The New England Journal of Medicine’s Lisa Rosenbaum speaks with University of Pennsylvania’s internal medicine physicians Paula Chatterjee (also a health services researcher) and Atheen Venkataramani (also a health economist and founder of Penn’s Opportunity for Health lab) about the role of values in health care, social determinants of health and what physicians can do to improve U.S. health care. An excerpt of the audio interview:
[Rosenbaum] Atheen, I know that you also had a formative experience, I think when you were a resident at MGH. Can you talk a little bit about that and how that experience informed your overarching research agenda?
[Venkataramani] Back when I was a senior resident, it was actually the last, I think, 6 months of residency and of having this care panel in Charlestown. I had a patient who I’d been working with for a few years on a number of different issues, including substance use disorder, of which one was tobacco. Every year we talked about smoking cessation. There was some, I think precontemplative, occasionally contemplative statements, and we sort of worked within that. So the final year I was with him, probably the last time I was going to see him, I said, “Just so I can tell the next person who takes over the panel, what happened with smoking cessation? We talk about it a lot. We always put it on the agenda, but it looks like I haven’t been able to help you. So what’s going on?”
He said something really interesting, which was “I’m really never going to get out of here. So what’s the point?” And when I pushed him on it, what he meant was, he was kind of in this working-class life in Charlestown. He was one of the, quote, Townies. And that part of Charlestown had really benefited during the heyday of American industry with ship building and other things. People were living these very middle-class lives. And as those industries disappeared, a lot of those folks ran out of the same economic opportunities. And his whole point was like, this is me, there’s nothing for me here. So why am I going to spend all this time working on quitting smoking? And a light bulb went off for me because that’s actually, there’s this famous economic model called the Grossman model, which talks about how people’s demand for health care and the stock of their health over the life course.
And one of the statements in that model is that if people have the ability to earn higher wages, it actually makes more sense to invest in their own health in order to capture those higher wages. And the corollary here is if he felt the hope to have a better life, he basically was saying that that would’ve been a reason to invest more in his health, but without that hope, he didn’t. And so it immediately connected me to this idea of people’s hopes for the future, the American Dream, and how just the psychology of that could shape their decisions when it came to health behavior, their mental health, and their physical health as well. And so we pulled on that thread and we’ve been pulling on it now for, I think, almost 7 years. The lab, which is 2 years old, as of, I think, yesterday, it really owes itself to this patient insight.
I don’t like to call myself a social determinants of health researcher, but let’s just use that term. Osler said something like “Listen to the patient, they’re telling you the diagnosis.” And I think it’s true also for some of these social factors — people are pretty clear about what are the things that are going on in their broader lives, whether in their households, in their communities, or even broader than that, that affect the way they feel when they see you in the hospital or in the clinic or so forth. And listening to that and then taking that to the data in ways that might speak to other people who feel the same thing I think has been a very rewarding exercise for me.
[Rosenbaum] Can you talk a little bit about some of the studies that have been born of that observation, that hope and despair play these key roles in people’s lives in terms of their willingness to invest in their own health?
[Venkataramani] Yeah, sure thing. I think our lab has looked at a bunch of different exposures that we think are tied together, not necessarily in the eyes of the public, but are tied together theoretically because they do change people’s opportunities, real or perceived. Those things include automobile plant closures in the industrial Midwest, banning of affirmative action in university admission decisions at the state level, police killings of unarmed Black American individuals, the rise of industrial robots that replace manufacturing jobs. These are all different things we’ve looked at and we’ve tied to phenomena like mental health decrements, worsening mortality, opioid use disorder.
But the fundamental idea in all of these studies is that there’s something that’s happening to people that, regardless of what station of life you are, what race, ethnicity you might be, what strata of American society you occupy, something is happening that is fundamentally changing the way you think about the future or what you’re able to do in the future. And that that powerfully changes the way your health evolves over the next few years and even long run.
[Rosenbaum] What do you think, then, is the responsibility of the health care system to address these so-called social determinants of health? Obviously, we’re talking a lot about the role these social determinants play in our patients’ lives, but the question still remains, what do we do about it? So what do you think is the responsibility of our health care systems to remedy these social determinants of health?
[Venkataramani] Hospitals have, or health systems have, the advantage of seeing people in a very vulnerable place in their lives as it relates to their health. And so the sum influence of all of these factors that have come to shape their health appears in front of you in the form of a patient. I think hospitals, by virtue of collecting those stories, can play an important role in telling those stories. So that’s one piece of it.
Functionally what can hospitals do to address social determinants of health? I think there’s some things that are within the wheelhouse of hospitals, and there are other things that I just don’t think we do in medicine very well and we probably shouldn’t do. The things that we can do well is at the point of care, we can connect people to services. We can work with community organizations in ways that reimagine what the handoff is at discharge, so that people don’t fall through the safety net but rather have a place to go.
I think these are all things that hospitals can do. I get more worried when I see things like hospitals are investing in housing or areas of health where we don’t actually know a lot about those markets. We don’t know what our involvement will do in the housing market. And it goes beyond, I think, medicine and the point of care to something that we run the risk of doing harm because we just don’t know how to do that well. And perhaps the effort there is better spent by the state or federal housing authority, who understands the problems better than a private organization like a hospital. So there’s some delineating on rules, but it’s not like we can’t do anything. Let’s just focus on what our comparative advantage really is.
