Beyond the Blame Game: The Patient’s Choices

One of the easiest traps for healthcare professionals to fall into is blaming the very people they are serving for breaking the system, over-utilizing care, not taking care of themselves, or behaving poorly and acting in a way where they will never be satisfied.

Walk into any emergency room and I will almost guarantee that you will find a jaded old ER nurse who could complain for hours about the homeless frequent flyer who keeps acting out or the “entitled” patient who lives in a delusional land of instant results and answers. Or, watch as s hospitalist is doing back-of-the-napkin math to calculate the mind-boggling cost of the 92-year-old patient that was just readmitted to their service for the 10th time in 8 months.  At the insurance company board room table, listen to the conversations about catastrophic claimants, medical-loss ratio, and how if only their members were healthier, they would be able to better control their risk.

These are all real conversations I have had in my career. But there is one more that will forever stick with me. I was called down to talk with a family of a younger developmentally disabled patient with relatively minor chronic medical issues who had been in the emergency room for nearly a week, on-and-off of restraints due to causing staff injuries, unable to be placed in an appropriate state facility, but also unable to be discharged safely. I am not sure what I was expecting, but it wasn’t the emotionally charged conversation that ensued with the family eventually asking for hospice care because they couldn’t keep watching how the system was treating their loved one. 

How could patients cause so many problems for a system that was designed to serve them? The reality is that the system wasn’t designed to serve them. Perhaps an individual part of the system or an individual service was designed with the patient at the center, but the overall system does not work together in a way that adequately responds to the incentives and choices that patients face daily. When you understand those incentives and choices, you can start to understand how and why patients act the way they do.

We all know that only 20% of health outcomes for patients are due to clinical care and the remaining is tied to psychosocial, economic, behavioral, and physical environment factors. Many of these same factors came into play in every conversation I had trying to understand why patients make the choices they make.

· Economics: Healthcare is expensive. Even middle-class families struggle with the costs of insurance, deductibles, co-pays, and out-of-pocket costs related to accessing care. Consider the low-income patient who didn’t go get their diabetic foot ulcer checked out because they couldn’t afford the gas to drive to the doctor’s office, and now, they are facing a life-changing amputation. Without insurance, some catastrophic care would bankrupt even those who many would consider wealthy. The concept of insurance in the US healthcare system is absolutely critical to spreading the risk of financially crippling debt associated with healthcare services across a larger population. But, that same insurance concept leads rise to Moral Hazard, an economic concept that essentially states that when individuals don’t experience the full cost of a good or service, the demand for that good or service will increase. Think about how many people track their deductible closely and try to “squeeze” in elective surgeries before the plan year is over and their deductible resets. Too often in our system, patients have to struggle to make a  logical choice between health and economics.

· Psychosocial: The impact of the intricate interplay between social realities and psychological pressures for individuals on healthcare decision making cannot be understated. In the world of social networks, Dr. Google, and AI-enabled healthcare experts, healthcare information (and misinformation) is readily available leading to a wide range of expectations that may or may not be based in reality. A great example that stuck out in my career was having a conversation with a family of a patient in the ICU with COVID-19 demanding an administration of hydroxychloroquine. Add in the micro-cultures and norms across the melting pot of the US demographic, patients can have wildly different needs and perspectives which ultimately lead to nearly unique ways of individual making decisions. Understanding the psychosocial reasoning of an individual is hard. It takes time, engagement, energy, and resources… things that the overall healthcare system in the US is sorely challenged with currently and are nearly impossible to do at scale.

· Behavioral: Human beings are remarkably predictable in one regard; we tend to optimize for what is easiest in the moment rather than what is best in the long term. Every one of us has delayed an oil change, ignored a persistent cough, skipped the gym after a long day, or promised ourselves we would start eating better on Monday. Healthcare is no different. The challenge is that the consequences are often much greater. Patients miss appointments because they can't take another day off work. They don't take medications because they don't like the side effects, can't afford the refill, or simply forget. They continue smoking despite understanding the risks because addiction is powerful. They choose the emergency department over primary care because it is open at 2:00 a.m. and guarantees they will be seen eventually. These are rarely decisions made due to ignorance. They are decisions made by imperfect people balancing competing priorities with limited time, money, energy, and information. If we want different behaviors, we must build systems that make the healthier choice the easier choice. Behavioral economics has taught us that defaults, convenience, incentives, and friction often matter more than education alone. Yet our healthcare system continues to rely heavily on expecting patients to overcome enormous barriers through willpower.

· Physical Environment: Where someone lives frequently predicts their health better than what hospital they go to. Access to healthy food, safe neighborhoods, reliable transportation, stable housing, clean air, broadband internet, and nearby healthcare services all influence decisions long before a physician enters the picture. I think back to patients who repeatedly returned to the emergency department because they had nowhere else to go. Others couldn't refrigerate insulin because they lacked stable housing. Some were discharged with careful follow-up plans only to discover they had no transportation to their appointments. We often documented these as "non-compliance" when, in reality, many were simply impossible situations. Healthcare organizations have become increasingly aware of social determinants of health, but awareness alone does not solve them. Hospitals cannot fix housing shortages, food insecurity, education, transportation, or poverty by themselves. Yet these realities continue to drive demand for healthcare services every day.

When viewed individually, it is easy to criticize many patient decisions. When viewed collectively through the lens of economics, psychology, behavior, and environment, those same decisions become much easier to understand. That doesn't mean patients bear no responsibility. Personal accountability matters. Healthy choices matter. Following treatment plans matters. But responsibility exists within the constraints people face, and those constraints are far more influential than many of us like to admit.

This is why I struggle when I hear someone say that "patients are the problem." A healthcare system that rewards episodic treatment over prevention, creates financial uncertainty around seeking care, fragments information across countless providers, and expects people to navigate incredible complexity during the most stressful moments of their lives should not be surprised by the choices people make.

If we truly want different patient behaviors, we need to stop asking why patients keep making bad choices and start asking why our system keeps making those choices the easiest ones to make.

That's not a patient problem.

It's a system design problem.

This is the second article in this series with new installments posting on Thursdays.

Intro - Beyond the Blame Game: An Operator’s Perspective

Post 1 - Beyond the Blame Game: The Patient’s Choices

Post 2 - Beyond the Blame Game: Why Employers Keep Paying More for Less

Post 3 - Beyond the Blame Game: The Insurance Company’s Paradox

Post 4 - Beyond the Blame Game: Hospitals aren’t the Problem… but They are a Problem

Post 5 - Beyond the Blame Game: Why Physicians Feel Trapped

Post 6 - Beyond the Blame Game: Regulation and Over-Regulation

Post 7 - Beyond the Blame Game: The Role of Private Equity in our Tangled System

Post 8 - Beyond the Blame Game: Don’t/Do Drugs

Post 9 - Beyond the Blame Game: A Fragile Workforce

Post 10 - Beyond the Blame Game: What Can We Do?