by Stephen M. Shortell, Jodi Halpern, and Barry Schwartz, Health Affairs
By nearly all measures, the complex, fragmented US health care system is failing its people. Despite spending 17 percent of gross domestic product on health care, representing $4.9 trillion, the US system ranks near the bottom among the Organization for Economic Cooperation and Development countries on almost all measures of performance. There is high variance in infant and maternal mortality, risk-adjusted hospital mortality, and patient safety, with minority groups faring worse than other groups on most measures.
A common thread in efforts to improve the system is to become more patient-centered, as emphasized in the landmark Institute of Medicine Report, “Crossing the Quality Chasm,” nearly 25 years ago. To date, various combinations of regulations/rules and incentives have been used in attempts to make the system more affordable, higher quality, safer, and more attuned to patient needs and preferences. These have met with mixed success at best. The missing element in many of these initiatives is the practical wisdom that enables clinicians and the organizations in which they work to adapt the regulations/rules and incentives to meet the changing needs, preferences, and circumstances of individual patients.
Practical Wisdom
Practical wisdom is the moral will to do the right thing and the skill to figure out what doing the right thing requires. It draws on Aristotle’s belief that most human activities have their own, specific telos, or purpose, and that internalizing this purpose motivates people to do the activity well and virtuously. The purpose of health care is to prevent and cure disease, and to ease suffering. Excellent clinicians will strive to do what is best for each patient—to make effective decisions and good judgments, adapting rules/regulations and incentives to meet the unique needs of each patient and their circumstances.
Individual, organizational, and societal factors are involved in the development of practical wisdom. These include education and training that develops clinicians’ empathic curiosity and listening skills so that they are truly patient-centered; organizational cultures and management systems that promote and nurture patient-centeredness; and the larger payment, political, and economic environment that can either promote or constrain the ability to innovate and adapt individual and organizational behaviors to meet patient needs and preferences.
The need for practical wisdom is central to current efforts to move toward a more patient-centered health care system grounded in greater investment in primary care. Patient-centered primary care involves the development of a partnership between clinicians and patients based on clear, reciprocal communication, shared goals, mutual respect, and trust. Patients’ needs, preferences, and values guide clinical decisions. Early efforts by the Centers for Medicare and Medicaid Services (CMS) to develop value-based payment models to advance patient-centered primary care have yielded mixed results. Some have suggested that part of the reason for mixed results may be the need for earlier and greater involvement of patients in the design of new payment and care-delivery models. This requires clinicians and health care organizations to use practical wisdom in recognizing where the regulations/rules and incentives can act as an impediment to meaningful engagement with their patients.
The Insufficiency Of Rules/Regulations
Rules/regulations are needed to safeguard basic patient safety and quality of care. Advances in clinical guidelines, checklists, and artificial intelligence (AI)-generated protocols are examples, but they tend to be blunt instruments based on “one size fits all reasoning” that cannot be applied to all patients. Clinicians need to rely on their practical wisdom in making adjustments to meet the needs of the patient in front of them. Regulations provide important signposts as to standards of care, but one can have standards without demanding standardization. It is also important to review and revise rules/regulations to keep up with advances in technology and changes in what patients want and value. Otherwise, the regulations become entrenched and create an administrative burden, taking time away from interacting with patients.
Regulations tend to provide only a minimum standard or floor, inducing a compliance culture and mindset rather than a continuous improvement mindset. Current rules/regulations governing prior authorization for care are a case in point. Practical wisdom is needed to limit or target prior authorization to those truly low or no value services that add to costs without improving care and, in some cases, actually harm patients. AI-generated algorithms can assist the clinicians’ judgement in this process and reduce the current frustration experienced by clinicians and patients alike.
The Insufficiency Of Incentives
If rules/regulations set a floor, policy makers have turned to incentives (including disincentives or penalties) to induce high performance. Positive incentives include pay-for-performance programs, quality bonuses, and various shared savings arrangements associated with CMS accountable care organizations initiatives. Penalties have been created for hospitals that fail to reduce their 30-day preventable readmission rate and hospital-acquired infections under Medicare’s Value-Based Payment Program.
