Q&A: Business, public policy, and medicine professor Peter Ubel on medicine and health care

Peter Ubel is the author of Sick to Debt: How Smarter Markets Lead to Better Care. He’s a professor of business, public policy, and medicine.

Is there a just-right model for health care somewhere?

The United Kingdom has a completely socialized, topdown system that works fairly well. Then there’s Germany, where the system is built on heavily regulated private insurance, and it meets their needs pretty well. There are lots of ways to get it right, though no system is perfect. The U.S. has found lots of ways to get it wrong.

You write about Germany, in the era of Bismarck, as an illustration of moral hazard—that is, how lowering the price of medical care can also lower the individual’s motivation to make smart decisions.

At the end of the nineteenth century, more and more Germans were moving from small farming communities to larger cities. If a farmer broke his wrist, his family and neighbors could take over his chores until he recovered. If a factory worker broke his wrist, he might face financial ruin. So a new law required large factories and professional guilds to care for employees’ financial needs when they were too sick to work—with an emphasis on lost wages rather than hospital bills. After the law, German workers became less likely to shrug off ailments. They called in sick at double the previous rate. And their illnesses lasted longer.

You don’t favor a free-market model that throws all the costs to society. You also don’t favor forcing consumers to choose only what they can afford to pay for.

The debt I’m talking about is in part the debt incurred by society when people demand more health care than they need or seek out care that is not worth the associated cost. I’m also concerned about personal debt for people with high out-of-pocket expenses. In 2006, 10 percent of American workers had plans that carried deductibles of $1,000 or more; ten years later, it was more than 50 percent. Much of this move toward high-deductible plans came from employers: As employers sought to reduce the cost of employee benefits, out-of-pocket rates soared.

You open the book with a story that illustrates the importance of physicianpatient conversations around costs.

A thirty-nine-year-old guy receives chemotherapy to shrink a tumor. When they get him to surgery, they find the cancer has spread from his colon to his liver. His Duke oncologist says, “Why don’t we put you back on the chemotherapy that shrank the original tumor?” At which point the patient says, “I can’t do that. I went bankrupt paying from the first round.” Intravenous therapy rather than a pill would have cost the patient next to nothing. The oncologist thought it would be more convenient for the patient to take a pill. He didn’t realize such convenience was bankrupting his patient.

Don’t incentives sometimes play out in just the wrong way in health care?

There are some things that are really expensive and are life-altering. Why should you be unable to afford that? If some treatment or medication is priced high but brings a lot of benefits, that should be affordable for the patient. If it’s priced high and brings almost no benefits, I’d like to see the patient pay for most of that.

How do your fellow physicians feel about the health-care system in its current form?

We have record-high levels of burnout among physicians; in some specialties, the majority of physicians report being burned out. Some of these reimbursement models force them to spend more time tracking every decision than listening to their patients. Or they feel compelled to prescribe overly expensive medicines, because that’s how their clinic pays its bills. Most of us enter the medical profession to interact with people at some of the most meaningful moments. Those meaningful moments can’t be reduced to a twelve-minute office visit.