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    Tuesday, September 29, 2009

    Unintended consequences of applying a business mindset to medicine

    As medicine changes during the past decades and even just in the past few years doctors have had to become more business-like. Drs.Hartzband, and Groopman write that rapidly rising health care costs over recent decades have prompted the application of business practices to medicine, with the goals of improving efficiency, restraining expenses, and increasing quality. Price tags are being applied to every aspect of a doctor's day, creating an acute awareness of costs and reimbursement. Physicians are now routinely provided with profit-and-loss reports reflecting their activity, and metrics are calculated to measure the cost-effectiveness of their work. Many business managers believe that clinicians will change their behavior to meet the imperatives of increased efficiency, cost containment, and improved quality only by increasing their focus on the flow of money in their work environment.

    But are there unintended consequences of applying a business mindset to medicine?
    Assigning a monetary value to every aspect of a physician's time and effort may actually reduce productivity, impair the quality of performance, and thereby even increase costs. Studies have shown that even the suggestion of money promotes behavior marked by selfishness and lack of collegiality.
    In one experiment, a control group performed a series of tasks, such as unscrambling phrases, in a "neutral" environment, whereas another group was "primed" through the inclusion of the concept of money in the scrambled phrases and the placement of play money within their visual periphery during the exercise. In a series of such experiments, money-primed subjects were consistently less willing to extend themselves to those in need of assistance. The authors concluded, "People reminded of money reliably performed independent but socially insensitive actions."

    Another recent experiment, involving 614 undergraduates, assessed the willingness of passersby to move a sofa onto a truck. The control group was asked to do it as a favor (without monetary compensation), whereas another group was offered 50 cents to help. The controls were significantly more willing to assist. When students were offered a piece of candy to help, there was no difference in willingness relative to the control group. But when the cost of the candy was mentioned ("a 50-cent candy"), willingness declined significantly, to the same low level as with the offer of 50 cents. Only by offering a substantially larger amount of money (10 times as much) did the cash group reach the same level of willingness to help as the control group. How could 50 cents be worth less as a motivator than no money at all?

    The answer may lie in the difference between "social" or "communal" interactions and "market" or "exchange" interactions.

    Researchers have described two types of relationships that involve giving a benefit to someone else.In a market relationship, when you provide goods or services, you expect to receive cash or bartered goods of similar value in return. In a communal relationship, you are expected to help when there is a need, irrespective of payment. In a communal relationship, an expectation and obligation to help when assistance is needed. Drs.Hartzband, and Groopman believe that in the current environment, the balance has tipped toward market exchanges at the expense of medicine's communal or social dimension. In the new business model there is no metric for the quality that derives from the communal dimension of medicine.

    How can we restore the balance between communal and market exchange in medicine in the current economic environment, ask Drs.Hartzband, and Groopman, given the imperative to cut costs? One answer may lie in an experimental new paradigm in primary care termed the "patient-centered medical home." The term itself suggests an emphasis on the social exchange that exists in a family rather than the market exchange of a business. The medical home is envisioned as a "compassionate partnership" of primary care providers and patients, with coordinated care for patients' ongoing problems and increased attention to preventive measures.

    The insurer would pay a set fee for each patient cared for in the medical home to cover what is now non-reimbursed time. Substantial cost savings are expected to result from coordination of care. As policymakers refine this model and extend it to include medical specialists, they should take into account the lessons of behavioral economics.

    Caregivers should be appropriately reimbursed but should not be constantly primed by money. Success in such a model will require collegiality, cooperation, and teamwork — precisely the behaviors that are predictably eroded by a marketplace environment.

    Dr. Hartzband is an endocrinologist at Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School, and Dr. Groopman is a hematologist–oncologist at Beth Israel Deaconess Medical Center and a professor of medicine at Harvard Medical School — both in Boston.

    Vohs KD, Mead NL, Goode MR. The psychological consequences of money. Science 2006;314:1154-1156. ;Heyman J, Ariely D. Effort for payment: a tale of two markets. Psychol Sci 2004;15:787-793. ;Ariely D. Predictably irrational: the hidden forces that shape our decisions. New York: Harper Collins, 2008.;Clark MS, Mills J. Interpersonal attraction in exchange and communal relationships. J Pers Soc Psychol 1979;37:12-24.

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