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The “what, when, where, and how much” dilemma of health care

October 10, 2016 | Steve Delaronde

The Triple Aim of health care often focuses on reducing cost and improving outcomes.  The third component of the Triple Aim – improving the patient experience of care – is also an important part that often gets overlooked.  However, the patient experience can be measured in many ways, and is not just about how nicely they were treated in the hospital or doctor’s office.  Patients will often rate their experience as more satisfactory when they receive care that they perceive as preferred, immediate, convenient and abundant, as well as effective.

Human nature is such that when we identify a need, we typically want it met as quickly, conveniently and copiously as possible.  This is our programmed response to alleviate hunger, remove ourselves from danger, or avoid pain.  There is a tendency for patients to behave similarly when seeking healthcare services – they want the best medical care (sometimes misinterpreted as the newest approach or latest breakthrough), they want it now, they want it delivered in the most accessible location, and typically prefer more of it rather than less.  This is the “what, when, where, and how much” of health care.

The “what”

Ideally, patients learn about treatment options from a knowledgeable, unbiased and properly trained medical professional that has the patient’s best interest in mind.  Unfortunately, the Internet, direct-to-consumer (DTC) television advertisements, billboards and anecdotal testimonials from others are additional sources that inform (or in many cases, misinform) people about their treatment options when faced with a specific disease, condition or ailment.  The new drugs, medical products and procedures marketed to prospective patients are often less-extensively tested and more expensive than traditional treatment options and less invasive approaches.  Brand drugs are preferred to generics, the latest surgical technique compared to a traditional one, invasive surgery to a “wait-and-see” approach, and new “state-of-the-art” implants and medical devices are thought to offer more benefits than risks.

The “when”

We are hardwired to crave and seek immediate satisfaction.  This is especially true when a person experiences pain, discomfort or any other symptom that they would like to have relieved.  The problem with treating a symptom immediately is that very often it would have gone away on its own.  This is especially true for musculoskeletal pain, and particularly low back pain, which is the most common reason for an outpatient visit.  The American Academy of Family Physicians does not recommend imaging (X-ray, CT scan or MRI) for low back pain before 6 weeks.

Patients sometimes request treatment when the best approach may be behavior change or “wait-and-see.”  High cholesterol, elevated blood sugar and high blood pressure can often be reduced with changes in eating and exercise, thereby delaying or eliminating the need for pharmacotherapy.  Additionally, conservative approaches to back pain, such as non-steroidal anti-inflammatory drugs or physical therapy will often negate the need for injections or surgery.

The “where”

Patients will seek treatment at the most convenient location, which increasingly has become an emergency room (ER), urgent care center, retail clinic or in their homes via the telephone or Internet.  There are certainly advantages to providing timely treatment, which includes less costly urgent care center visits that can replace ER visits and prevent hospital admissions.  However, there are two risks with making health care more accessible for certain conditions.  The first is that people may seek care for low acuity conditions that do not necessarily require treatment, thereby increasing costs and the risk of unnecessary tests and treatment.  This increase in utilization and cost associated with retail clinic visits was identified in a March 2016 publication in Health Affairs.  The second issue, particularly for patients with chronic conditions, is they will seek care outside of the care system of their primary care physician, leading to uncoordinated, and sometimes, unnecessary care.

The “how much”

More does not mean better.  Patients often measure value in terms of the quantity of services rendered and medications prescribed than simply receiving a positive outcome.  The placebo effect is a testament to the value that patients place on receiving something rather than nothing and more rather than less.  In fact, it isn’t even necessary to deceive a patient to get the benefit of a placebo treatment.  A 2014 study of 66 patients treated the 459 migraine attacks found that even when a placebo was honestly labeled as “placebo,” patients reported significantly more pain relief than no treatment and nearly half the benefit of the painkiller Maxalt.

Equating more as better does not just apply to what we receive, but also what we pay.  Studies have shown that people relate higher price with higher quality and will shun low cost medication and treatment for more expensive approaches, believing they offer the chance of a better or quicker outcome.  Contributing to this phenomenon in health care is the “moral hazard” problem.  Since insured patients are often shielded from the full impact of treatment costs, once their deductible is met, there is little incentive to choose lower cost services that they may be considered inferior to those with the higher price tag.

Addressing the “what, when, where, and how much” dilemma

Understanding human behavior – both the patient’s and the provider’s – is the key to creating incentives that will keep the population healthy and healthcare costs low.  While economists agree that behavior is rooted in obtaining the most optimal level of benefit or utility from our decisions, we often operate under false assumptions that doing something is better than doing nothing, more is better than less, now is better than later, and new is better than old.  The healthcare system must systematically address these assumptions to achieve the value that is the goal of the Triple Aim.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.

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