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medicine a nd so cie t y Debra Malina, Ph.D., Editor

On Marginal Health Care — Probability Inflation and the Tragedy of the Commons Benjamin R. Roman, M.D., M.S.H.P. Lying in bed talking to my wife one night last year, I suddenly couldn’t hear what she was saying. No, this was not a case of selective deafness. One second everything was fine, and the next, my right ear started ringing, loudly. Coincidentally, I am an otolaryngologist, and so I had two initial thoughts: “I have sudden sensorineural hearing loss” and “No wonder van Gogh cut off his ear!” (although that theory is apparently in doubt). In that moment, I certainly wasn’t thinking about health care costs and the tragedy of the commons, but that’s what this story is about. Sudden sensorineural hearing loss (SSNHL) affects roughly 4000 people in the United States every year. It usually resolves on its own, with or without a course of steroids. Most of the time, we never figure out the cause and presume that it can be attributed to a viral infection, but 4 to 10% of the time it’s caused by a benign tumor of the cranial nerves known as an acoustic neuroma. These tumors are rare, grow slowly, and once found don’t necessarily require treatment. A patient with an acoustic neuroma that is large or causes symptoms may be offered surgery or radiation treatment. My hearing and tinnitus did not get better by the next day. An audiologist performed an ear exam and a hearing test. Sure enough, I had hearing loss in my right ear, but it wasn’t bad enough to meet strict criteria for SSNHL: it was a 30-dB loss, but it affected only one frequency. In other words, one pitch — the note of one of the beeps in the test — had to be a little louder than normal for me to hear it, but only one pitch and not that much louder. I talked to an ear specialist who recommended oral steroids and an MRI to rule out a tumor. “MRI?” I thought. MRIs are not even strongly recommended in guidelines for patients with 572

true SSNHL, let alone those whose conditions don’t meet the diagnostic criteria, and there are other, cheaper diagnostic tests.1 Yet during my residency, which I finished 2 years ago, I was trained to order MRIs in exactly this scenario. (I sometimes rebelled, but my protests usually fell on deaf ears.) If there is waste in health care, $1,000 for an MRI for ringing in the ears, absent proof that such imaging results in longer or better lives, always seemed like a glaring example. Believing I should decline the MRI, I tried to rationalize the decision to my wife. “I don’t even meet criteria for SSNHL,” I pointed out. “The chance of my having an acoustic neuroma is exceedingly small.” “But your doctor wants you to get it,” she said. “You’re getting that MRI.” That settled it — I gave in as meekly as I had as a resident. Two weeks later, the MRI came back negative, and my hearing had already returned to normal.

The Tr agedy of the Commons The concept of “the tragedy of the commons” was described by Garrett Hardin in 1968 using the following situation first described in a 19thcentury pamphlet: herdsmen who allow their cattle to graze on a common pasture keep adding to their own stock because they reap the benefits but don’t bear the costs of feeding the extra cows. But when everyone worries only about his or her own lot and not the commons, the grass is eventually depleted and everyone suffers.2,3 The commons problem may be most visible today in environmental domains such as fishing, forestry, and pollution. But the goods and services that our country can collectively pay for are similarly finite. As health care costs have increased as a percentage of the gross domestic product, middle-class salaries have stagnated,

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necessary care has become inaccessible to more people, and policymakers on both sides of the political aisle have grown worried about the consequences for future investments in infrastructure, education, and national security.4 Increasing overall health care expenditures may also mean less money spent on the health care services that have proven benefits. To be sure, we should save money by reducing waste in health care — avoidable complications, inefficiencies, excess administrative costs, prices that do not reflect cost inputs, and fraud.5 The need for such reductions is uncontested, except perhaps by the people and organizations that benefit financially from the various forms of waste. It is much more difficult, however, to address overuse of medical services that are of marginal value — cases in which our self-interest, like that of the herdsmen, may cause us to act in ways that conflict with the greater good.

