The Invisible Foreigner

(Download “This American Life” podcast below)

American health care costs have been rising for years and the situation is unsustainable, threatening the health of people and the economy. Why is it so hard for the players in the health care system to reduce costs?

The fascinating  podcast  from NPR’s “This American Life” downloadable above (episode 391, one hour, program details here) explains it well: it’s the complex interaction of emotions, ideas, values, and economic incentives within the system that keeps pushing up cost and preventing systemic reform.

The podcast is about our health care culture, which I define as the deeply embedded and sometimes invisible ways of thinking that affect our behavior, expectations, and aspirations about healthcare. Although the word “culture” barely mentioned, the concept of “our current ways of thinking” pervades the entire podcast. When one faces an inexplicable situation, it’s helpful to look underneath the behaviors to look for the cultural ideas and values that drive them.

When thinking of the whole healthcare system, it makes sense to prevent unnecessary procedures. In other words, less is more.

However, from the perspective of each of the players in the system, their values and their economic needs demand that more procedures are done. More is more.

As I heard the podcast I listened for cultural elements. Here’s what I caught:

Doctors:

• Are paid by “fee for service”. The more tests and procedures they do, the more they get paid.

• Have an incentive to protect themselves from lawsuits by doing more tests as a “cover your ass” activity.

• Have a taboo about talking about money, preventing discussion of how to reduce costs.

• Are often driven by “more is more”.

Patients:

• Expect that more treatment and more tests are better for them because they are unaware of the complex risks that medical procedures expose them to.

• Value the relationship they have with their doctor above cost and other factors.

• Want emotional support from friends and family when they are ill, even though this might not be cost effective.

• Are often driven by “more is more”.

Insurance providers:

• Are paid by the total volume of medical spending that doctors order. There is no incentive for them to reduce costs.

• Anger patients and hospitals when they try to reduce medical costs by asking patients to switch doctors and hospitals.

• Are often driven by “more is more”.

Government:

• Is reluctant to change doctor’s “fee for service” model of compensation because this is politically difficult.

• Cannot openly address the idea that less medical procedure might be better for everyone because it’s political suicide.

• Can’t get support for “less is more”.

When viewed as a whole, the health care system seems badly broken. But when viewing the behavior of each individual player from their own perspective, each is responding with their values and their economic interest to the incentives the system offers them. The podcast shows how culture works: many individuals interact in ways consistent with with their personal viewpoints, values and needs to create a system or society that works in mysterious ways.

Culture is complex. It doesn’t always create the systems or societies that are best for all. It doesn’t always create sustainable systems or societies either.