 Our next speaker is going to be Dr. Peter Ubel, the Madge and Dennis McLehorn University Professor of Business, Public Policy and Medicine at Duke University. Peter is a physician and a behavioral scientist whose research and writing explores the mixture of rational and irrational forces that affect our decision-making, our health, our happiness, and the ways in which our society functions. Peter uses the tools of decision psychology and behavioral economics to investigate topics like informed consent, shared decision-making, and healthcare cost-containment. Peter's won many research awards, including a Presidential Early Career Award for scientists and engineers that was presented by President Clinton. He publishes articles in the lay press in the New York Times and the Los Angeles Times and the Huffington Post. He's the author of Pricing Life, Why It is Time for Healthcare Rationing, and also more recently two books, one called Free Market Madness, Why Economics Is at Odds with Human Nature and Why It Matters, and his latest book is Critical Decisions. Today, Peter Uble will speak to us on the topic of what is wrong with healthcare. No, actually, the way I pronounce it matters. What's wrong with healthcare rationing? Peter. I'll start with the quiz portion of our session, actually more of an opinion poll. Raise your hand if you think that to control healthcare costs, part of what we need to do is reduce wasteful practices. Pretty simple. Okay, how about part of what we need to do is discourage low-value care, increase preventive care. David, you've got to be for that. I don't see your hand going up. Thank you. The part of what we need to do is to ration healthcare. Fair number. What a weird crowd you are. Okay, when caring for their patients, physicians should. How many think that sometimes when caring for patients, physicians should sometimes consider societal costs, sometimes rationed at the bedside, practice parsimoniously. I can define that word for you, but yeah, it's a big word. All right, how many people think healthcare costs would largely be where we need them to be if we just eliminated all waste? Now how many think no, we'd still have something more to do. Very interesting. Okay, this is going to be fun. Okay, I don't know, a handful of years ago I was asked to give a pro-con talk at the annual meeting of the AMA about bedside rationing. I was the pro, not like professional, but like in favor of it. In my book, Pricing Life, subtitled Why It's Time for Healthcare Rationing, I had a whole section in there on why I thought part of the way to control healthcare costs would be to rely on careful use of bedside rationing. And then I had a person who was going to follow me on stage and basically shred my argument, which I'm totally comfortable with. But I kind of pulled a little bit of baited switch on him. I got up there and I opened up by talking about antibiotic prescribing and how sometimes you might have a very powerful antibiotic that you're pretty sure would rid a patient of an infection, but there's a less powerful antibiotic almost as likely to rid the patient of the infection. And you're not going to be generating a bunch of antibiotic resistance to the population at large. There's a big movement, the CDC is playing a big role in it called antibiotic stewardship. And the thought behind it is the physicians need to think not only about curing the patient in front of them, but the public health implications of their antibiotic prescribing and so be, I guess, parsimonious in how you prescribe antibiotics. I said that already establishes that we as physicians, our duties are not just to the patient in front of us, but we need to think about broader societal duties and think about now a related concept of financial stewardship. It's the high cost of healthcare that is what makes it hard for many people to afford health insurance, and this I gave the talk before Obamacare came into law. And so there was even a higher rate of uninsurance in the country. I'd say a lot of that was caused by physicians who were ordering marginally beneficial, very expensive tests and procedures for patients, driving up the costs and therefore the premiums and pricing people out of health insurance with predictable health consequences that lacking health insurance can be bad for your health. And so I said, you can make a public health argument for financial stewardship that the same reason that we're parsimonious about using antibiotics, we should be parsimonious about using expensive tests and procedures when less expensive tests and procedures would be just about as good. And then I kind of, I think I did a better job than what I did right now, but I ended the talk there. I never used the word rationing in my talk. And then my opponent came up and he just didn't know what to say. He said, I think I pretty much agree with everything Peter said and that's not what I thought he'd say, but I really hadn't said anything different than I would if I just used the word rationing. And so what really struck me about it was that he disagreed with me about whether we should have a ration at the bedside, but did not disagree with me about topics like antibiotic stewardship, financial stewardship, parsimonious practice and the like. And so that's kind of what I want to, not kind of, that is what I want to talk about now is how important language can be in moral persuasion. So early in my career, I purpose, I was thoughtful already about thoughtful that nobody's ever used that word to describe me. I purposely used the word rationing in a lot of my writing, recognizing that it was a loaded term. And in fact, it was the in-your-faceness of the word that was one of the reasons I used it in much of my writing. I wanted people to pay attention to what I thought were really important issues. I think that there were lots of things we were already doing, so we'd have these debates about whether we should ever ration medical care, and then I'd see people who couldn't afford their own treatments and went without. And I said, we're rationing by ability to pay. So we shouldn't be arguing about whether to ration, but instead about how and which ways are fair, and that doesn't strike me as a fair way to