Risk In Health Care: Case Studies

When Daniel Kahneman and Amos Tversky shared their findingsin the 1970s about how human beings evaluate information andmake decisions, they enlightened the field of economics andspawned the field of behavioral economics. No longer—ifever he was—solely a rational actor directly motivatedby his own self-interest, man was found to be both more complexand more limited. It turns out that human beings make decisionsthat are often illogical, that do not maximize their economicinterests, or that even, in some cases, result in the best healthoutcomes possible. In hindsight, some of these findings seemto confirm the obvious—for example, that people don’talways behave rationally, and that one person’s "rational"is another’s "crazy."

Knowing that individuals sometimes act in their own best interestand sometimes act in ways that seem to undermine their own success,do policymakers have an obligation to direct individuals’behavior toward some established ideal that will optimize thechances of individuals’ success? Should information becommunicated and decisions framed in ways that will maximizespecific desired outcomes? If so, how is this best achieved?Or should policymakers endeavor to educate and inform peopleand then respect the decisions that they make, even if somewould regard the outcomes as less than optimal?

The case studies that follow present findings of efforts atthe federal and individual levels to influence treatment decisionsusing different incentives and information. In the first, JenniferPolinski, Philip Wang, and Michael Fischer (of Brigham and Women’sHospital in Boston, Massachusetts, and the National Instituteof Mental Health in Bethesda, Maryland) examine the effectivenessof efforts to get the word out about the elevated risks to selectedpatient populations of prescribing atypical antipsychotic medications.They find that Medicaid prior authorization, one tool policymakersuse to shape treatment patterns, might not be nimble enoughto respond to changing safety guidance.

Swooping down from the broad national picture, Steven Katz andSarah Hawley of the University of Michigan examine the decision-makingchallenge that confronts a patient who is diagnosed with breastcancer. What is the role of the physician in guiding, informing,and ultimately honoring the treatment decision that the patientmakes? Are there ways in which respecting individual choicecan be measured and reflected in the quality indicators of agiven facility when the decision goes against commonly recommendedbest practice? Who has the ultimate right to define what isthe "rational" choice?

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Risk In Health Care: Case Studies