Behavioral (Cultural ) Change – The Biggest, Rarely Acknowledged,  Challenge of Health Reform

Physics does not change the world it studies. And no science of behavior can change the essential nature of man, even though both sciences yield technologies with a vast power to manipulate their subject matters.

Burrhus Frederic Skinner (1904-1990), Cumulative Record (1972)

July 27, 2012 -  Health reform,  however well-intentioned, seldom changes the fundamental behavioral patterns of man  These  patterns are ingrained over a life-time and are the product of our culture and our training.  Nor does reform reverse cumulative disease processes,  which are embedded in our organs, our nervous systems, and are derived from our behavioral patterns.   That is why some reform measures designed  to alter clinical behaviors or  outcomes are destined to either fail or have little impact.

Three of these measures come to mind.

One, failure of pay for performance programs for physicians to improve outcomes.   It is thought if we only incentivize physicians to meet quality standards by paying them for performance , they will perform better.   Yet  studies here and in the United Kingdom show P-4-P does little if anything to enhance performance.   In euphemistic academic circles,  this is known as the “null effect” (Jha AK, et al, “The Long-Term Effect of Premier Pay for Performance on Patient Outcomes, “ NEJM, 2012: 366: 1602-1615).  The article refers  to the Medicare Premier Hospital Quality Incentive Demontration project, which offers bonuses of 1% and 2% to hospitals reaching th top tier of  quality indicators.  The outcome changes were insignificant. The explanation for this failure is that the failure to improve outcomes “suggests that we have not yet learned to struture pay-for - performance programs.”  Nothing is said of the reality  that maybe hospitals and physicians everywhere seek to practice good medicine, regardless of financial incentives, and they are doing the best they can and the best that can be expected in most clinical circumstances.

Two,  failure of federal punishments of hospitals to reduce 30-day hospital  readmissions. The rationale here is that doctors and hospitals somehow fail to treat hospitalized patients appropriately,  fail to teat their basic disease outcomes correctly in the hospital,  do not give them proper instructions on what do once they return home, do not give them proper support in a home-bound environment, or  somehow fail to treat or improve their disease condition while hospitalized.   It is seldom, if ever mentioned  that chronic conditions, such as heart failure,  culminate from a variety of causes – genetic, environmental, social deprivation, and past behaviors that are beyond the reach of hospitals and doctors.   The typical patient may spend a few hours to several weeks with a doctor or hospital, but they have spent a lifetime developing what ails them.  As someone has observed,  “We dig our graves with our own teeth.”  And “ We fail to use our two legs for what they were intended,  to move us and keep the blood circulating.”   Furthermore,  chronically ill patients, once home , tend to return to the behaviors and habits of a lifetime.

Three,   there is a national reform movement afoot, known as “Value-based Purchasing - National Programs To Move from Volume to Value”(see July 26 NEJM article).  The theory is that if only we could get hospitals and doctors to change their behaviors and modify their outlooks by concentrating on patient safety, patient and care-giver centered experience and outcomes, coordinating care,  improving clinical  process meaures, concentrating on populution and commuintiy heath, and developing efficiency and cost reduction, we could achieve better health and better care.  In short, if only hospitals and physicians could change their past behavior could make decisions based on “value,” i.e, “quality and efficiency as perceived by top=down reformers,  all would be well. 

Tweet:   Changing the medical culture by altering hospital and physician behaviors through  financial incentives is an “iffy” proposition and often fails to improve outcomes.