Can Standards of Care Become Barriers to Care?

Standards of care exist to protect patients and make doctors accountable. So higher standards of care can only be a good thing, right? The reality is more nuanced. Particularly when you factor in access and value (both real and perceived).

Background

We are fortunate in the United States to have some of the best medical amenities in the world… leading medical schools, highly trained and experienced physicians, cutting-edge medical technologies, well-equipped hospitals, well-developed medical infrastructure, strict quality controls, and, of course, high standards of care.

So why does the healthcare system in this country feel so broken?

The United States spent 3.8 trillion dollars on healthcare in 2019. As a percentage of GDP, that is over 3.5x higher than what we were spending in 1960. For some context, GDP itself has increased from $543 billion in 1960 to $21.43 trillion in 2019 (CAGR of around 5.5%).

US National Health Expenditure as Percent of GDP from 1960 to 2020

Here are a few of the most significant causes of ballooning healthcare costs:

• Increases in lifestyle-driven chronic diseases.
• Remarkable – but expensive – advancements in medical technology. These advancements are primarily oriented toward treating the sick and injured. Some technologies are able to restore health... some merely sustain or prolong life.
• There have been relatively few tangible advancements in illness prevention… primarily because the economic incentives are not appropriately aligned with prevention.
• A broken insurance industry (see this post for more about insurance).
• The prevalence of malpractice suits.

The two questions we explore in this article are:

1. Do standard of care regulations also put inflationary pressure on healthcare costs?
2. Would a less prescriptive approach to the standard of care benefit both doctors and patients?

Who determines the standard of care?

Standards of care are determined by medical boards comprised of doctors that are specialists in the field of medicine for which the board is responsible. These people are among the most knowledgeable and experienced in their respective fields. So it makes sense that they would be the ones to establish the standards that regulate how care should be administered, right? Again, the answer is nuanced.

While eminently qualified, medical boards are also extremely susceptible to biases that result from the value systems of their members. Consider some of the factors that shape the perspective of a typical doctor:

• A genuine desire to help people and do everything in their power to facilitate the best possible clinical outcomes
• Risk avoidance: a doctor's training and experience teach them to avoid anything that could potentially lead to an undesirable patient outcome and/or a malpractice claim.
• Knowledge of the data surrounding how different treatments and levels of care affect patient outcomes.
• The reality is that, as a provider, you make more money when you provide more – and more expensive – services.

I would like to make it clear that this is in no way intended to be an indictment on doctors. Far from it. And it is not intended to suggest that the perspective of these experts is wrong. Far from it. Their professional perspective is crucial and invaluable… but it is only one perspective. The point is that medical boards - just like everyone else - are subject to certain biases in how they view the world. And those biases likely result in a different value hierarchy than that of the average consumer of medicine. Specifically, a group of doctors is likely to be more risk-averse and less concerned about the affordability of care.

Should the standard of care determined by a board of medical professionals take precedence over the collaboration between patient and doctor when deciding on affordable treatment options?

Value Systems

For the purposes of this discussion, we will define a “value system” in less of a moral sense and more of a practical sense. It is:

“The importance an individual assigns to something based on their beliefs, experiences, and circumstances... as demonstrated by their choices.”

Does our medical system give enough priority to the patients' value system when determining the standard of care? Imagine if you walked into a hospital and there was a huge fast-food style “menu board” behind the reception desk:

That would allow patients to make decisions based on their value system. And, more importantly, it may reduce some of the economic barriers to care. If the prices listed on this hypothetical menu board seem outrageous, consider that last week a friend of mine was charged $2000 at the emergency room for her husband to get a few stitches in his hand. It probably took less than 30 minutes of actual treatment time. I didn’t ask if the stitches were put in by an actual doctor or not.

In all other areas of our lives, our consumption behavior is driven by our uniquely personal value system. It’s true for vehicles, restaurants, shoes, houses, electronics, etc. And our financial situation is a HUGE part of that equation. Consider the automobile industry as an obvious way to illustrate this principle:

Vehicle	Ferrari	Mercedes SUV	Honda Minivan	Dodge Dart
Price	$200,000	$100,000	$40,000	$20,000
Values	Status, Performance	Luxury, Status, Performance	Practicality, Reliability, Safety	Affordability, Economy

Simply put, people value things differently. That is why there are literally millions of options out there when it comes to vehicles. We could all agree that most Dodge Dart owners would probably rather be driving a nice 5-series BMW or perhaps even a $200,000 Ferrari. So why don’t they? They don’t because affordability is at the top of their value hierarchy. They drive the Dodge Dart because it is accessible to them… and it is better than walking.

Whether automobiles or healthcare, we would all prefer to have the very best available. But the reality is that we can’t all afford the very best. So what happens if high standards of care in healthcare impede doctors from providing more affordable “Dodge Dart” options for lower-income patients? The intention of establishing standards of care is to protect patients and make doctors accountable. The unintended consequence is that high standards of care that are excessive can contribute to high costs and limit the doctors' discretion to customize the level of care according to the value system of the patient.

At this point, the contrarian might counter with a “but we need to protect people from themselves” type of argument. To that I would offer two comments:

1. It is the height of arrogance to presume you know what is best for another person, and it conflicts with the principles of freedom that are a cherished part of our national identity here in the United States. What is medically advisable or preferable is not always what is best according to the value system of that individual.
2. It isn’t consistent with how other industries are regulated. In keeping with our automobile analogy, consider this data surrounding motor vehicle fatalities:

In 2018, motorcyclists were 27 times more likely than passenger car occupants to die in a crash per vehicle miles traveled.

Why then isn’t it illegal to sell motorcycles to protect people from themselves? The data supports it after all.

Between 2014 and 2017, the death rate for drivers of Chevrolet Silverado 1500 Crew Cab 2WD was over 7x that of Toyota Tundra Crew Max 4WD

Does that mean that we should mandate that dealerships only sell Toyota Tundras?

Thousands of people die and are seriously injured on our roads each year. But that doesn’t mean we restrict freedoms by outlawing motorcycles or other, less-safe vehicles. We do have minimum vehicle safety standards that must be met. We attempt to educate people about the risks. Then, we allow people to choose for themselves which vehicle is right for them. We’d prefer that everyone drives in the safest vehicles with the most advanced safety features… but we acknowledge that not everyone can afford a $100,000 Mercedes SUV.

Conclusion

Standard of care is just one relatively small factor when it comes to the affordability of healthcare in the United States. Those that are responsible for determining standards of care are knowledgeable and well-intentioned, but they represent only one perspective in what is a very complex discussion.

Ultimately, shouldn't patients have the autonomy to determine the standard of care that is right for them… based on their own value system and the advice of healthcare professionals? Doctors would then be free to customize care to the patient, or decline to provide care if they are not comfortable providing whatever standard of care is demanded by the patient. Fortunately, many areas of medicine are becoming more patient-centric in this way. Direct to consumer orthodontics is a great example. In this relatively new care model, the patient makes the informed decision to forgo a clinical exam, frequent in-person check-ups, and sometimes even more comprehensive treatment, in order to save thousands of dollars. The impact of this model is clear... expanded access. More people now have access to limited orthodontic treatment than ever before.

What opportunities are out there to bring similar innovations to other areas of healthcare so that people stop avoiding needed healthcare because of financial constraints? Please leave your thoughts below.