Opinion
VIEWPOINT
Brian W. Powers, AB Harvard Medical School, Boston, Massachusetts. Christine K. Cassel, MD National Quality Forum, Washington, DC. Sachin H. Jain, MD, MBA Harvard Medical School, Boston, Massachusetts; Boston-VA Medical Center, Boston, Massachusetts; and Merck and Co Inc, Boston, Massachusetts.
Editorial page 2099
Author Reading at jama.com
Ending the Cycle of Blame in US Health Care Despite unparalleled financial and human capital investments, the quality, safety, and value of US health care remain suboptimal. 1 There is general agreement on the scope and implications of these trends, but far less consensus on the fundamental drivers of health system underperformance. The disconnect stems from the fundamental difficulty in identifying the causes behind complex policy problems. In biomedical research and clinical investigation, problems and questions are identified, hypotheses are generated, and data are collected; causality is built into the investigative process Similar assumptions are often applied to policy analysis, but the reality is inherently less precise. Stone2 has written extensively on how societies grapple with policy challenges, suggesting that such issues do not have inherent properties that make them more or less likely to be seen as problems. Rather, individual parties and stakeholders construct “causal stories” to attribute blame and responsibility in an effort to shape how societies conceive of and respond to policy challenges. According to Stone, many policy problems do not have objective causes, but subjective narratives about causation that gain variable traction in the public imagination.2 Stone’s model of causal stories is manifest in the current national dialogue on health care quality and improvement. Consider how the following narratives—prevalent among researchers, policy
Life Science Industry
Product manufacturers saddle patients and payers with high prices and too often fail to invest in therapeutics that are beneficial to society. Drug and device companies, using insights from federally funded research, market products at excessive prices. These high prices not only make it difficult for patients to access important therapies but are one of the principal reasons health care costs in the United States exceed those of peer countries. Instead of investing in discovery for novel therapeutics, product manufacturers often devote resources to marketing and sure-bet profit such as off-label indications, modified formulation, and “me too” drugs. Physicians and Hospitals
Physicians, hospitals, and the heath care systems that they belong to are more responsive to financial incentives than they are to the tenets of the Hippocratic Oath. The health care system’s costs and quality challenges are the result of clinicians and health care organizations focusing on delivering volume over value. Trainees are attracted to high-paying specialties, leading to an oversupply of expensive specialists and an undersupply of primary care physicians. Hospitals overinvest in services lines such as cardiology, orthopedics, and oncology because of high margins, leaving vulnerability in essential services such as obstetrics and psychiatry.
Solving the US health care crisis has evolved into a cycle of blame and shifting culpability, a futile pattern that stymies meaningful reform. makers, journalists, and the public—have been used to assign primary responsibility for health system underperformance and poor health care value to various stakeholders. Payers
Corresponding Author: Sachin H. Jain, MD, MBA, Harvard Medical School, 65 E India Row, 33B, Boston, MA 02110 (shjain@post .harvard.edu).
Insurance companies are responsible for barriers to health care and for excess administrative waste. Chiefly concerned with maintaining profit margins, insurance companies limit access for covered patients through high deductibles and gatekeepers and have attempted to obstruct coverage for potentially costly patients through policies such as exclusions for preexisting conditions and lifetime limits. Payers create administrative inefficiencies from billing and coding, driving excess costs of billions of dollars a year without any benefits on quality of care or health outcomes.
Patients
Poor health outcomes and high costs are the result of health-related behaviors of US citizens and are made worse by their disregard for the costs of medical services. Most health care spending is directed at chronic conditions, the majority of which are the result of modifiable lifestyle decisions and overdependence on medical solutions rather than self-management. Clinicians, health systems, and payers dedicate increasing efforts to aid patients in managing their own health. This drives up costs for healthy individuals, who are forced to subsidize unhealthy individuals through insurance and social programs.