Pr o b a bilit y Infl ation The herdsman’s extra cattle will certainly benefit him, but there is no such certainty with marginalvalue health care. The fundamental problem is that even when there is only, say, a 1% chance that some health care service will benefit us, or only a 1% chance that we’d regret not undergoing some test, procedure, or intervention, we usually choose to go ahead with it (if we are fortunate enough to have the choice). This problem arises from the way we deal emotionally with risk and uncertainty, which are givens in health care, and the way we make decisions in the face of low-probability outcomes. One explanation for our behavior comes from cumulative prospect theory, which says that we tend to assign too much weight to probabilities when they are low.6 As a result, when the probability that a given good thing will occur is low, say 1%, we feel that our chances are higher, and we therefore behave in risk-seeking ways — for example, buying lottery tickets or choosing to undergo chemotherapy at the end of life. On the flip side, when the probability that a given bad thing will occur is low, we also feel that the chances are higher and behave in risk-averse ways — for example, buying too much insurance for things like consumer electronics. Such risk aversion, whether my own or my wife’s, is why I agreed to have an MRI.

This psychological phenomenon applies to any decision related to low-probability outcomes made under conditions of uncertainty, but it is exacerbated for decisions about health care, which are intrinsically more emotional. (My wife: “It’s your hearing for God’s sake!”) Strong emotions only amplify the type of response we might have to decisions about lottery tickets or insurance.7 My doctor’s recommendation was based on a similar reaction. Besides wanting to reassure himself and his patients that there is no acoustic neuroma, he told me, another reason he suggests MRIs in situations like mine is that he fears being sued should he fail to order one and end up missing something. He noted that court malpractice awards for missed acoustic neuromas commonly reach into the millions of dollars and that until we agree to an acceptable miss rate and physicians are no longer liable for missing just a single such case, their practices will not change. I’m not sure how common such verdicts are, but this rationale also reflects risk aversion in the face of a low-probability bad event — it’s simply the doctor’s risk that’s at issue, rather than the patient’s.8 A 1% chance of benefit also tends to outweigh in our minds the chances of harm. My MRI showed a benign pituitary cyst, and even though my doctors determined that I didn’t need any additional tests or procedures, the finding still stirred up a little anxiety. The harm for me was psychological, but a biopsy, with its attendant risks, might have also caused physical harm. Chemotherapy at the end of life is a more common example of an intervention that often carries a greater chance of causing harm than resulting in good. Facing a 1% chance of benefit, most of us want to do something, because action seems to have several advantages. The one that counts the most is the 1% chance that the chemotherapy will lead to meaningfully longer life or that the MRI will reveal an acoustic neuroma and help to preserve long-term hearing. But we also choose action because it helps us avoid what may be a 1% chance of a bad outcome due to omission (an untreated acoustic neuroma or certain death that chemotherapy might have offered a slim chance of averting). Finally, there’s a pretty good chance that the patient and the physician will receive reassurance, hope, or some

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other psychological benefits from the intervention,9 although it’s not clear that these outcomes couldn’t be achieved in some other way. Given all the possible advantages, it may seem as if we’ve bought something useful much more than 1% of the time — but the price is high, given the benefits we actually receive. When examined from a population perspective, the lottery ticket, cell-phone insurance, futile chemotherapy, and my MRI are indeed expensive, potentially harmful, and of only marginal value. But though we can analyze our medical decisions at the population level, we experience and feel them at the individual level.10,11 Here at the bedside, the 1% chance looms large; it doesn’t feel marginal at all.

