Patients, providers and a bus full of backseat drivers

In my younger years, I’d visit my grandparents in Florida. In their garage, they had an old white Toyota Corolla. Despite the vehicle’s advanced age, it remained in immaculate condition. After all, it had just 300 miles on it. Not 300,000 miles–no comma required–just the equivalent of one full trip from Jacksonville to Miami on the odometer. My grandparents reserved the car specifically for visiting family to “drive.” Those quotes are important.

When I was of driving age, my grandmother–now in her 80s and buckled into the back, with a couple of cataracts to her credit–offered generous input and colorful commentary on my motoring. She made it a point to point out that I shouldn’t follow the car ahead of me too closely. Yet I wasn’t to let the car to my rear follow me too closely either. I was told, in no uncertain terms, that I must both speed up and slow down, at the same time, always.

This conundrum presented itself again on one particularly memorable trip down I-95  I was stuck between slowing down to yield more distance to the car in front of me, and speeding up to lengthen the distance away from the car behind me. If I’d chosen to do neither, or merely one of the above? I’d have more accurately chosen my grandmother’s wrath. If you knew her, you’d know I did not want that wrath. Neither would you.

So while I may have been at the wheel, I sure didn’t feel like it. This colorful anecdote draws an important parallel to how we experience, deliver, and engage with the healthcare system. For many patients piloting their own health journeys, that lack of control mixed with confusing advice must feel eerily similar to a fraught drive with frantic passengers calling the shots.

Who Drives Healthcare?

Driving change in the health sector is challenging precisely because no one can seem to agree upon who’s driving who, or when, or where. In theory, the ecosystem’s set up to benefit the patient first. When we think of patient-centered care, we like to envision them in the driver’s seat of their own health.

However, our current care delivery model operates more like a bus with everyone giving directions, telling the patient how to drive, and where to stop or get off, often with contradictory input. Some clamor for the fastest route, some avoid (or encourage) tolls, some tell patients to take only the roads with which they’re familiar … speed up, slow down, turn here, go straight, drive on the shoulder and dodge all this traffic.

The question of who drives healthcare is not easily answered, nor is it always answered in the way that best serves the one at the wheel. Backseat drivers can’t agree, take turns steering and dictating directions (in no small part in service of satisfying their own interests) and ultimately leave patients unable to drive with sufficient degrees of confidence or know-how. This is a textbook illustration of the principal-agent problem, which although it doesn’t originate from and isn’t exclusive to healthcare, this problem’s especially pronounced.

Examples of Principal-Agent Problem(s)

When priorities differ between a person or entity that can make decisions or take actions (the “agent”) on behalf of (or that impact) another (the “principal”), this creates a moral hazard. In care delivery, since the patient is clearly the principal, this also can create a potential health hazard. The scope of the principal-agent problem is as wide and severe as the size of the system and the variety of agents.

A wide array of people and entities beholden to diverse interests, incentives, and obligations, routinely make decisions on behalf of patients. These agents mostly fall into three broad categories: payers, providers, and caregivers.

Payers cover the costs of patient care, but every dollar doled out means less money for shareholders. To the extent they see fit and to the extent they’re permitted within legal and compliance bounds, payers can maximize profits by denying care payment to patients.

Providers work to make the patient healthier, but must also comply with regulatory, legal, and ethical mandates, and operate within budget and administrative constrictions. They must also act to ensure they can continue to make a living to support themselves, their families, and their care delivery infrastructure (i.e. staff, tech, licensing, overhead).

Caregivers want to improve the patient’s health, too, but also hold a significant emotional investment in the patient’s journey. A caregiver’s desired outcome or means of arriving there may differ wildly from that of the patient. As an example, if antibiotics decrease the length of time a child suffers from an ear infection by 24 hours, but increase the risk of diarrhea and other unpleasant side-effects, then what the caregiver chooses might vary depending upon infection severity, who has to change the diapers, and who has to wake up in the night with the crying child.

Solutions (and Directions) to Navigate the Road Ahead

A 2011 analysis examining the prescribing patterns of private providers in Vietnam suggests that empowering patients with greater education may help lessen the principal-agent problem in healthcare. The more a patient knows about their health and how healthcare works, the more confident they can be while advocating on their own behalf, and the more likely they’ll appropriately weigh all treatment or prevention options, or push back against superfluous treatment.

The analysis also proposes improving regulatory oversight and public-private collaboration to better align provider and payer incentives with patient interests, echoing research from Tennessee State University published a decade earlier.

Incentivization, of course, remains the not-so-invisible hand on the wheel. To further balance the scales of input between patients and agents, a 2012 presentation at the 4th International Scientific Conference proposes a payment system designed to “contribute the most to the motivation of the physician to maximize the patient’s utility.”

This utility-based reward system must, by its nature, incentivize optimal resource consumption. Optimal finds the sweet spot between our present-day twin systemic ills of ruthless efficiency and superfluous excess. Care can focus more squarely on the patients’ interests when the system recalibrates its incentives–financial, regulatory, professional, emotional–to more closely align with patient outcomes.

Empowering Patients to Take the Wheel

To drive progress in healthcare means, as often and expertly as possible, helping patients drive instead of “drive.” This requires centering the patient and protecting the sacred trust in the patient-provider relationship. A principal-agent problem, even if not directly caused by the providers themselves, erodes that trust. Payers, caregivers, providers, and the greater healthcare ecosystem all play a role in aligning with what’s best for the patient and valuing their trust above all.

The easiest way to get a patient to take the wheel in their health journey is to remind them at every turn that they’re the driver and to equip them with the education, confidence, transparency, and support system to keep their eyes on the road and their desired destination within reach. The less backseat driving, the more likely patients are to listen to vital input or figure things out for themselves.

Or else they’ll end up as I did, on I-95 in Florida, with my grandmother sitting in the back of the Corolla. That day, torn between speeding up and slowing down yet expected to do both at once, I thought I had found a very clever out: I pointed at the mirror, then pointed out to her that the car behind us was not that close.

But my grandmother was not about to be so easily hoodwinked, for the rear-view clearly stated, “Objects in mirror are closer than they appear.”

“Oy,” she said, “it’s even worse than I thought. You better change lanes.”

Of course. Now, why didn’t I think of that? After all, I was the one driving.

Photo: Boogich, Getty Images