing.”

 

People are not actually that good at thinking about value. We will go out of our way for free stuff, we will hoard things to avoid feelings of loss, and we will collect items that don’t have the same economic value as the emotional value we attach to them once they are in our possession. This impulse helps drive our economy, but it can also drive us as individuals into madness.

 

I think that it is important to understand the quote from Sunstein and Thaler. When we recognize that we are not very good at thinking about value objectively, we can recognize irrational ways that we become attached to mere objects. We can start to shift the way we think about the material things in our lives and to really consider if they provide us value. We might find that our Hot Wheels collection really does provide us value, but at the same time, we may recognize that the decorative thing that someone gave us years ago doesn’t provide value. We can look at items that sit around taking up space, requiring cleaning, and cluttering our lives and feel more freedom with parting from those items. Understanding our irrational tendency towards objects and value can help us rethink what we keep, what we fill our lives with, and can help us get beyond the loss aversion we feel when we think about selling something or tossing it out.
Endowment Effects Joe Abittan

Endowment Effects

In his book Thinking Fast and Slow, Daniel Kahneman discusses an experiment he helped run to explore the endowment effect. The endowment effect is a cognitive fallacy that helps explain our attachment to things and our unwillingness to part with objects, even when we are offered something greater than the objective value of the the object itself. We endow the object with greater significance than is really warranted, and in his book, Kahneman shows that this has been studied with Super Bowl tickets, wine, and coffee mugs.

 

Kahneman helped run experiments at a few different universities where college students were randomly given coffee mugs with the university logo. The mugs were worth about $6 each, and were randomly distributed to about half of a classroom. Students were allowed to buy or sell the mugs, and the researchers saw a divergence in the value assigned to the mugs by the students who randomly obtained a mug and those who didn’t. Potential sellers were willing to part with the mug for about $7 dollars, a price above the actual value of the mug. Buyers, however, were generally only willing to purchase a mug for about $3, or half the value of the mug.

 

Kahneman suggests that the endowment effect has something to do with the unequal values assigned to the mug by those who received a mug and those who didn’t. He suggests that it is unlikely that those who received the mugs really wanted a university mug and particularly valued a mug relative to those who didn’t receive a mug. Those students should have been willing to trade the mug for $3 dollars which could be used to purchase something that they may have actually wanted, rather than a random mug. To explain why they didn’t sell their mugs, Kahneman suggests that the mugs became endowed with additional value by those who received them.

 

A further study showed similar effects. When all students in the class randomly received either a chocolate bar or a mug, researchers found that fewer students were willing to make a trade than the researchers predicted. Again, it is unlikely that a random distribution of mugs and candy perfectly matched the mug versus candy preferences of the students. There should have been plenty of students who could have used a sugar boost more than an extra mug (and vice versa), but little trading actually took place. It appears that once someone randomly receives a gift, even if the value of the gift was very small, they are not likely to give it up. The gift becomes endowed with some meaning beyond its pure utility and value.

 

Kahneman describes part of what takes place in our minds when the endowment effect is at work, “the shoes the merchant sells you and the money you spend from your budget for shoes are held for exchange. They are intended to be traded for other goods. Other goods, such as wine and Super Bowl tickets, are held for use to be consumed or otherwise enjoyed. Your leisure time and the standard of living that your income supports are also not intended for sale or exchange.”

 

The random mug or candy bar were not seen as objective items intended to be traded or bartered in exchange for something that we actually want. They were viewed as a windfall over the status quo, and thus their inherent value to the individual was greater than the actual value of the object. Kahneman suggests that this is why so few students traded candy for mugs, and why mug sellers asked far more than what mug buyers wanted to pay in his experiments. The endowment effect is another example of how our emotional valence and narrative surrounding an otherwise objectively unimportant object can shape our behaviors in ways that can seem irrational. Next spring when you are trying to de-clutter your house, remember this post and the endowment effect. Remember that you are imbuing objects with value simply because you happen to own it, and remember that you would only pay half price for it if it was actually offered to you for purchase now. Hopefully that helps you minimalize the number of mugs you own and declutter some of your cabinets.
Value in Healthcare

Value in Healthcare

A common complaint about healthcare in the United States is that it has traditionally operated on a fee for service (FFS) based model. It is a natural and easy to understand system, and generally the type of system that both patients and providers prefer. The idea is that you pay for the services you receive from a healthcare provider. So if you need a tooth extracted, you go and have the tooth extracted and pay for the extraction. If you need a skin check, you go and get a skin check and pay for it. However, this FFS model can encourage a lot of waste through unnecessary medical procedures, and the value in healthcare is sometimes lost when we wait until someone has a problem before we help them with their health.

 

A lot of government programs, employers, and insurance companies are making efforts to push against FFS in an effort to provide greater value in the healthcare services we pay for, but it is worth asking, what is value and how can healthcare systems provide it? Is value just better health? Is it services that a patient said they were happy about? Is it care that saves a life or can it just be care that makes a life somewhat more comfortable? Dave Chase helps explain one aspect of value in healthcare in his book The Opioid Crisis Wake-Up Call, “Value is defined as the ratio of quality to cost. Value increases as the quality of the care increases or the cost of care decreases.”

 

FFS encourages short appointments where doctors cram as much as they can bill for into the shortest possible time before moving on to the next patient to do the same. Value based models, on the other hand, seek to improve the quality of the care provided without adding more costs to the patient and their insurer. As opposed to simply cramming in more tests, treatments, and procedures to get more money, value based systems that increase quality focus on improving health outcomes while keeping costs stable.

 

Alternatively, value based models might seek to keep quality the same, but reduce overall costs. This can wade into territory we don’t necessarily want to support, such as cutting nurse management staff to keep overhead low, but it could also look like more comprehensive care to reduce costly re-admissions after a procedure. When we think about value and try to build systems around value, we ultimately have to think about quality and cost, and how those are related. We can cut pieces out of the system that are just meant for signaling and cut pieces out that might be unnecessary without diminishing quality. But at the same time, we really need to examine whether the pieces we want to cut really do help with the quality of the care, especially over the long run.

 

Thinking about value in healthcare isn’t entirely new, but it is receiving increased focus, which is important if we want to have a healthcare system that people actually trust and are willing to engage with when necessary.
Health Care Supply

Health Care Supply

Dave Chase makes an argument in his book The Opioid Crisis Wake-Up Call that healthcare has a substantial supply side drive, not just a demand side drive. This argument doesn’t align with standard pictures of healthcare, the idea that people seek care when they are sick, and don’t use care when they are well. Its troubling, but evidence does support the idea that the healthcare market is in some very important ways a supply driven market, meaning that as supply and capacity increases, demand also increases.

 

I’m not completely sure I understand this idea, but it is important for us to acknowledge and think about, especially if we live in growing cities, gentrifying regions of the country, and areas of the United States that have real opportunities for reinvention. When looking to the future of healthcare in the United States, Chase includes many elements from Bruce Katz and Jeremy Nowak’s book The New Localism and thinks there is an important role for new models of city and local government to play in shaping local healthcare ecosystems. He is also heavily influenced by Jim Clifton’s book The Coming Jobs War and the importance that local communities invest in sectors that are likely to be highly productive in the future. Chase writes,

 

“Sooner rather than later, we can expect other developments along the same 3.0 spectrum [More info on Economic Development 3.0 here]. Cities will incorporate true health needs into mater planning and review building permit applications with a deep understanding that health care is a supply-driven market. The more supply there is, the more demand will increase, with little regard for value and community well-being. Approving more health care build-out virtually guarantees a massive burden on local citizens.”

 

It is important that we think about what it is in healthcare that actually provides value. If simply adding more healthcare capacity will lead to greater demand and utilization, then we need to take steps to ensure that an uptick in services is actually accompanied by improvements in health. When communities are redeveloping and growing, they should be focused on upstream social determinants of health rather than just hospitals and healthcare service buildings. Designing communities that will have ample green space for outdoor activity, that will control noise, and will have well lit parks and outdoor areas will help build healthy communities. Plopping a hospital in a space that doesn’t include these elements might give people a place to go when they are stressed, overweight, and injured by debris in the streets, but it will not help people actually live healthier, it will capitalize on a broken environment that fails to support health.

 

I think that is part of the idea that Chase argues for. We should maintain the healthcare capacity and services which actually improve health, and we should be weary of systems that provide healthcare but fail to demonstrate real health improvements for citizens and communities.
Thoughts on Health Insurance Companies

Thoughts on Health Insurance Companies

Moving to a universal healthcare system with everything run by the Federal government might not solve all the problems in our healthcare system, and it might not really reduce all of our healthcare costs, but at least it would give us someone to hold accountable for rising costs, challenges with accessing care, and questionable quality of care. People across the United States are frustrated by healthcare providers and systems that seem to always be raising their costs and charging outrageous fees for basic medical care. Younger people today seem to find the idea of profiting on medical care to be slightly unethical, and health insurance company practices do a lot to increase people’s discontent with the current system and actors. In short, a lot of people probably just want to move to universal coverage provided by the government just to simplify the process and cut out insurance companies, especially when the average consumer can’t understand what benefit the insurance company provides.

 

These thoughts about our discontent with our current system came to mind this morning after reading the following passage that I highlighted in Dave Chase’s book The Opioid Crisis Wake-Up Call. Chase writes, “If you’re a fully insured employer and have higher-than-expected claims in one year, your insurance carrier will work to get as much back as possible in subsequent years through larger premium increases.”

 

What Chase describes is something that not everyone is directly aware of or able to explain, but it is something many of us have a vague feeling of or intuitive expectation of. Rather than existing as organizations to help us be healthy, rather than trying to solve a problem, rather than caring about our health needs, many people simply see health insurance as stealing a few bucks from them, their employers, their providers, and from people who really need medical care. Insurance companies are seen as morally unethical, powerful government lobbiers, and as bureaucratic machines that treat everyone like numbers.

 

If you are not in favor of a public health insurance program, and if you think that private insurance is the way to go, ask yourself what the industry could do better to actually provide value to patients. If you are in a health insurance company and think you do provide value to your patients, ask yourself, why don’t people see it? Perhaps we only see the games that insurance plays to limit access to care, to increase premiums every year, and to squeeze hospitals and providers, causing us to misunderstand the benefits that insurance provides. If private health insurance really wants to survive in the future, the industry needs to do better at showing its value, and minimizing its greedy tricks, otherwise, you can’t blame the public for wanting to eliminate insurance companies and have an accountable government take on universal coverage.
Healthcare Stagnation

Healthcare Stagnation

We are facing a disastrous healthcare stagnation in the United States. Our hospitals are getting older, Medical providers are aging with too few young providers to replace them, and the quality of care that many of us experience is not getting much better. Despite this, the cost of healthcare has been soaring. Healthcare expenditures, including the costs of our deductibles, co-pays, and what our insurance pays out, has been going up at a rate reliably above inflation.

 

In The Opioid Crisis Wake-Up Call, Dave Chase writes the following about our healthcare stagnation, “Unlike virtually every other item in our economy, where the value proposition improves every year, the norm in health care for decades has been to pay more and get less. Also, unlike nearly every other industry, healthcare hasn’t had a productivity gain in 20 years.”

 

Productivity is how much we produce per unit of time spent on production. A factory that makes 5,000 widgets per hour is more productive than a factory that makes 1,000 widgets per hour. Automation and new technologies have helped factories and offices become more productive, but our healthcare stagnation is evidence that we are not seeing the same gains in healthcare. Technology has improved, but not in areas that seem to produce more healthy patients given the same amount of time and effort from our medical providers. We have some new technologies, but somehow those technologies have not translated into a healthcare system that supports the same number of people with fewer resources.

 

Chase continues, “In other words, for the last two decades, there has been a redistribution tax from the working and middle class and highly efficient industries to the least productive industry in America.” 

 

As your job has become more efficient and more productive, your healthcare costs have risen. Chase equates this healthcare stagnation price increase to a tax. Factories that can work with fewer employees, software engineers, and other employees form highly productive sectors are paying more in healthcare for services that haven’t kept the same pace as the industries of the patients they treat. This is the cost of healthcare stagnation that chase wants to push back against by demanding better systems and structures from healthcare providers, insurance companies, and benefits brokers. Chase believes we can find a way to improve our healthcare system and help people live healthier lives for less cost, if employers are willing to make real investments in their employees healthcare, and are willing to hold their brokers and insurance providers accountable for the value their products provide.
Health Insurance Company Games

Health Insurance Company Games

Dave Chase’s book The Opioid Crisis Wake-Up Call was an interesting read because Chase highlights many of the health insurance company games that add to the cost of healthcare in the United States without providing additional value. I’m skeptical of health insurance companies, and Chase’s book discusses some of the nitty-gritty details of misaligned incentives that lead to unending increases in healthcare premiums and costs.

 

An example that Chase highlights is early renewal discounts for companies that chose to stay with their current health insurance company or plan administrator. Throughout the book, Chase discusses how businesses are letting their employees down and allowing healthcare costs to skyrocket by accepting increasing healthcare costs from health insurance companies each year. Many companies don’t have someone who really understands healthcare or health insurance in charge of their benefits programs, and as a result those individuals are often more focused on not being yelled at by employees than on reducing costs and providing a valuable health insurance package. Insurance companies take advantage of this by pressuring businesses to accept increases in the cost of healthcare administration each year at rates far above inflation.

 

Insurance companies know that businesses don’t actually want to shop around for health insurance and they know that employees don’t want to have a change in insurance each year. Insurance companies will offer benefits for early renewals from companies, and as Chase writes, “Often these early renewals come with no-shop clauses. So, a 20 percent rate increase may only be a 15 percent if you sign today and agree not to shop the competition. This should be viewed as a red-flag, not a great deal on a premium reduction.”