ration. And so I would try to define rationing very carefully. I try to give examples of rationing. It's a primary care doctor not checking between patients' toes for melanoma with every visit. They're rationing. They're deciding that's not worth it and that there's better ways for them to spend their time, et cetera. And I thought I did a really eloquent job of making the case for rationing, but for many people they lost me. I lost them at the word rationing. And I think that's what's really important. I did a survey early in my career where I gave physicians scenarios of a physician who has two colon cancer screening tests for the patient. One has this cost, this benefit, saves this many years of life. The other one, much more expensive, slightly better, $800,000 per year of life gained. The physician decides not to do that. Is that appropriate? Is that rationing? And I found that appropriateness and rationing ran together. That if you liked whatever I described the physician did, you would say it was appropriate but not an example of rationing. If you didn't like what the physician did, of course, you'd say it's inappropriate and it's rationing. And yet I thought all of these things were examples of rationing. And so to me, I saw the word as carrying a moral connotation to at least a subset of people that meant you're not going to persuade them to agree that rationing is okay because they already know by definition it's not. Around that time, David Asch and I wrote an article in the New England Journal. It was called Rationing by Any Other Name, where we basically looked at all these other, this language that was out there that we thought was euphemistic. And both of us believed that we needed to have, we needed some amount of rationing in healthcare and that we needed to really be clear on what we meant by rationing. The editor of the New England Journal thought we were writing a diatribe against rationing. And in fact, all these other things that were just as bad as rationing, and we're ignoring it, since we wanted to get it published in the New England Journal, we didn't change that misconception of his or clarify our language because we were worried it wouldn't get published. That's dishonest. That's one of my conflicts of interest. In fact, speaking of conflict of interest, I mean, what Stacey talked about, I think conflict of interest is another one of those loaded terms. There was an article in drama not long ago where a couple people wrote that the very term, the phrase conflict of interest is pejorative. And then they argued in favor of confluence of interest, which I didn't, it made no sense to me at all. What struck me was, though, that I've had that problem. When I've talked to people about conflict of interest, they get their neck hairs up just at the mention of that phrase. Whereas I think, no, no, conflict of interest are all over the place. I mean, I have a conflict of interest when it's the end of the day in clinic and I want to get home and be with my family. But I should be spending more time with the patient. That's a conflict of interest. Why don't we just admit it that there's a tension and then we just realize our job as professionals is to try to overcome some of those, but you lose a lot of people at the phrase conflict of interest. So language really matters. So I think it's time for us to figure out how to use better language or at least how to be more open-minded to the moral connotations that our language carries. Another example in my career, we had a person come visit at the biothic center at Penn where I was at the time. And this was someone who had been an ardent opponent of bedside rationing and came in and gave a very eloquent lecture on against bedside rationing but in favor of physicians practicing parsimoniously. And I remember as this person defined parsimonious, I thought that sounds to me just like rationing marginally beneficial services. I saw absolutely no moral distinction. I remember thinking, this person is saying the same thing as me but they're not brave enough to use the R word. And so of course I was there in attack mode. I'm really such a fun guy. And instead of saying this person is saying the same thing as me but not brave, I should have said this person is saying the same thing as me. That in fact I would have been a much better advocate of my own positions if I'd embraced our common ground rather than just get hung up about how this person wasn't willing to use the word that I was brave enough to use. In fact I was obnoxious enough to use and stupid enough to use and ignorant enough to use and I think that's really important. So I essentially ignored very powerful psychology. Let me give you an example of this. A while ago in 2009 a person posted something on Facebook that accused the Democrats who were then writing a very large health care law of creating death panels that would basically decide whether her grandmother or her disabled child should be allowed to live or die. That Facebook post was written by Sarah Palin and 40% of Americans still believe that claim to be true. That there was a death panel in Obamacare. So several years ago with Brendan Nye and Jason Rifler, two political scientists, we did a survey where we put that Facebook post, first we asked people like their attitudes towards a whole bunch of celebrities. How warm or cold do you feel towards Justin Bieber? I mean of course everybody loved Justin at the time. George Bush, Sarah Palin, Barack Obama, etc. And so and then we asked them, we gave them the Facebook post and we asked them, do you believe it's true, this claim? Not surprisingly, the people who loved Sarah Palin believed it and the people who didn't like Sarah Palin so much were less likely to believe it. This is not a profound finding. This is just part of the study. I don't know if it gets a whole lot more profound, but in any case. So for another half of the people, we not only gave them the Facebook post but we put in some language from a fact-checking website, a nonpartisan website that had actually, this was named the lie of the year by one of those websites. But just saying that independent experts have concluded that the Facebook post was incorrect that in fact there was only