Lawyers
Rapacious and often unfounded litigation fuels the practice of “defensive medicine.” Fear of litigation drives overuse of unnecessary medical services, resulting in substantial waste and harm. This prevents physicians and hospitals from making wise choices and focusing on evidence-based treatment. Despite considerable regulation and oversight, the current malpractice system is ineffective in appropriately
jama.com
JAMA November 26, 2014 Volume 312, Number 20
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Eastern Kentucky University User on 05/25/2015
2091
Opinion Viewpoint
compensating patients, punishing negligence, and promoting quality and safety. Government
Overly burdensome regulations and government inefficiency stifle market forces that would otherwise drive down cost and improve value by promoting competition and consumer choice. Physician practices, hospitals, and health systems are required to meet costly bureaucratic requirements while being limited in their ability to respond creatively and nimbly to the demands of their local marketplace. These simplistic narratives directly inform strategies for health care improvement and reform. When payers are cast as the source of health care system underperformance, regulating profits and coverage requirements or shifting to a single-payer system is necessary.3 If product manufacturers are to blame, stringent price control and governmental influence on priorities for research and development are needed.4 Controlling clinician-driven overuse requires risk- and performance-based payment models.5 When patients are viewed as the root cause of health care underperformance, their financial liability for health care costs must increase.6 Reducing the inefficiencies of government regulation requires rolling back federal and state oversight and promoting market-based competition.7 Over the past 2 decades, one-dimensional causal stories and their associated reforms have shaped domestic health policy. In the 1990s, backlash against health maintenance organizations led most states to impose coverage standards on payers. Years later, Medicare Part D was established to lift the burden of excessive drug prices from seniors. Long protected from blame, physicians are increasingly the target of accountability for health care inefficiencies and high cost, spurred by stories in the popular media and regulatory zeal surrounding hospital mergers. Patients, too, are ARTICLE INFORMATION Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Disclaimer: The views expressed in this article represent the authors’ views and not the views or policies of their respective affiliated institutions. REFERENCES 1. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012.
2092
shouldering more of the blame, with growth in the use of highdeductible health plans and incentives and penalties for healthrelated behaviors. Many earlier dialogues have come full circle, with the Affordable Care Act regulating profits and coverage requirements for insurers and levying a fee on product manufacturers to support coverage expansion. With frustrating regularity, these causal stories are recycled and reused. The result is a policy process that is reactive, with stakeholders defending their turf, rather than proactive, with collaboration toward goals in the public interest. Solving the US health care crisis has evolved into a cycle of blame and shifting culpability—a futile pattern that stymies meaningful reform. Fortunately, Stone’s model holds cause for optimism. She suggests that causal stories can depict the roots of policy problems as either purposeful/intentional or inadvertent/unintentional.3 Among the prevailing narratives discussed above, health system underperformance is attributed to the intentional actions of specific stakeholders. But what if these zero-sum causal stories are rewritten to focus on inadvertent causes: unforeseen consequences, inefficiencies, and misaligned incentives? This recasts the system as a whole, not its component parts, as the appropriate target for reform. Doing so will require open, multistakeholder discussions and a focus on consensus-based policy solutions. Making clear each sector’s special interests prevents the reliance on simplistic causal stories and allows for a focus on productive compromises. Embracing this multistakeholder model is necessary to address the various dimensions of health system underperformance in a productive and holistic fashion. Participants must commit to valuing a resolution that benefits social sustainability and patient well-being over sectorial turf victories. Acknowledging the harmful fallout from a focus on winning and losing will ultimately result in more collaboration and less adversity. Well executed, it could serve as the foundation for developing collective solutions to some of health care’s enduring challenges.
2. Stone DA. Policy Paradox and Political Reason. Glenview, IL: Scott Foresman; 1988.
6. Jain SH, Rother J. Are patients knights, knaves, or pawns? JAMA. 2011;305(20):2112-2113.
3. Woolhandler S, Himmelstein D, Angell M, Young Q. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003:290(6):798-805.
7. Antos JR, Pauly MV, Wilensky GR. Bending the cost curve through market-based incentives. N Engl J Med. 2012:367(10):954-958.
4. Treasure CL, Avorn J, Kesselheim AS. What is the public’s right to access medical discoveries based on federally funded research? JAMA. 2014;311(9): 907-908. 5. Jain SH, Cassel CK. Societal perceptions of physicians: knights, knaves, or pawns? JAMA. 2010; 304(9):1009-1010.
JAMA November 26, 2014 Volume 312, Number 20
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Eastern Kentucky University User on 05/25/2015
jama.com
VIEWPOINT
Brian W. Powers, AB Harvard Medical School, Boston, Massachusetts. Christine K. Cassel, MD National Quality Forum, Washington, DC. Sachin H. Jain, MD, MBA Harvard Medical School, Boston, Massachusetts; Boston-VA Medical Center, Boston, Massachusetts; and Merck and Co Inc, Boston, Massachusetts.
Editorial page 2099
Author Reading at jama.com
Ending the Cycle of Blame in US Health Care Despite unparalleled financial and human capital investments, the quality, safety, and value of US health care remain suboptimal. 1 There is general agreement on the scope and implications of these trends, but far less consensus on the fundamental drivers of health system underperformance. The disconnect stems from the fundamental difficulty in identifying the causes behind complex policy problems. In biomedical research and clinical investigation, problems and questions are identified, hypotheses are generated, and data are collected; causality is built into the investigative process Similar assumptions are often applied to policy analysis, but the reality is inherently less precise. Stone2 has written extensively on how societies grapple with policy challenges, suggesting that such issues do not have inherent properties that make them more or less likely to be seen as problems. Rather, individual parties and stakeholders construct “causal stories” to attribute blame and responsibility in an effort to shape how societies conceive of and respond to policy challenges. According to Stone, many policy problems do not have objective causes, but subjective narratives about causation that gain variable traction in the public imagination.2 Stone’s model of causal stories is manifest in the current national dialogue on health care quality and improvement. Consider how the following narratives—prevalent among researchers, policy
Life Science Industry
Product manufacturers saddle patients and payers with high prices and too often fail to invest in therapeutics that are beneficial to society. Drug and device companies, using insights from federally funded research, market products at excessive prices. These high prices not only make it difficult for patients to access important therapies but are one of the principal reasons health care costs in the United States exceed those of peer countries. Instead of investing in discovery for novel therapeutics, product manufacturers often devote resources to marketing and sure-bet profit such as off-label indications, modified formulation, and “me too” drugs. Physicians and Hospitals
Physicians, hospitals, and the heath care systems that they belong to are more responsive to financial incentives than they are to the tenets of the Hippocratic Oath. The health care system’s costs and quality challenges are the result of clinicians and health care organizations focusing on delivering volume over value. Trainees are attracted to high-paying specialties, leading to an oversupply of expensive specialists and an undersupply of primary care physicians. Hospitals overinvest in services lines such as cardiology, orthopedics, and oncology because of high margins, leaving vulnerability in essential services such as obstetrics and psychiatry.
Solving the US health care crisis has evolved into a cycle of blame and shifting culpability, a futile pattern that stymies meaningful reform. makers, journalists, and the public—have been used to assign primary responsibility for health system underperformance and poor health care value to various stakeholders. Payers
Corresponding Author: Sachin H. Jain, MD, MBA, Harvard Medical School, 65 E India Row, 33B, Boston, MA 02110 (shjain@post .harvard.edu).
Insurance companies are responsible for barriers to health care and for excess administrative waste. Chiefly concerned with maintaining profit margins, insurance companies limit access for covered patients through high deductibles and gatekeepers and have attempted to obstruct coverage for potentially costly patients through policies such as exclusions for preexisting conditions and lifetime limits. Payers create administrative inefficiencies from billing and coding, driving excess costs of billions of dollars a year without any benefits on quality of care or health outcomes.
Patients
Poor health outcomes and high costs are the result of health-related behaviors of US citizens and are made worse by their disregard for the costs of medical services. Most health care spending is directed at chronic conditions, the majority of which are the result of modifiable lifestyle decisions and overdependence on medical solutions rather than self-management. Clinicians, health systems, and payers dedicate increasing efforts to aid patients in managing their own health. This drives up costs for healthy individuals, who are forced to subsidize unhealthy individuals through insurance and social programs.