 

Insurance companies position themselves as offering a good deal, but they are increasing the cost of the insurance plan by 15%. Busy employers with small HR staff often see this as a win because it reduces their effort and while employees see costs rise they don’t have to hassle with changing insurance and unknown insurance processes. This is part of why premiums in the United States are rising so fast. Insurance companies hide information and data, and make it difficult for overwhelmed staff to pick benefits that will truly help employees.
Employers, Employees, and Opioids

Employers, Employees, and Opioids

One of the frustrations I have with modern day America is how frequently employers say that their greatest asset is their employees, but don’t back that statement up with actual action that helps improve the lives of their employees. Many of us work 40 hours when our work could reasonably be completed in fewer hours, alternatively many of us have incredible demands and insufficient help or time to complete our work. On the benefits side, many of us have health plans that don’t make preventative care affordable and have high deductibles and copays which place basic medical care beyond our reach. These frustrations, incursions into our non-work-lives, and a lack of support for living healthy lives are examples where employers are failing to live up to the claim that so many of them make about the care and value they have for their employees.

 

In the end, a failure to take care of employees and a willingness to let workers languish hurts the employers as much as the employees. In his book, The Opioid Crisis Wake-Up Call Dave Chase writes, “Ohio attorney general Mike DeWine estimated that 40 percent of job applicants in the state either failed or refused a drug test. The result: In certain places, solid middle-class jobs can’t be filled.”

 

On a first read, the problem sounds like it is on the job applicants. Why are so many job applicants using drugs, refusing drug tests, and unable to be hired for work? Shouldn’t they stop using drugs, get their lives together, and do the sensible things to be responsible humans and find employment? From the outside, as someone with a job who doesn’t have an opioid addiction, this is easy to say and think, but it’s also shortsighted.

 

Many of us have incredibly lengthy commutes, decimated social lives, no meaningful civic or religious organizations to give us purpose outside of work, and lack access to supportive mental health and general healthcare services. When we fall on hard times and need assistance, we don’t have a social safety net that we can fall back upon with encouragement and understanding. We feel isolated, can barely afford healthcare, don’t have much time outside of work and commutes for social or civic engagement, and if we do need welfare, the system is designed to make us feel like abject failures for turning to public support programs for help.

 

The blame can’t fall entirely on the individual. Businesses have to be held accountable as well, after all, employers count on a strong labor market to stay afloat and be productive. If they truly value their employees, they should prioritize a happy, healthy, and effective workplace by pushing back against institutions and structures in our lives that make us miserable, depressed, unhealthy, and uncommitted to the work we do. Chase’s book shows how employers are beginning to do this, by providing more services (in healthcare) to their employees and actually saving money while doing so. Employers can let their actions speak louder than their HR slogans, and can help their employees actually live healthy lives. In the end, the workforce that they rely upon will indeed be more reliable.
Making People Feel Valuable

Making People Feel Valuable

Toward the end of his book Dreamland, Sam Quinones quotes a the VP of sales from a shoelace factory in Portsmouth Ohio named Bryan Davis. Speaking of the company that Davis helps run, and discussing how Davis and a few others took over a failing shoelace company and reinvented it, Davis says, “It’s all been about money, the mighty dollar. The true entrepreneurial spirit of  the U.S. has to be about more than that. It has to be about people, relationships, about building communities.”

 

Quinones writes about how the decline of manufacturing has harmed cities across the United States. He understands why companies have relocated oversees, and in some ways accepts that businesses move and that economies change, but he sees the abandonment of American workers and the lack of supports for those workers when opportunities disappear as a major contributing factor to the Nation’s current opioid epidemic. When people suddenly lose the job they have held for years, when there is no clear alternative for them to turn to in order to feel useful, valuable, and like a contributing member of society, an alternative to ease the pain of their new reality is often pain killing opioid medications. It is an easy recipe for widespread addiction.

 

I don’t understand economics well enough to place criticism on businesses and factories that move operations to different cities, different states, or different countries altogether. I won’t criticize or praise these companies, but what is clear to me, is that we need to find ways to be more respectful of the people who work for and with us. We need to find real ways to make people feel valuable in their jobs, whether they are call center staff, healthcare workers, or a VP of a successful company. We can’t set out with a goal to make money and then withdraw ourselves from the lives of our fellow Americans and communities. We have to develop real relationships with people across the political, economic, and cultural spectrum of the communities where we live, otherwise we turn toward isolation, which isn’t helpful or healthy for ourselves or others in the long run.

 

This is the idea that Bryan Davis expressed. We can be inventive, creative, and push for economic success, but we should do so in a way that supports our community and values relationships with those around us and in our lives. If we only drive toward our own wealth and bottom line, we risk exploiting people, and that ultimately leaves them in a vulnerable position where isolation, depression, and isolation are all the more possible.