[Chatterjee] I think two points come to mind. The first point is I think that there are a lot of things within the wheelhouse of hospitals and health systems that we are leaving on the table in terms of achieving goals related to equity or addressing a subset of social determinants of health, that I think the health system is well-equipped to do. So for example, we can ask hospitals and health systems, and incentivize them, to measure within-hospital disparities, whether it’s by race, whether it’s by other socioeconomic strata, we can incentivize the measurement and then incentivize the closure of those gaps within a given hospital. That seems within the purview of their existing resources. We could of course get into a separate conversation of well-resourced and less well-resourced hospitals, but I think that is in the wheelhouse of what hospitals can do.
They can make sure that all of their patients have access to mortality-reducing therapies, for which we know that there are already existing disparities. These are aligned with the clinical goals of hospitals and health systems and within their reach.
I think my second thought is that there is a whole area of questioning that we should be asking about “What is the relationship between a hospital and health system and its surrounding community?” And this gets back at your points of if a hospital understands a patient to be experiencing homelessness, what should the interaction be with Housing and Urban Development? What should the interaction be with local public health resources, with existing government infrastructure that technically should be providing these services? [..]
[Rosenbaum] What do you think, then, is keeping us from thinking hard enough about these questions? Is it a conceptual problem, or is it a problem in the way we ask research questions?
[Chatterjee] One example that comes to mind, I think, is our conceptualization of value. I think that we have really adhered to this monolithic definition of value as quality and returns to your patient in terms of outcomes over the cost to a variety of different actors. And I think that that framework has motivated a lot of the field of health services research, but I think it doesn’t answer the question of value to whom. I think we all wanted to believe that it’s value to the patient, but I’m not convinced that it is, and I’m not convinced that we’re measuring it to be. And so that’s something that I find myself thinking about a lot. I do think that there’s a lot of exciting work that’s challenging some of these original paradigms. I think about Ziad Obermeyer’s work, who asked the question of, yes, there is low value-care and we should probably use less of it, but when are we underusing high-value care?
We have to ask both sides of that coin. I also think that there’s a whole crop of people who are asking questions about this — there are groups of patients who are so overserviced by the health care system, but yet extremely underserved when it comes to their well-being and their outcomes. And I think there are people thinking transformatively about what value looks like to those patients in a way where throwing more services at them is not necessarily the answer. And maybe we can think about that differently. A theme that I come back to a lot is the canonical approach to value can inform some really, really important questions, but it cannot give us every goal of the health care system. [..]
[Rosenbaum] I think the value story is really an interesting one, because it has its origins in the Dartmouth data. And those data essentially were set of observations looking at the associations between health care spending and outcomes and basically finding that higher spending wasn’t always correlated with better outcomes, and sometimes higher spending was associated with harm.
And those data have had what I would argue is more influence than any other health services research I’ve ever come across, because they really launched what I’ve come to think of as the less-is-more narrative, which essentially suggests that not only are a third of health care dollars wasted, but this important corollary, which is that if we then just pay doctors not for how much they do, but for how well they do it, our quality will be better and we’ll have massive cost savings. Which of course then became the bedrock principle of all these value-based payment designs.
But what’s always been so fascinating to me about all of this is that you really just have these observations, which didn’t test an intervention; they’re a series of correlations. But then they were translated into health policy that affects all of us and all of our patients, and it’s a health policy that’s never been tested prior to implementation. And it’s not a health policy that’s clearly working. And so it’s not just, as you’re saying, this question of value to whom, it’s all these other questions, like, what is value? What is quality? Can we measure it? Do we save money by trying to pay for it? And are we all losing our minds in the process? So many questions.
And so as I’ve tried to understand it, part of what I’ve always found so interesting about all of this, was that it’s just such a compelling narrative. Because it was a narrative that didn’t force us to make any trade-offs — we could improve quality and cut costs at the same time. And there’s so much about that that’s appealing. And so I guess what I’m wondering, really, I think I have two questions. One is, what do you make of how health services research kind of got lost in translation in this instance? But also, maybe even more importantly, what do we learn from that? How do we better use health services research to inform policy?
[Venkataramani] I think one of the problems with that narrative is on this fundamental margin that this is a story about care. Every so often, in social media, there’s that chart from the New York Times which plots the spending of different countries in the health care system and what happened to trajectories and life expectancy. And you see the U.S. lonely with this precipitous rise in spending in health care while falling off of the curve in every sense when it comes to longevity compared to peer countries. I think that story has brought about, it’s like, wow, there’s so much waste in our health care. But to believe that is the whole thing, you have to think that not only is there waste in health care, it’s that the marginal dollar is causing irreparable harm.
