Doctor Jekyll and Mr. Hyde

I had a moment last week during a recitation discussion for my course on the U.S. health care system that brought into drastic relief for me the tension between my pre-med aspirations and my current infatuation with health care systems. It occurred during a discussion of the apparently-controversial “health care warranties”.

In brief, here’s how a warranty in health care would work. Analogous to the warranty you might receive for your car or new iPad, a provider would issue a warranty to a payer or patient, guaranteeing a certain health outcome following a procedure.  Of course, it’s not really a guarantee as much as an agreement to cover the costs if something goes wrong. Rather than being reimbursed for every procedure they do (even those which they must do to fix complications that they caused), providers would be paid a set amount, which means if costs rise above that set amount, they eat the difference. A layperson-friendly description of health care warranties can be found in this New York Times article, and a more technical model and historical background can be found here.

As soon as our instructor raised the topic, an outspoken doctor in the class immediately raised her hand and said indignantly, “Warranties ruin the patient-doctor relationship.” People are not cars, she said, and a warranty in health care would only commoditize human life, reduce patient trust in doctors, and give patients unrealistic expectations, leading them to place all blame on the doctor when something goes wrong. And given the inherently uncertain nature of medicine, a warranty-like guarantee is unrealistic. “Doctors,” she declared, “have already taken the Hippocratic Oath to do their best, and a health care warranty would only bring the profit motive in.”

It was at this point that I raised my hand. “First of all, I’m not a doctor,” I began tentatively. “But I feel like we can overlay warranties and other incentives onto the practice of medicine without distorting the patient-doctor relationship. I’m sure that many doctors have taken the Oath to heart and practice with the best intentions, and we could simply accept their pledge and leave it at that—but judging from the current state of our health care system, that’s not good enough. My position stems from the assumption that at least some doctors can do better, and that these doctors need those additional incentives.”

Plus, it’s not just about the doctors. It’s about putting pressure on health care managers to get their act together, to invest in scrutinizing their current models of care delivery, and to implement best practices that squeeze out as much patient safety and value as possible.

Yet despite my best rhetoric, the doctor was not swayed, and in that moment I became acutely aware of the tensions surrounding someone in my position—self-proclaiming to be interested in medicine but lacking clinical experience; fascinated by health care management despite many doctors’ distaste of the subject.

“Maybe it’s just the label ‘warranty’ that turns us off,” our instructor postulates as he concludes our discussion. That realization reminds me of an exchange I had with my own research mentor two years ago, when he suggested I investigate “P4P4P” (Pay-for-Performance-for-Patients) as a way to encourage rural Chinese patients to accept eye care.

“I feel like dangling financial incentives in front of poor rural patients undermines their inherent motive to be healthy,” the still-naïve, social-justice-promoting me had whined. Amused, my mentor directed me to a piece written by Kevin Volpp, a professor at Wharton who is one of the foremost champions of P4P4P. “Some people have somewhat amorphous moral or ethical reservations about paying people to take actions that it is felt they should take on their own,” Volpp writes. But in a prior paper, Volpp and co-authors had found that patient opinions regarding P4P4P were influenced by the framing of the question, with more people responding positively when P4P4P was framed as “rewards” rather than as “punishments”. The bottom line, I believe, is that we have to look at the evidence.

For P4P4P, turns out the evidence is mixed. Some studies have indeed shown significant short-term effects in changing patient behaviors such as smoking cessation and weight loss. But evidence is lacking on long-term effects, and may even suggest that once financial incentives are removed, patients revert to their old behaviors, and in some cases to even “worse” behaviors than they had before. As my psychology professor Barry Schwartz would complain, “Psychologists have known [about this phenomenon] for decades, and it’s time for policymakers to start paying attention and listen to the psychologists a little bit, instead of economists.”

(A subsequent focus-group study we carried out in China revealed that rural patients hated the idea of P4P4P, and the idea was scrapped.)

As for “health care warranties”, similarly the evidence base is slim. The promise of warranties have been extolled in popular blogs and news sources such as here, here, and here. But as for peer-reviewed evaluations, I could find about one study in Pubmed evaluating warranties for a single procedure. Until that evidence base comes out, all I’m going to have are my abstract rationalizations of how things should work—without the clinical experience to inform those rationalizations.

And as such, I can only humbly say that this pre-med still has a lot to learn.

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