Seasickness, Service Disparities, and Healthcare Pricing

by Tom Robertson

Executive Director, Vizient Research Institute

I first learned that I’m susceptible to motion sickness on a fishing excursion off the Pacific coast over 30 years ago. I felt fine as the boat cruised out to sea, but when the engines stopped and the deck began its rhythmic rolling, I became violently ill. You may have encountered similar if perhaps less severe symptoms while riding in the back seat of a car, or on a roller coaster, or even in an elevator. With advances in virtual reality software, it’s now possible to experience that discomfort without even moving; it’s called cybersickness. 

The underlying cause of motion sickness is sensory conflict, most commonly between visual and vestibular signals to the brain. When our eyes tell our brains one thing about whether we are or are not moving and our ears tell it something different, the resulting confusion of perceived motion can manifest itself in the form of headaches, dizziness, or nausea. The idea of sensory conflict – a disconnect between where our brain thinks we should be going and the reality of where we are (or are not) headed – applies to the way we pay for healthcare. 

In a recent conversation related to our latest research, the chief operating officer of a major health system used a term that struck a chord with me; she observed that the clinicians in her organization were struggling with what she called “moral distress”. The disparities in access to and affordability of lifesaving or life-changing medical services are at odds with the moral compass of the clinician. Brought into sharper focus by the pandemic but by no means originating with it, these disparities serve as a form of sensory conflict for providers; a disconnect between where their instincts tell them they should be going and where their senses say they are. 

The traditional financing system, with its Byzantine cross-subsidies that virtually require competition over privately insured elective surgeries while medical deserts are left largely unattended, deserves a disproportionate share of the responsibility for the clinicians’ uneasiness. We all nod when we hear the old mantra “no margin, no mission” but have we ever asked ourselves at what cost? In a system entirely dependent upon cross-subsidization, with private sector patients covering the economic shortfalls of the government-sponsored or the uninsured, it’s not only prudent but often downright necessary for providers to prioritize investments in profitable service lines in affluent service areas over arguably more pressing clinical needs in historically underserved geography. An economic imperative to chase the margin to achieve as much of the mission as they can afford. But doing so intensifies what clinicians describe as their moral distress. Hoping to reduce health inequities while entrusting access and price to the market is like having our eyes going one way and our ears going the other. Markets create disparities, they don’t solve for them. 

What if the only path to profitable revenue was not more privately insured business at the expense of government-sponsored patients?  

What if the only way to afford care for the underserved was not more elective services by the well-insured?  

What if we did something crazy? 

What if instead of trying to eliminate health disparities while spending less, we carefully and calculatingly decided to spend more? 

What if instead of trying to figure out a way to change both private and public pricing simultaneously, the government decided to unilaterally increase public prices sufficiently to enable providers to invest in medically underserved areas without first earning higher margins in the private sector? 

Overall spending would increase in the short term, but we would disrupt an arguably unsustainable reliance on private to public subsidies in the face of an aging population. In the meantime, we would provide new revenue directly tied to the traditionally underserved, rather than relying on the redirection of even higher private sector margins. And we’d be one step closer to a cure for the motion sickness caused by 50 years of irrational pricing. 

At the root of the sensory conflict being expressed by medical providers is a fundamental economic conflict. Healthcare has been delivered and paid for as a private good when society – and especially clinicians – aspire for it to be considered a common good. The dissonance between where our brains tell us we should be going and the visual cues as to where we are is making us dizzy. Health system mergers are not unlike efforts to escape seasickness by building a bigger boat. 

Instead of calming the seas, the traditional financing system has been churning the water.