And I think that’s where things have gone wrong, because what’s actually happening in that curve, you can trace back to the early 1980s and potentially a large series of changes in American society — the opportunities people had, the rise in inequality, a number of other forces that have patterned mortality in ways that occur outside the health care system. So if our fundamental problem that we all agree on is that we are spending a lot but our life expectancy is relatively bad compared to our peer countries, then we actually have to look at why that’s happening, and it’s not in the health care system. So for me, to see so many people spending energy on the relationship between healthcare spending and outcomes, I wonder if some of that talent is misallocated, because there is actually this whole other thing that’s going on that’s patterning health in American society outside the health care system that we should probably be talking about more. And I think we are talking about it more now.
[Chatterjee] There’s deconstruction of what the determinants of health are. If you make the pie chart about the determinants of health, health care is but a very small sliver of that. I think health services research can maybe focus on what the achievable goals of the health care system are, relative to these other contributors. Not to beat a dead horse, but I go back to this point about understanding the role of the health care system as it fits into a broader world, I think, is an underdeveloped area. We don’t know that, we don’t how hospitals are supposed to interact with local governments, how hospitals are supposed to interact with public health agencies. But those are the questions we should be asking, because if the goal is to improve health, we have to engage outside of health care. That just seems part and parcel. [..]
[Rosenbaum] I guess then the question becomes, why are we so wedded to things like pay for performance, which doesn’t seem to be working that well? We know extrinsic motivators likely undermine intrinsic motivation, and we know doctors are so burned out, so what is it that’s tying us to this system that isn’t working, and is probably quite demoralizing to lots of physicians? It kind of actually blows my mind.
[Venkataramani] It’s always interesting, I was looking at some new research on peer comparisons with physicians and how that’s not motivating, actually, it’s the opposite. You’re told you do worse than your peers, you actually get, the gap even increases. It’s so interesting that we add systems on top of systems that are already circumscribing the work of physicians in some ways that might be necessary, in other ways that might be limiting. And then we’re adding more things to that without asking the fundamental questions about what they might do to people and whether that further undermines their scope of practice and authority. It’s funny, if I were to say these things 20 years ago, there’s a whole movement of people that would be like, we need to circumscribe that authority of physicians because they’re contributing to health care costs and waste and stuff like that.
And I find myself on the other side of it now, being like I just wish you would leave me alone, because I think I know exactly what to do here. I’m the only person who has the knowledge of this particular patient because I’m the one involved in the episode of care. And so you just have to, if you could trust me to know that this is the right plan of action, I have spent a week thinking about this. There is a fundamental disconnect there. And I think we have this idea of physician autonomy, the place in the system, there’s multiple different, I think, opinions about what the degree of autonomy should look like, what that means for cost, because things always come back to cost and waste and all of that. And if we can free ourselves of those concepts for a few minutes and think about what is it that you want a given doctor to be able to do and feel that they can do credibly? What can we actually subtract from what we’re making them do?
[Chatterjee] The other thing is the goal of value-based payment, as you said, Lisa, is to improve quality and reduce costs. And if those are the goals, there are such bigger fish to fry than rearranging the deck chairs on physician payment. If you want to reduce costs, let’s have a conversation about hospital prices. That is an actual big-ticket item. It’s inconvenient, and it’s hard, and it’s wrapped up in a whole bunch of complicated stuff, but so is this current thing that we’re trying to do that is only getting us incrementally anywhere.
[Rosenbaum] [..] When you talk to psychologists about what makes for intrinsic motivation, they’ll tell you it’s mastery, relatedness, and autonomy, but they always emphasize that it’s autonomy that’s most important.
And so it just seems like this huge oversight as we have these simultaneous conversations about burnout and about quality, that there’s little talk about what our metricized system is doing to physician spirit and agency. [..]
[..] can you talk a little bit about how that observation played out during the pandemic? Because I think what you’re getting at, and that we really need to pay attention to, is this bigger question of where science ends and values begin. I’m not sure we ever had that conversation with the public during Covid or even amongst ourselves.
[Venkataramani] As a health economist, we would specify a model of people’s happiness or utility, and the thing which is an argument over many things that they want in their lives and that carry value — relationships with people, the development of their child, maybe, or their ability to engage in certain activities and their health. That’s part of it. And everyone weighs those things differently. Different communities in the aggregate may even have different preferences over all of those things.
We can, let’s say, and we don’t, let’s say we had perfect data on the effect of every possible Covid-19–mitigation strategy. And you can define “perfect” in whatever way you want. Let’s say we had that knowledge and that the standard errors, the confidence intervals were really narrow.
People could still reasonably make very different choices or societies could choose to do things differently, as we’ve seen in different countries, on the basis of that even certain knowledge, because they have different beliefs over what they’re trying to maximize. And I think that’s, when you have a conversation in private about Covid, which often goes pretty well, it’s because you’re able to talk through those values. When these conversations happen online or on cable news, that kind of understanding of another person’s set of values and the preferences they have over the things they do in life is not there. And so in being prescriptive, we often assume an objective function for society to maximize, which may or may not be what other people agree with.
And then we can get into trouble because that recommendation is not going to land, because they fundamentally reject the premise of what we’re trying to do. Every Covid-19 conversation, I think, comes down to this lack of stasis in terms of what we are trying to do as a society.”
Full article, Perspective, New England Journal of Medicine, 2023.3.9