Uwe Reinhardt is one of the nation’s most respected health care economists, professor at the prestigious Woodrow Wilson School at Princeton, fellow of the Institute of Medicine, and one of the shining lights in health policymaking circles.
But alas, even the best and the brightest are wrong sometimes. Case in point: Reinhardt’s recent comments in the New York Times on the role of the American business community in fueling our nation’s health care problems. To paraphrase, Reinhardt believes that employer purchasers of health care are 1) dim bulbs and 2) responsible for the escalating costs of care.
This seemed puzzling coming from Reinhardt, whose views are widely respected by purchasers. But I was able to diagnose the problem by drawing on insights from social psychology.
Social psychology investigates “attribution,” our mind’s process for inferring the causes of events or behaviors. It’s how we describe why things happen — to us or to someone else. It turns out, we humans aren’t very accurate in our attribution processes because all of us suffer from at least one of the following problems. In his New York Times piece, poor Professor Reinhardt appears afflicted by all three at the same time. Let’s take a closer look at each:
1. Actor-Observer Bias: This is the notion that when it comes to explaining our own behavior, we tend to blame external forces more often than our own personal characteristics.
Reinhardt is rightfully troubled by a decade of escalating health care cost growth under employment-based health insurance. But seized by Actor-Observer Bias, Reinhardt blames this problem not on the world of health care that he played such an influential role in over the past few decades, but on external forces, the employers who purchase health care.
In Reinhardt’s thinking, employers did two things wrong. First, they were stupid: “For more than half a century, employers have passively paid just about every health care bill that has been put before them, with few questions asked.” Second, they were sneaks: “All along, they have been party to a deal to keep the chaotic price system they helped create opaque from the public and even from their own employees.”
Employers in my acquaintance fight tooth and nail for more transparency from our reticent colleagues in the provider community; I have never had the privilege of meeting these low-IQ, scheming employers who are desperate to hide prices. Nor have I met an employer who looks forward to a day of mindlessly paying escalating health care bills; the ones I know try everything in their power to get those bills down.
In fact, these employers aren’t real people; they are straw men created to justify the Professor’s contortionist logic that health cost inflation has nothing to do with actions of the health care industry itself.
2. Self-Serving Bias. This is a variation of Actor-Observer Bias, focused on attributions of success and failure. We humans like to think our success is our own, while failure comes from factors outside of our control.
The failures of American health care are well known. We lag behind other industrialized countries in every known indicator of health status or quality, while we pay more per capita than any of them. Errors, accidents, injuries and infections are rampant: one-third of dollars are likely wasted on these, as well as misdiagnoses and overuse, and one out of four patients will be harmed in some way during a hospital stay.
Reinhardt, one of the titans of American health policy and among its most influential leaders, blames not himself or his colleagues, but health care outsiders (employers) for all of this, and credits his own success for telling it like it is. As he describes his own sagacity: “In the early 1990s … at the annual gathering of the Business Council, I bluntly told the top chief executives assembled there, ‘If you want to find the culprit behind the health care cost explosion in the U.S., go to the bathroom and look in the mirror.’ After years of further study, I stand by that remark.”
This is like blaming the closing of Lehman Brothers on Lehman customers. After all, Lehman customers had the nerve to open accounts, take out loans and buy securities. Obviously these customers failed to use the bank wisely, so when the bank failed they should be looking in the mirror to figure out why.
Reinhardt’s attribution bias leads him to point fingers outside of health care, at business leaders who spend their day opening factories, manufacturing minivans, baking bread, making computers, selling distributor caps, designing toys, producing movies, owning restaurants, etc. These people, in his mind, are more to blame for the problems in health care than, say, doctors, or hospital administrators — or revered Ivy League health economists.
3. Fundamental Attribution Error. When faced with other people’s woes, we tend to attribute their problems to something intrinsic to them and minimize external variables that might have caused the problems. This results in the phenomenon better known as “blaming the victim.”
Reinhardt knows that cost growth in health care troubles employers, but he thinks they brought it all on themselves. “A decade of health care cost growth under employment-based health insurance has wiped out the real income gains for an average family with employment-based health insurance,” he observes. “One must wonder how any employer as agent for employees can take pride in that outcome.”
Indeed, it makes me wonder, too. I’m left wondering where Dr. Reinhardt finds this crowd of witless yet diabolical employers, who take such pride in undermining their employees’ well-being. Do they live under rocks in the storied halls of Princeton? No, alas, this is a flare-up of Fundamental Attribution Error, assigning weird and frankly illogical qualities to employers in order to evade the obvious culpability of his own health policy community.
I’ve poked some fun at Professor Reinhardt, but in truth his leadership and courage over the years has made a major difference in U.S. health care. Many of us look to his wisdom to help navigate our country through the many changes and challenges ahead. Undoubtedly, we need more action from the business community to solve some seemingly intractable problems in health care. But scapegoating employers won’t get us there.
Leah Binder is the CEO of The Leapfrog Group, a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded.