How to Not Punish Hospitals for Good Care

Question: Is there enough room for medical experimentation in the current health reform bill?

Atul Gawande: Yes and no. So if this health reform bill goes through, and I think it's looking like every sign will, it is about health reform, but not reforming health care, which is what we really need; meaning redesigning health care to be better quality, better safety, lower cost, getting rid of wasted, unnecessary steps and moves and the harmful components of care. It has the experiments in it to be able to start having us try to innovate on that systems level. So when we've talked about innovation in medicine, what we've usually meant is, will there be a new drug? Will we have a cure for cancer? And we are on our way, with or without reform, to spending 18, 19, perhaps even 20 percent of our whole economy on health care. There's no shortage of money for those kinds of innovations, and I think those fields will prosper. But to take advantage of them and be sure we're using them in every community in the right way, at the right time, we have not been innovating. I think if health reform doesn't pass that we will be very slow to innovate.

But there are components in the health reform package that include innovations both at that front end, trying to design, say, the checklists for the right kind of care, and also on the incentives end. That is, one of the reasons we don't come up with these kinds of checklists is that hospitals and doctors don't do better financially when they put in these kinds of tools. For example, Children's Hospital in Boston came up with a checklist for asthma patients, children who are severely asthmatic enough to end up admitted to the hospital. And they recognized that a couple of components were key: making phone calls to the families to make sure the children were taking their inhalers, and having a look at their apartments to make sure that -- or homes -- to make sure that dust and mites were not a problem in the homes. By tackling just those two things, they reduced admissions for kids with asthma by 87 percent. But asthma was their number one admission to Children's Hospital. And the found this experiment lost them millions of dollars. And so they suddenly were face to face with, well, maybe we need to shut down this program in order to survive as a hospital. That's when you know there's just something wrong with the way we are designing our system.

And the reform bill -- we don't know what is the best way to pay that hospital so that it does the right thing, but we have some good ideas about the experiments to try. One is, for example, paying the doctors and hospital together, whether that kid is admitted to the hospital or not, so that they're on the same page about taking care of this kid with asthma. The kid with asthma might get -- I don't know; I'm pulling a number out of the hat -- $5,000 for that diagnosis and care in that year. And so let's simply give that money and then have them work to try to make the best of that financial situation, which I think leads -- can lead -- to better care.

Question: Is the Massachusetts health care system working?

Atul Gawande: What's right about the Massachusetts system is coverage. We went from 12 percent uninsured to 2 percent uninsured, and that's very impressive. European countries are at 98 to 99 percent coverage of their populations, and Massachusetts did it without -- with most of the people in the population not even noticing. It was through private coverage; basically, if you are uninsured or can't afford insurance coverage, you can go on the Web and get subsidized insurance policies that limit your costs to about 8 percent of your income. Not everybody's happy about that. If you're only earning $30,000 a year and have $2400 -- that's 8 percent -- to have to pay, that seems like a lot. But insurance premiums are typically 15 or 16 percent of people's income, so it's heavily subsidized.

The down side: cost. There was nothing in the Massachusetts plan to deal with costs. Now, the costs have not -- contrary to many of the news reports -- have not outstripped the budget. The Massachusetts health care costs have continued to rise about 8 percent or so per year, which is right in the middle of where the country's costs have been rising. And the program for the uninsured actually came in under budget. If the recession hadn't dropped the bottom out of tax revenues, then this would have gone on as if there were no issues at all. But the pressure of the loss of that tax revenue led the hospitals and doctors and insurers to actually be serious about cost controls. And I'd say in the state we're a couple years ahead of other places in starting to try innovations, paying doctors and hospitals differently. Instead of fee-for-service, just being paid for every time you do an operation, for example, there's a shift towards saying, let's pay for results, and let's figure out how to do it. So that kind of pay-for-results system is now being tested and experimented with, though it's still not easy to figure out.

Question: What are the biggest advantages being proposed in the current healthcare reform package?

Atul Gawande: The national reform package actually looks a lot like the Massachusetts package. It has coverage through private insurers that people would get to choose from -- go on the Web and sign up for a health plan if you don't have coverage or can't afford it. There's more in the bill to do with trying to control the costs, and that is also a plus. There's more in there than we see in Massachusetts by far. Some of it is to try to really drive insurance competition by, for example, having insurers pay a premium tax if their insurance plans comes to cost more than $23,000 a year. Most plans are far from costing that much right now, but they're on their way to doing it if they don't figure out how to organize better.

Second, though, is whether it's private insurance or federal programs like Medicare, there are very interesting experiments, pilot programs, to test out paying doctors in different ways from the way we've done it; for example, paying a hospital system that actually encompasses both hospital care and outpatient care -- what they call gain sharing. If they bring their costs down, the Medicare program would let them keep half of the reduction in costs, to try to provide an incentive for controlling costs, as long as they meet basic quality control measures and have good access to primary care. Can hospitals actually learn to do this? Can we organize to get our act together? I think the answer is going to depend on their adopting things like checklists for the most costly and harmful conditions, where we see a lot of mistakes and waste. But this is tough stuff. Doctors and hospitals are quite fragmented, very disorganized, and learning how to really work as a system of people is going to take us -- it's not going to be a matter of two or three years; this is going to be a generational effort. But I think the clear signs are, we can first end up reducing just the rate of inflation, but then over time if we are able to learn and use the lessons, we could even bring the cost down, which has been feasible in other lines of work.

You can tell a system is broken when a prominent children’s hospital devises a system that reduces local asthma cases by 87%, but then has to cancel the program due to the lack of revenue from new and recurring patients. Can the current healthcare reform bill end this ridiculous approach?

Are we really addicted to technology?

Fear that new technologies are addictive isn't a modern phenomenon.

Credit: Rodion Kutsaev via Unsplash
Technology & Innovation

This article was originally published on our sister site, Freethink, which has partnered with the Build for Tomorrow podcast to go inside new episodes each month. Subscribe here to learn more about the crazy, curious things from history that shaped us, and how we can shape the future.

In many ways, technology has made our lives better. Through smartphones, apps, and social media platforms we can now work more efficiently and connect in ways that would have been unimaginable just decades ago.

But as we've grown to rely on technology for a lot of our professional and personal needs, most of us are asking tough questions about the role technology plays in our own lives. Are we becoming too dependent on technology to the point that it's actually harming us?

In the latest episode of Build for Tomorrow, host and Entrepreneur Editor-in-Chief Jason Feifer takes on the thorny question: is technology addictive?

Popularizing medical language

What makes something addictive rather than just engaging? It's a meaningful distinction because if technology is addictive, the next question could be: are the creators of popular digital technologies, like smartphones and social media apps, intentionally creating things that are addictive? If so, should they be held responsible?

To answer those questions, we've first got to agree on a definition of "addiction." As it turns out, that's not quite as easy as it sounds.

If we don't have a good definition of what we're talking about, then we can't properly help people.


"Over the past few decades, a lot of effort has gone into destigmatizing conversations about mental health, which of course is a very good thing," Feifer explains. It also means that medical language has entered into our vernacular —we're now more comfortable using clinical words outside of a specific diagnosis.

"We've all got that one friend who says, 'Oh, I'm a little bit OCD' or that friend who says, 'Oh, this is my big PTSD moment,'" Liam Satchell, a lecturer in psychology at the University of Winchester and guest on the podcast, says. He's concerned about how the word "addiction" gets tossed around by people with no background in mental health. An increased concern surrounding "tech addiction" isn't actually being driven by concern among psychiatric professionals, he says.

"These sorts of concerns about things like internet use or social media use haven't come from the psychiatric community as much," Satchell says. "They've come from people who are interested in technology first."

The casual use of medical language can lead to confusion about what is actually a mental health concern. We need a reliable standard for recognizing, discussing, and ultimately treating psychological conditions.

"If we don't have a good definition of what we're talking about, then we can't properly help people," Satchell says. That's why, according to Satchell, the psychiatric definition of addiction being based around experiencing distress or significant family, social, or occupational disruption needs to be included in any definition of addiction we may use.

Too much reading causes... heat rashes?

But as Feifer points out in his podcast, both popularizing medical language and the fear that new technologies are addictive aren't totally modern phenomena.

Take, for instance, the concept of "reading mania."

In the 18th Century, an author named J. G. Heinzmann claimed that people who read too many novels could experience something called "reading mania." This condition, Heinzmann explained, could cause many symptoms, including: "weakening of the eyes, heat rashes, gout, arthritis, hemorrhoids, asthma, apoplexy, pulmonary disease, indigestion, blocking of the bowels, nervous disorder, migraines, epilepsy, hypochondria, and melancholy."