language being drafted at the time to pay for end of life counseling. Now what happens to people's belief in whether death panels exist or not? Well, let me give you one other little piece of information. We also asked people some basic questions about their knowledge of American politics. I'll give you guys a quick quiz. How many U.S. senators in each state? Two, very good. How many terms can a president serve consecutively in the United States? Two, good. I think every question we asked had the answer two. We asked six such questions and very sadly there was a high percentage of people who got two, maybe three of these things correct. So there was not a great knowledge in some Americans. What do you think happens to belief in death panels? Suppose you love Sarah Palin or feel warmly towards her, whatever. You hear about the death panel claim and you see it debunked and you know very little about politics. What do you think happens to your beliefs in death panels? Huh? They'll double down on it. In fact, no. They'll go, wait a second. Okay, I guess I was wrong. I still love Sarah Palin. Great glasses, awesome hair, but she can be wrong once in a while. And so it actually we found that debunking worked, which is really great because what do you want and the democracy you want to inform population and so fact checking, the reason they're out there, fact checking all the time is to help correct people's beliefs. The problem here was that the people who got those questions correct and showed some basic political knowledge doubled down. They believed more strongly in death panels than they did before we debunked the claim. This is what happens when you challenge people's core beliefs. If they are intellectually invested in it and have the wherewithal to do so, they will double down. They will find reasons to blame the mainstream media, the lame stream media too. They have that kind of ability to do it. And I think the same goes on. When we're arguing with ethicists, my God, you want to find a group of people that have the intellectual role to go fight against something they don't believe in. And so I think this is what happened when I'd have rationing debates with people. I was debating with really smart people who had all kinds of ways to see the flaws in what I was saying. And we weren't finding common ground, but we're nitpicking about language. And I was missing the point of the reason for us to have this debate is we needed to figure out how we should spend healthcare resources and what we shouldn't give to whom. But instead we found ourselves arguing about words, meaning of words. So I think words are important. I'm not sure how much time I have. Mark, good. So let me give you just a... The way I've seen language about rationing evolve over the years, because when I first started working in this area, it was pretty lonely because most people didn't think we had a healthcare cost-spending problem in the United States, the only country where it's just optional to die. And that has really changed now. There's huge momentum towards trying to control healthcare costs. And part of that is because costs have continued to rise, because people haven't been listening to me for the years now. Also, it's partly just... There's been some great exposés about high prices and such, and you heard a couple of great examples today about how expensive healthcare can be. But another thing is there's been a shift in language. In the 90s, we were talking about rationing. We were talking about the use of cost-effectiveness analysis and trying to decide what to spend healthcare dollars on. Today, the big phrase is value, and compared of effectiveness research, not cost-effectiveness analysis, and value was defined in the New England Journal as health outcomes achieved per dollar spent, which sounds very much like cost-effectiveness to me. But, you know, cost-effectiveness sounds kind of nasty, and it's got a lot of baggage to it, and value, who would not be in favor of promoting value? It's a brilliant switch in language, and I think with that is coming a lot of momentum of people who are willing to embrace how to promote value, who would not have embraced trying to have cost-effectiveness care. I think this shift from bedside rationing towards financial stewardship is similar. We're trying to reframe the debate. I think to open more people's minds so that we can start tackling the issues without just being confronted by language that we don't like. So I'm going to close, and then I want to open it up to your discussion, and you can tell me how euphemistically lame I am. I think our job as ethicists includes, does include to bravely and rigorously dissect moral ideas and find distinctions when they're morally relevant, and point out when those distinctions cannot stand the glare of keen analysis. That's absolutely one of our jobs. And now, I could wax eloquent on the vanishingly thin difference between rationing and parsimony, between value and cost-effectiveness, but as a behavioral scientist, I think those differences are enormous. I think all ethical scholarship is ultimately about persuasion. It's about changing the way people think about moral problems. But moral argumentation will not succeed in changing people's thinking if we insist on using language that closes people's minds. For that reason, I no longer support healthcare rationing. Yeah, I'm brave of me, I'm a brave guy, yeah. I think healthcare professionals not only need to reduce healthcare waste, but also need to act as financial stewards of societal resources that are always limited, and they need to tweet very intelligently to fight the system, of course. I think to most people such stewardship and such parsimony does not equate to rationing, and that's good enough for me. Thanks. Questions, comments? So, great talk, Peter. For me, value has been very interesting, and language, of course, is important. I think there's a meaningful addition when you encompass the phrase volume to value. Volume to value, have you heard that? Volume to value. The transition from volume to value in healthcare, because the economic incentives when it's volume are very problematic. So, I think it's a pure synonym when you just say value cost