Solu tions What can be done? First, if we support comparative effectiveness and outcomes research, it may lead to clearer understanding of the benefits, harms, and costs of our diagnostic and therapeutic interventions. But evidence that calls into question prior beliefs about the value of health care services may not hold as much sway as we might hope.12 Second, we can do a better job educating doctors about how to discuss uncertainty, risk, and probability. But it may be too much to ask doctors to take responsibility for changing the risk-related behavior of the patients in front of them, since they may be as concerned about patients’ 1% chance as the patients themselves. So though these approaches are essential, they will not necessarily overcome emotions regarding health care decisions. Only by addressing the emotions and psychology of patients and physicians can we create enduring change. In his classic description of the tragedy of the commons, Hardin argued that the solution to the problem lies in “mutual coercion, mutually agreed upon.”2 In other words, we need to acknowledge the inability of the individual to hold back, and then accept and promote ways of nudging one another to do the collective right thing.13 Three levels of nudges are possible in health care. Consumers could share the cost of the bill; I might not have had an MRI if I’d had to pay $1,000 out of pocket. Alternatively, the government could play a stronger role in regulating health care spending, as it does in European countries. A middle ground is to give local 574

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communities responsibility for governance of common-pool resources.14,15 That is roughly the idea behind accountable care organizations. I believe we need an all-of-the-above approach: patients can be better consumers, providers and communities can be better stewards of resources, and coverage and reimbursement for services can be more closely linked with their value. There is room for optimism that these approaches might work precisely because marginal health care is different from marginal cows — its benefits are sometimes more imagined than real, and it may even cause harm. Furthermore, although reassurance undoubtedly has value, it can probably be derived in cheaper ways. But I believe that optimism about these solutions is not warranted without what Hardin called a “fundamental extension in morality,” a shift in how we think about ourselves. No one will accept mutual coercion and nudges about expensive marginal health care unless we first admit to the inevitable role of probability inflation in our risk-related behavior. Perhaps at least giving the phenomenon some airtime will help us come to terms with it. Emotional misunderstanding of low-probability events may be inevitable, but if we can start to grapple with it, we may be able to avert a resulting tragedy of the commons. Disclosure forms provided by the author are available with the full text of this article at NEJM.org. I thank David Asch for his insight and input. From the Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia; and the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York. 1. Stachler RJ, Chandrasekhar SS, Archer SM, et al. Clinical

practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg 2012;146:Suppl:S1-S35. 2. Hardin G. The tragedy of the commons: the population problem has no technical solution; it requires a fundamental extension in morality. Science 1968;162:1243-8. 3. Hiatt HH. Protecting the medical commons: who is responsible? N Engl J Med 1975;293:235-41. 4. Emanuel EJ. What we give up for health care. New York Times. January 21, 2012. 5. Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. Washington, DC: National Academies Press, 2012. 6. Tversky A, Kahneman D. Advances in prospect theory: cumulative representation of uncertainty. J Risk Uncertain 1992;5:297323. 7. Rottenstreich Y, Hsee CK. Money, kisses, and electric shocks: on the affective psychology of risk. Psychol Sci 2001;12:185-90. 8. DeKay ML, Asch DA. Is the defensive use of diagnostic tests good for patients, or bad? Med Decis Making 1998;18:19-28. 9. Asch DA, Patton JP, Hershey JC. Knowing for the sake of

n engl j med 372;6 nejm.org february 5, 2015

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Medicine and Society knowing: the value of prognostic information. Med Decis Making 1990;10:47-57. 10. Redelmeier DA, Tversky A. Discrepancy between medical decisions for individual patients and for groups. N Engl J Med 1990;322:1162-4. 11. Asch DA, Hershey JC. Why some health policies don’t make sense at the bedside. Ann Intern Med 1995;122:846-50. 12. Roman BR, Asch DA. Faded promises: the challenge of deadopting low-value care. Ann Intern Med 2014;161:149-50.

13. Thaler RH, Sunstein CR. Nudge: improving decisions about

health, wealth, and happiness. New York: Penguin Books, 2009.

14. Ostrom E. Beyond markets and states: polycentric governance

of complex economic systems. Am Econ Rev 2010;100:641-72.

15. National Research Council. The drama of the commons.

Washington, DC: National Academies Press, 2002.

DOI: 10.1056/NEJMms1407446 Copyright © 2015 Massachusetts Medical Society.



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On marginal health care--probability inflation and the tragedy of the commons.

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