While well-intentioned, there are also limitations with incentives. Any incentive system requires that the measures used to assess performance are reliable and valid across different types of patients, placing a premium on adequate risk adjustment. Incentives can also divert attention from what is really important to patients by focusing efforts on meeting the incentive measure; a practice known as “goal displacement.” Examples include spending time on coding and documentation for insurance requirements rather than focusing on patient needs and working to achieve higher scores on a flu vaccine quality measure rather than prioritizing managing care for diabetes patients whose blood sugar or blood pressure levels are out of control. Incentives can also increase the administrative burden for provider organizations, particularly when payers use different measures in calculating quality bonuses or related rewards. Furthermore, many incentive programs do not reward improvement over time. Underlying all these issues is that incentives can “crowd out” or compromise the telos of physicians, nurses, and other health care professionals to do the right thing. Most physicians are motivated more by achieving a sense of mastery and serving patients well than by money. In the words of one physician, “Why do you have to pay me more to do the right thing?”
Rules/regulations and incentives work best when they build on the motivation of health care professionals to do the right thing by drawing on their practical wisdom to adapt care to meet the changing needs of their patients. We suggest three sets of initiatives to advance practical wisdom involving education and training, organization design and leadership, and payment reform.
Educating And Training For Practical Wisdom
Medical schools and other health science professional schools can promote practical wisdom by educating and training for empathic curiosity. “Empathic curiosity” begins with medical students recognizing that they do not know how their patients feel because they have not lived in their patients’ situations. This inspires listening to patients more carefully, both their words and their non-verbal cues, to elicit their needs, fears, and hopes. Early student exposure to patients and their families guided by mentors who model listening needs to be built into internship and residency experiences. For example, students can be assigned to follow patients with chronic illness for several months or years. Courses in narrative medicine in which students read and reflect upon patient memoirs can also be built into the curriculum. Empathy in physician-patient communication produces more effective care, partly by improving patient adherence to care recommendations. In addition, evidence suggests that developing empathic curiosity skills by the end of medical school provides some protection against burnout.
Organizing For Practical Wisdom
Health care organizations need to be designed, led, and managed to promote practical wisdom in continuously improving care. Common elements include the development of cultures based on respect for people, with everyone focusing on doing the right thing for patients even when no one is watching. Emphasis is placed on teamwork. Leaders in such organizations spend less time solving problems themselves and more time coaching others, humbly listening, and learning from front-line staff who are closest to the patients. Plan, do, study, adjust cycles are used to continuously improve processes. In such organizations, the motivation of health care professionals to do the right thing is magnified and fully expressed. While two-thirds of US hospitals report using some elements of such systems in some areas, only 10 percent of hospitals have implemented them throughout the organization although two-thirds report some use.
Paying For Practical Wisdom
The long-entrenched fee-for-service system of paying for care rewards physicians, hospitals, and other health care organizations for providing more care. The underlying assumption has been that more care is better care. It is better to avoid the type two error of missing a diagnosis by calling someone well when they are ill, than the type one error of designating someone ill when they are well. But a growing body of research suggests that this is often not the case. Type one errors produce care that is often of little or no value and, in some cases, actually harms patients. The fee-for-service payment system is an example of the folly of “paying for A while hoping for B”; paying for more care, while hoping for better care.
CMS has a goal of moving all provider organizations away from fee-for-service to risk-adjusted prospective payments (value-based payment models) by 2030, and California has set similar targets for all payers by 2035. Implemented well, these in effect create budgets for provider organizations to keep people well by providing an upfront revenue stream to invest in prevention, health promotion, patient engagement, and care coordination, eliminating wasteful and non-value-adding care in the process. These payment models reward smart care, not more care.
Conclusion
The ground-breaking 2001 Institute of Medicine (now the National Academy of Medicine) report “Crossing the Quality Chasm” put forth 10 rules to continuously improve patient-centered care. Underlying all the rules (including the need to move away from care based on visits and fees) was the need for wise judgment in fostering trustworthy, healing relationships with patients. Practical wisdom is particularly needed to address ambiguous, complex, and uncertain situations that are associated with the chronic illnesses faced by a growing number of Americans. It is instructive to note that other countries, such as the Netherlands and Germany, that spend far less on health care than the US, have better health outcomes and health system performance. Their approach is characterized by having strong patient-centered primary care systems in which clinicians have considerable autonomy to use their judgment, their practical wisdom, in adapting rules/regulations and incentives to meet their patients’ needs.