effectiveness. What was the other one you used, I forget. Parsimony. Parsimony, thank you. But if we think of it as a transition from volume to value, I think it's a more substantive idea. But we could have volume to cost effective. Now, it doesn't have alliteration, but more importantly, it doesn't have, I don't think it had backing. So, I do think that the word value is a really brilliant switch in language that opens people up to things. Now, if you're eliminating no value services, that's waste, and everybody's on board with that. So, but low value services mean there's value. But we think that the value is not really commensurate with how much we're spending, and to me that's a marginally beneficial, not cost effective service. But that's okay. It's volume to value. I'm in favor of it. But there is no precedent for a volume sort of discussion. Well, I guess there is. When we got to DRG's was in some ways a volume based. Yeah, no. We were talking about volume for a very long time, and that's part of what we're talking about with when we were debating rationing, was how to reduce the volume of these marginally beneficial services. We don't use rationing anymore. I've never heard of it. I'm guessing I was the person. You were, and I was adjourned to you. I apologize because it was such a great talk. That's right. Actually, I don't remember your comments because you were kind compared to everybody else. But what I would like to ask, again, this is sort of regardless of what we want to call it, whether you think there's a moral distinction between those who would try to practice parsimonious care, not providing marginally beneficial, but very much highly expensive treatments to patients, at least as first line therapy, versus a sort of set of activities that I consider to be different morally, sometimes also included under the umbrella term of bedside ration, which would be to take in a setting in which there's not an acute local shortage, a particular therapy which is not marginally beneficial from the perspective of the particular patient, but potentially costly, and withheld explicitly because the clinician's version of what is a high value care is not going to be met by that treatment with a motivation of redistributing healthcare resources. I think when people talk about the R word and its negative connotations and when they reject that term, it's because of that set of decisions. So for instance, an example might be not putting in a feeding tube on someone with cerebral palsy because we think that the quality of life and the benefit for that person is not what we should be spending our resources on. And I think it's the distinction between not giving the very high, expensive, marginally beneficial treatment and that and the other scenario that I just described for you all being described into the same word that I think disturbed people. I wonder whether you think that's just a slight variation along the spectrum where there is a really moral distinction between those two classes of action. Yeah, one of the problems with the word rationing is you need a lot of adjectives. Like rationing of marginally beneficial services for the purposes of the little law. And a lot of what I was trying to do early on was saying, of course we need to do that at some point. Now, what we need to argue about is when and what constitutes kind of morally justifiable bedside rationing at the time. But people would say, well rationing, no, no, no, because that could mean you're just deciding who should live and who should die. No, absolutely not. So you do think there is a distinction? I think that rationing, the word rationing is much bigger so there's a wider range. Whatever we call on those two classes of actions may be morally distinct and we ought to have the conversation about which ones we ought to permit in which we should preclude. So I don't believe in rationing, of course. We've established that. So seriously, I thought of parsimony as the subset of rationing that felt most morally appropriate. Maybe part of the problem with the two classes of actions we have here, the one, the no value care that we all agree shouldn't be done and then the more complicated decisions that Dr. Salmezi was alluding to is nobody wants to admit they're doing no value care. It's another terminology thing. There are a bunch of clinicians doing it right now. Who would be favorite? Of course I would be doing something that has no benefit to my patient. It's really about being a good doctor and these physicians aren't practicing adequate medical care. They're providing services that are unnecessary. So how do we call that something different so they stop doing it? To the point of your talk, how can language be used in a behavioral science sense of the way to limit no value care which everyone agrees needs to be separated out and reduced? Did you say no value care? Yeah, no value care. We're working at it and so the whole choosing wisely campaign is trying to go after that and I think it needs to be tied to reimbursement changes to have much effect. Last question. Sorry, I know we're trying to get through on time. In regards to value, I've done some work here on trying to dissuade people from low value services and I think de-adopting something is very difficult and I'd be curious of your thoughts on the psychology of that. Yeah, de-adopting. So David and I actually wrote something in health affairs recently on that topic and it's really hard once you've given someone something to take it away is very hard but if you look at something just give an example of cancer screening where we think there's very low value screening in some settings for some populations where you have same breast cancer you have tens of thousands of women convinced their life is safe because somebody found a DCIS which may not even be a cancer it's probably an over diagnosis of cancer but they become part of a survivors community you have physicians who are convinced they see patients who don't get diagnosed in time and they can't imagine how you would ever back up on screening because of that without seeing the harm of the people who are over diagnosed and realizing that it's over diagnosis it's a rich and thick psychology Thanks Thank you