"That is all very specific! But really, even the term 'reading mania' is medical," Feifer says.

"Manic episodes are not a joke, folks. But this didn't stop people a century later from applying the same term to wristwatches."

Indeed, an 1889 piece in the Newcastle Weekly Courant declared: "The watch mania, as it is called, is certainly excessive; indeed it becomes rabid."

Similar concerns have echoed throughout history about the radio, telephone, TV, and video games.

"It may sound comical in our modern context, but back then, when those new technologies were the latest distraction, they were probably really engaging. People spent too much time doing them," Feifer says. "And what can we say about that now, having seen it play out over and over and over again? We can say it's common. It's a common behavior. Doesn't mean it's the healthiest one. It's just not a medical problem."

Few today would argue that novels are in-and-of-themselves addictive — regardless of how voraciously you may have consumed your last favorite novel. So, what happened? Were these things ever addictive — and if not, what was happening in these moments of concern?

People are complicated, our relationship with new technology is complicated, and addiction is complicated — and our efforts to simplify very complex things, and make generalizations across broad portions of the population, can lead to real harm.


There's a risk of pathologizing normal behavior, says Joel Billieux, professor of clinical psychology and psychological assessment at the University of Lausanne in Switzerland, and guest on the podcast. He's on a mission to understand how we can suss out what is truly addictive behavior versus what is normal behavior that we're calling addictive.

For Billieux and other professionals, this isn't just a rhetorical game. He uses the example of gaming addiction, which has come under increased scrutiny over the past half-decade. The language used around the subject of gaming addiction will determine how behaviors of potential patients are analyzed — and ultimately what treatment is recommended.

"For a lot of people you can realize that the gaming is actually a coping (mechanism for) social anxiety or trauma or depression," says Billieux.

"Those cases, of course, you will not necessarily target gaming per se. You will target what caused depression. And then as a result, If you succeed, gaming will diminish."

In some instances, a person might legitimately be addicted to gaming or technology, and require the corresponding treatment — but that treatment might be the wrong answer for another person.

"None of this is to discount that for some people, technology is a factor in a mental health problem," says Feifer.

"I am also not discounting that individual people can use technology such as smartphones or social media to a degree where it has a genuine negative impact on their lives. But the point here to understand is that people are complicated, our relationship with new technology is complicated, and addiction is complicated — and our efforts to simplify very complex things, and make generalizations across broad portions of the population, can lead to real harm."

Behavioral addiction is a notoriously complex thing for professionals to diagnose — even more so since the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the book professionals use to classify mental disorders, introduced a new idea about addiction in 2013.

"The DSM-5 grouped substance addiction with gambling addiction — this is the first time that substance addiction was directly categorized with any kind of behavioral addiction," Feifer says.

"And then, the DSM-5 went a tiny bit further — and proposed that other potentially addictive behaviors require further study."

This might not sound like that big of a deal to laypeople, but its effect was massive in medicine.

"Researchers started launching studies — not to see if a behavior like social media use can be addictive, but rather, to start with the assumption that social media use is addictive, and then to see how many people have the addiction," says Feifer.

Learned helplessness

The assumption that a lot of us are addicted to technology may itself be harming us by undermining our autonomy and belief that we have agency to create change in our own lives. That's what Nir Eyal, author of the books Hooked and Indistractable, calls 'learned helplessness.'

"The price of living in a world with so many good things in it is that sometimes we have to learn these new skills, these new behaviors to moderate our use," Eyal says. "One surefire way to not do anything is to believe you are powerless. That's what learned helplessness is all about."

So if it's not an addiction that most of us are experiencing when we check our phones 90 times a day or are wondering about what our followers are saying on Twitter — then what is it?

"A choice, a willful choice, and perhaps some people would not agree or would criticize your choices. But I think we cannot consider that as something that is pathological in the clinical sense," says Billieux.

Of course, for some people technology can be addictive.

"If something is genuinely interfering with your social or occupational life, and you have no ability to control it, then please seek help," says Feifer.

But for the vast majority of people, thinking about our use of technology as a choice — albeit not always a healthy one — can be the first step to overcoming unwanted habits.

For more, be sure to check out the Build for Tomorrow episode here.

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Credit: World Values Survey, public domain.
Strange Maps
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Michael C. Crair et al, Science, 2021.
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