The Cost of Healing

There’s an account in the New Testament of Jesus Christ healing a wild and unstable man possessed by evil spirits. This unnamed man of Gergesa spent his life outside the village, crying and injuring himself with rocks. His neighbors had tried to help and subdue him, going to the point of placing chains to physically restrain him, but he broke the bands and lived as an outcast.

When Christ met this man, He had compassion on him and cast out the legion of demons tormenting him, and they entered into a nearby herd of pigs. These animals then ran into the Sea of Galilee and drowned. The pig keepers, understandably shocked and alarmed, ran into town for help, and a crowd gathered and found Jesus and the man, now in his right mind. The townspeople were soon informed of the miracle and the disaster, and after hearing and seeing for themselves they asked Jesus to depart from their country. Christ assented, leaving only the healed man to share his experience and testimony with his neighbors.

Whether you read this account as a literal miracle, as I do (see note 1), or a literary story, there are lessons to be drawn for our day. What stood out to me this time in reading Luke 8 was not the experience of the healed man or the unfortunate pigs but the local people who witnessed the miracle. A member of their community who they had been unable to reach or assist was suddenly restored to stability and health by divine intervention. This should have been a cause for wonder and rejoicing, but this miracle had come at a high price: the loss of a whole herd of valuable livestock. The villagers weighed the costs and benefits brought to them by this remarkable visitor, and concluded in fear that they wanted Him to leave.

This decision was driven by more than just fear, a reflex rejection of a startling event which they did not understand. It was a manifestation of what they valued most: economic stability and prosperity, rather than human life and flourishing. As He so often did, Jesus had confronted these people with a dividing line where they had to choose one side or the other: their neighbor or their pigs, learning new ways of helping the needy or carrying on with business as usual, progression or complacency.

Modern medicine is confronted with this very choice today, as a field and as individual professionals. Will we go out of our way and even change our ways to serve the needs of our patients, even if it may involve personal economic cost? When we know what our most vulnerable patients need, will we devote the time and resources to deliver it to them, or are they brushed aside to carry on with another busy and productive workday?

I’ll acknowledge upfront that as a young doctor in training, this is unfairly easy for me to talk, ponder, and preach about. While I am already learning much about the conflict-laden challenges of medical documentation, trainees are shielded to a large degree from coding, billing, RVUs, prior authorizations, and direct grappling with insurance companies and healthcare administrators. I’ve never had to balance the budget for a private practice. I’ve never had to worry that I might have to lay off staff if I couldn’t adjust to the latest Medicare hurdle. I’ve never had an administrator announce that my clinic visits with patients would be cut down by another 5 minutes to catch up on the backlog of people waiting to be seen. I’ve never even had to look a patient in the eye and say that while we have teatments for their condition, we can’t do anything for them because they’re underinsured (my first training institution was a county hospital where uninsured was the norm and civic and charitable funding systems were well established, and my second is a world-renowned medical center where the underinsured usually can’t get in).

Nevertheless, money and medicine is a subject that weighs on my mind, and I feel it is vital for me to think about it now, rather than a year after signing my first contract. I don’t pretend to be an economist: I did work as an undergraduate research assistant to economist Dr. Arden Pope at Brigham Young University studying health effects of air pollution, but this mainly gave me great respect for the complexity of health economics rather than facility in working through the details myself. Dr. Pope did manage to impress upon me Ricardo’s theory of comparative advantage: to focus on doing what I do best and enlist other people to do what they do better, rather than trying to do everything myself. In writing about medicine and money, I will therfore try to focus on principles and patterns, along with frontline observations, and ask for the help of others in working through details and reconciling theory and practice. Here’s a starting list of topics on my mind:

• Caring for the sick, injured, and afflicted is not intrinsically profitable, it never has been, and I doubt it ever will be.
• Pure capitalism is an unsuitable foundation for a healthcare system, or at least insufficient. The profit incentive is a powerful servant in developing and implementing medical innovations on a large scale, but it is a dangerous and perverse master which quickly deviates from good patient care and real improvement in health.
• Transparency is one key to avoiding and minimizing perversions and externalities which distort the healthcare system.
• Those who work in healthcare should not expect to be rich. The current situation of high salaries in medicine is a very recent change which brings both benefits and dangers, the greatest of which is the danger of compromising patient care to maintain high income, individually and as a profession.
• Modern medicine requires real teamwork, collaboration between various skilled healthcare professionals built on a foundation of mutual respect and clear communication. This must replace the current situation of compartmentalism and turf wars.
• Physicians and healthcare workers should be paid in a manner that attempts to incentivize good patient care and outcomes. But incentives will never be sufficient without moral foundations, for by its nature as a complex profession, medicine will always have opportunity to take advantage of patients. Denying this reality leads to regulations that obstruct rather than assist patient care.
• Some of the most useful and important things that healthcare professionals do for patients are difficult to measure and track, such as assisting with behavioral change, and are therefore vulnerable to be smothered by lesser things which can be measured, from number of falls to patient satisfaction surveys.
• Everyone needs to pay in to healthcare system, for their own sake and the sake of the system. When people personally invest in a system, they are more likely to productively engage with the system, carefully evaluate options, and work to improve the system. And medicine cannot care for the sick without the support of the healthy, who should understand that they are paying to support their neighbor’s health and not just their own.
• Physicians have a moral duty to engage in the great debates of health economics as representatives of their patients and as leaders in healthcare. The age of “I take care of my patients, someone else can worry about the money,” is over. Lack of physician input is a major factor in the development of our healthcare system’s worst problems, and they will not improve without physician input and sacrifice.

The bottom line is that in healthcare economics, healthcare comes before economics. The focus must be squarely fixed on individual health outcomes, that is, on healing. This is not done “regardless” of cost, because a system that disregards cost will collapse and be unable to care for anyone. or be bought out by the more profitable. But considerations of cost must always be made with patients first in mind, with sustaining and improving our service to them. It’s not surprising that the system is currently messy: we’ve had less than a century of practice with genuinely effective medicine, and as Atul Gawande pointed out, deploying modern medical science to serve humanity is the most ambitious thing that human beings have ever attempted. I just know that healthcare won’t evolve into the system we want and need without solid principles and earnest effort by morally grounded doctors.

Marcus N. Callister

Last updated 3/26/2019

Note 1: It is not my purpose here to explore in detail the complex and speculative subject of psychiatric and neurologic illness and demonic possession as presented in the Bible. My general understanding is that the culture of the day treated them as one and the same, and the scriptural writers follow suit in their accounts of Christ’s miracles. In my reading some of these instances seem to involve strictly medical mental illness, some involve genuine affliction by unembodied spirits, and sometimes the distinction is unclear or there may even be overlap of both. I do not know how such relates and applies to our day, though I am inclined to agree with C. S. Lewis’ observation that in modern times Satan seems to have decided to play it subtle and mostly refrain from showing himself in open and dramatic fashion in order to focus on sinking us in secular unbelief (see The Screwtape Letters). But this matter is not relevant to the lesson I wanted to draw from the scriptural account for this post.