Harden Hearts

Steven R. Peskin, MD, MBA, FACP

This post is not about coronary artery disease. Nor is it about the “stiff” ventricles in diastolic heart failure.

Like “Never Rest”, which I posted several weeks ago, this brief discussion was inspired by Saturday morning Torah study. “Harden Heart” refers to the Pharaoh at the time of Moses and the Exodus from Egyptian slavery. What struck me from our discussion on Saturday morning that relates to health plans and health benefits is that those of us who have responsibility/authority over what is reimbursed, or not, how it is reimbursed, and at what level are — metaphorically — in a parallel role to the Higher Power in the Torah passage. Those whom the purchasers and payers are influencing, or who are on the receiving end of attempts at influence by the purchaser or payer are, metaphorically, in the position of Pharaoh (No implication or suggestion intended about virtue or lack thereof on either side of this analogy!). They are employees, plan members, health care professionals and facilities, ancillary providers, and any other entities that are being paid for services.

In the story, it takes many sticks (no carrots) to ultimately influence Pharaoh to free the Jews. The question that we discussed and debated is to what degree God hardened Pharaoh’s heart and to what degree did Pharaoh, using free will, refuse to set the slaves free even in the face of punitive actions — the plagues.

And in health care, we use sticks too, but also carrots, to influence patients. People who are managing care are involved in plan design that employs disincentives like higher premiums for people using tobacco products or greater cost sharing for certain services or products, and incentives like premium reduction, direct payment, or any of a panoply of other methods of encouraging the desired health outcomes. Are these patients acting with free will, or have we hardened their hearts?

And the same question can be asked of managed care’s dealings with providers. With respect to reimbursement of health care professionals, facilities, ancillary providers, devices, and medications, the purchaser and payer decision-makers may inadvertently harden hearts toward behaviors that are not achieving better, more affordable care. But the providers, using their free will, may resist or, it is to be hoped, see the incentives and disincentives as movement toward better, more affordable care.

We must critically and thoughtfully analyze the impact of our decisions that are intended to influence or shape behavior, course-correct for unintended negative consequences, sharpen and refine interventions that are effective, and appreciate that competing influences, rewards, or disincentives will invariably muddy the waters.

Steven R. Peskin, MD, MBA, FACP is executive vice president and chief medical officer of MediMedia, USA, which publishes Managed Care

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