Human civilisation has lofty aims of perfection, but at the end of the day, we are hampered. Not by technology but by psychology. Lapses of logic known as cognitive biases are common throughout life, and, that includes healthcare policymaking.
Even in this crucial arena, many decision makers are still mired in the wrong ways of thinking. Like measuring success in terms of “sick care” — treating diseases only once they have entirely reared their head — rather than preventing diseases in the first place. Professor Cai Jiangnan, Director of the China Europe International Business School (CEIBS) Centre for Health Care Management and Policy and Adjunct Professor of Economics, has decades of experience shaping medical policy in China and the United States. He shares how bias, blind spots, and fallacies can slow the pace of true healthcare evolution.
Many expect health policymakers to be wise, perfect beings. But mistakes can happen in any industry. Do you have any examples you can share of how illogical thinking has shaped healthcare delivery?
Yes, definitely. Let me give you an example. About 10 years ago, the Chinese government wanted to strengthen primary care by ensuring that doctors were satisfied with their job and protecting their income. So what did they do? They guaranteed their salary and delinked their income with their revenues. But what was the effect that stands to this day? Primary care doctors suddenly have no incentive: no matter how hard they work, their income is pretty much the same across the board. So, a lot of good doctors want to move out of primary care. And for the past 10 years in China, it’s become a big problem for the primary care sector; it can’t attract good talent.
That leads to another effect: patients trust primary care less because they feel the doctors are less capable. All of this stemmed from an original good intention: a policy to protect primary care — yet it achieved the opposite results.
What part does diagnostics play in helping a health system become more prepared for healthcare issues?
COVID-19 has taught everyone, from everyday people to governments, that testing is the first link in a chain that leads to early treatment. And if adequate testing isn’t there, then medical costs can soar.
However, I have to emphasise that there is a big “but”. And that “but” centres around the need to change people’s behaviours and correct another bias. As a consequence of human nature, people tend to be short-sighted. If people are diagnosed with a fast-acting disease, they will take serious action to prevent it. But if the water is muddier and timelines less clear, people become complacent. You only have to look at the number of people who know smoking is linked to cancer and smoke anyway to realise that.
So to truly change people into a preventative form of mind, you have to change behaviour. You have to mobilise society from the ground up to internalise the idea that early disease prevention is vital. Patients should learn this, and governments should support patients on that journey. Consumers are willing to get a COVID-19 test because it’s, in a sense, life or death. “If I don’t get a result on this, I may die in a few weeks,” people know. But things are different for longer-term health problems. They’re less willing to get tested for something that may affect them in a few years or decades. Finding a solution to this area, perhaps through training general practitioners to educate their patients, has massive potential to unlock true healthcare change. And behavioural change must go hand-in-hand with strengthening lab infrastructure and capabilities, so that as testing demand increases, the resources to handle it are more than adequate.
Have you seen any interesting government measures that “nudge” citizens towards testing and prevention?
Yes, in China, the government has played a crucial role in vaccinations. Positive incentives, even small gifts in the form of cooking oil for people who show up to get their jab, have been a powerful showcase of how the government can change behaviour for the better.
Another incentive is in changing the payment system. Like grouping preventative treatment so that patients can keep the savings. You incentivise the provider to make preventive diagnoses more. Instead, the system is geared around “sick care”: it’s usually when people are sick that they get treatment and insurance reimbursement for that sick care, rather than creating a system where people are rewarded for seeking preventative care.
In Shanghai, we are currently running an experiment where elderly patients pay a single lump sum to the healthcare provider ahead of time. And what we want to find out is, if providers are tied to this sum and no more, are they incentivised to keep people well and thereby keep the remaining savings?
What other ways of thinking can create hurdles in the world of health policy?
Well, it’s apt that we’re talking about bureaucracy and reluctance to change behaviour, because that is an issue in many countries. Government staff might be illogically tied to older ways of doing things. Another issue that nations face is, if you have a government tied to a term of a few years, then that limited time span is really when they want to see change happening, which is in a way understandable. If we can get policymakers around the world to grasp the value of “paying it forward”, to help — indeed, all of society — in the long-term, then we can start to see real exciting change.
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Read more about healthcare’s challenges in the shadow of COVID-19 in our in-depth issue.