Lawyers
Rapacious and often unfounded litigation fuels the practice of “defensive medicine.” Fear of litigation drives overuse of unnecessary medical services, resulting in substantial waste and harm. This prevents physicians and hospitals from making wise choices and focusing on evidence-based treatment. Despite considerable regulation and oversight, the current malpractice system is ineffective in appropriately
jama.com
JAMA November 26, 2014 Volume 312, Number 20
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Eastern Kentucky University User on 05/25/2015
2091
Opinion Viewpoint
compensating patients, punishing negligence, and promoting quality and safety. Government
Overly burdensome regulations and government inefficiency stifle market forces that would otherwise drive down cost and improve value by promoting competition and consumer choice. Physician practices, hospitals, and health systems are required to meet costly bureaucratic requirements while being limited in their ability to respond creatively and nimbly to the demands of their local marketplace. These simplistic narratives directly inform strategies for health care improvement and reform. When payers are cast as the source of health care system underperformance, regulating profits and coverage requirements or shifting to a single-payer system is necessary.3 If product manufacturers are to blame, stringent price control and governmental influence on priorities for research and development are needed.4 Controlling clinician-driven overuse requires risk- and performance-based payment models.5 When patients are viewed as the root cause of health care underperformance, their financial liability for health care costs must increase.6 Reducing the inefficiencies of government regulation requires rolling back federal and state oversight and promoting market-based competition.7 Over the past 2 decades, one-dimensional causal stories and their associated reforms have shaped domestic health policy. In the 1990s, backlash against health maintenance organizations led most states to impose coverage standards on payers. Years later, Medicare Part D was established to lift the burden of excessive drug prices from seniors. Long protected from blame, physicians are increasingly the target of accountability for health care inefficiencies and high cost, spurred by stories in the popular media and regulatory zeal surrounding hospital mergers. Patients, too, are ARTICLE INFORMATION Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Disclaimer: The views expressed in this article represent the authors’ views and not the views or policies of their respective affiliated institutions. REFERENCES 1. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012.
2092
shouldering more of the blame, with growth in the use of highdeductible health plans and incentives and penalties for healthrelated behaviors. Many earlier dialogues have come full circle, with the Affordable Care Act regulating profits and coverage requirements for insurers and levying a fee on product manufacturers to support coverage expansion. With frustrating regularity, these causal stories are recycled and reused. The result is a policy process that is reactive, with stakeholders defending their turf, rather than proactive, with collaboration toward goals in the public interest. Solving the US health care crisis has evolved into a cycle of blame and shifting culpability—a futile pattern that stymies meaningful reform. Fortunately, Stone’s model holds cause for optimism. She suggests that causal stories can depict the roots of policy problems as either purposeful/intentional or inadvertent/unintentional.3 Among the prevailing narratives discussed above, health system underperformance is attributed to the intentional actions of specific stakeholders. But what if these zero-sum causal stories are rewritten to focus on inadvertent causes: unforeseen consequences, inefficiencies, and misaligned incentives? This recasts the system as a whole, not its component parts, as the appropriate target for reform. Doing so will require open, multistakeholder discussions and a focus on consensus-based policy solutions. Making clear each sector’s special interests prevents the reliance on simplistic causal stories and allows for a focus on productive compromises. Embracing this multistakeholder model is necessary to address the various dimensions of health system underperformance in a productive and holistic fashion. Participants must commit to valuing a resolution that benefits social sustainability and patient well-being over sectorial turf victories. Acknowledging the harmful fallout from a focus on winning and losing will ultimately result in more collaboration and less adversity. Well executed, it could serve as the foundation for developing collective solutions to some of health care’s enduring challenges.
2. Stone DA. Policy Paradox and Political Reason. Glenview, IL: Scott Foresman; 1988.
6. Jain SH, Rother J. Are patients knights, knaves, or pawns? JAMA. 2011;305(20):2112-2113.
3. Woolhandler S, Himmelstein D, Angell M, Young Q. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003:290(6):798-805.
7. Antos JR, Pauly MV, Wilensky GR. Bending the cost curve through market-based incentives. N Engl J Med. 2012:367(10):954-958.
4. Treasure CL, Avorn J, Kesselheim AS. What is the public’s right to access medical discoveries based on federally funded research? JAMA. 2014;311(9): 907-908. 5. Jain SH, Cassel CK. Societal perceptions of physicians: knights, knaves, or pawns? JAMA. 2010; 304(9):1009-1010.
JAMA November 26, 2014 Volume 312, Number 20
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Eastern Kentucky University User on 05/25/2015
jama.com
