NEJM: Cost-containment focus could affect healthcare delivery
The drive toward containing healthcare costs could have the unintended consequence of reducing physician productivity, impairing quality and perhaps even increasing costs, according to a perspective written by two Beth Israel Deaconess Medical Center physicians in the Jan. 8 issue of New England Journal of Medicine.

Citing studies in behavioral economics and psychology, Pamela Hartzband, MD, and Jerome Groopman, MD, said that assigning a monetary value to every aspect of a physician's time could prove to be self-defeating.

“There is also a communal relationship, an expectation and obligation to help when assistance is needed,” they wrote. “We believe that in the current environment, the balance has tipped toward market exchanges at the expense of medicine's communal or social dimensions.”

The physicians noted that at Beth Israel, it is commonplace for a colleague to stop in a corridor and offer a colleague his or her thoughts on a complex case.

“Now imagine that they had just left a departmental meeting where a divisional budget was reviewed and goals for individual relative value units (RVUs) were presented. Would their interaction be different?” they questioned.

The physicians cited studies that suggested the accuracy of this statement. Experiments found money-primed subjects were consistently less willing to extend themselves to those who needed help.

In one study, a control group asked to do a favor without compensation was significantly more willing to help move a sofa than those offered a token payment.

The experiments have a greater meaning in a profession where marketplace and communal relationships live side by side.

"Many physicians we know are so alienated and angered by the relentless pricing of their day that they wind up having no desire to do more than the minimum required for the financial 'bottom line,'" they wrote. "In our view, this cultural shift risks destroying some essential aspects of the medical profession that contribute to high quality healthcare, including pride of profession, sense of duty, altruism and collegiality.

Hartzband and Groopman suggested that new trends in primary care may offer an opportunity to restore balance. The “patient-centered medical home” is being envisioned as a “compassionate partnership” between caregivers and patients, with compensation for what is now unreimbursed time.