Compassionomics: The Business Case for Caring

In August 2018, NBC News and The Wall Street Journal found that likely voters believed health care would be the most important issue for the midterm elections. The top four issues they identified in health care all centered around health care costs. By the time October arrived and the midterm election was upon us, Gallup's Midterm Election Benchmark poll confirmed that the most important issue for likely voters was, again, health care. An overwhelming 80% of registered voters said it was the top issue. It is almost a certainty that health care will not only play a very large role in the Democratic Primary, but it will also continue to be a major factor in the 2020 general election.

Unfortunately, our partisan climate tends to lock us into an incredibly impoverished debate. There is overwhelming rhetoric, an awful lot of promises, very little data, and almost no specifics about concrete solutions from either side of the aisle. Catchphrases and anecdotes dominate the news cycle. The public is generally forced to choose between one sound byte or another that represents an entire ideology like "government-run healthcare" or "pre-existing conditions." The issues are actually incredibly complex and do not lend themselves well to sound byte debates. Real understanding requires nuance and robust discussion. This is demonstrated by the fact that particular policies do not even consistently stay on one side of the aisle.

For example, the concept of the individual mandate was initially in the conservative answer to Hillarycare in the 1990s (then framed as “individual responsibility”). It then reappeared in Obamacare as “a mechanism for spreading costs”, but was opposed by Republicans as a government overreach.

According to the Centers for Medicare and Medicaid Services, U.S. spending on health care reached $3.5 trillion in 2017. As a share of the nation's GDP, health care accounts for 17.9% of GDP and is expected to rise to 19.4% or $6 trillion by 2027. Costs keep going up, and an increasing portion of those costs are getting passed on to employers, taxpayers, and patients. This is making it harder and harder for many to access the health care system.

If history repeats itself, we can save lots of cable news split screen debates with each side trying to talk over the other, and sum up the scenario that always seems to play out in health care. When put under a microscope, one candidate's plan will give more people access to health care, but it will be very costly. The other candidate's plan will finally address the U.S. health care system's cost conundrum, but will do it at the expense of access. However, both candidates will promise only the upside of their plans. Only their own surrogates on the campaign trail will back up their claims that their plans address all issues. Although welcomed, history tells us there is unlikely to be a third candidate’s plan that is substantively different, if there is a meaningful third candidate at all.

Are there any solutions that both sides of the aisle can agree on that can improve health care outcomes, decrease health care costs, and improve the health care system overall?  The answer is yes. And since Smerconish.com is the place for critical and evidentiary thinking, we want to lay out what should be a piece of every candidate’s platform.

In our new book, Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference, we systematically reviewed the biomedical literature — over 1000 scientific abstracts and over 250 peer-reviewed research papers — and found that compassionate care has distinct and measurable benefits that are rooted in science and can achieve much more in our health system than most people thought possible. The power of compassion in health care is not only meaningful from a moral and ethical perspective (it is proper and just), but it is also measurable from a scientific perspective. The evidence is clear: currently, there is a compassion crisis in the U.S. health care system, and that is a missed opportunity to improve care, lower costs, and improve our overall system of care. Research shows that there has been an erosion of the relationship between those that provide care and those that receive it, and it comes at a tremendous cost.

Aside from the book itself, we refer you to other sources where we have referenced an association between compassion for patients and improved health outcomes, from migraine headaches and back pain, to diabetes and HIV, to anxiety and depression. In nearly every condition it has been studied, compassion has been shown to make a measurable difference in outcomes — even for the common cold. Because voters’ top concerns in health care are focused on costs, we will review a sample of the data we found in which compassion for patients impacts the costs of care.

One of the mechanisms by which compassion for patients can improve patients’ health is through better patient adherence to prescribed therapy. When health care providers care deeply about patients, and patients are aware of that care and concern, rigorous research shows that patients are more likely to take their medicine. This holds down the costs of avoidable disease progression, which can be extremely costly.  Non-adherence to prescribed therapy — and the avoidable poor health outcomes that result from that — have been estimated to cost $100 billion to $290 billion annually in the U.S.

Compassionate patient-centered care is also associated with lower health care resource use and lower overall health care charges. It appears that health care providers who have strong connections and relationships with their patients are less reliant on expensive (and potentially unnecessary) testing and technology to take care of their patients. In one study, the proportion of patients who were referred to specialists was 59 percent lower, while those who underwent diagnostic testing was 84% lower. Again, when it comes to doctors and their patients, relationships matter. Furthermore, abundant research shows that physicians who are viewed as less caring by patients are more likely to find themselves sued for medical malpractice.

Clinician burnout is characterized by emotional exhaustion and the tendency to depersonalize patients (i.e., having no personal connection).  Burnout has contributed in a big way to the compassion crisis in health care today.  Burnout affects approximately a half million physicians in the U.S. While it’s difficult to calculate with precision, a conservative estimate is that the increase in physician turnover (e.g., leaving one practice for another or leaving clinical practice altogether) attributable to burnout costs the U.S. health care system approximately $12 billion annually. And this is just for physicians. When you factor in nursing burnout, considering the two together, think about how those costs must get absorbed and then passed on within the health care system. Importantly, emerging research has shown that increasing human connection in health care may be an antidote to burnout. Numerous studies in the medical literature show an inverse relationship between compassion and burnout among clinicians, suggesting that clinicians who have more compassion and better relationships with patients may have lower risk of getting burned out under the same stressful conditions. In other words, it appears that compassion for patients is actually protective.

There is also a strong link between the depersonalization and emotional exhaustion of the burnout syndrome in clinicians and a higher incidence of medical errors. Depersonalization and compassion are not opposites, but an inability to make a personal connection with patients makes compassion impossible. As such, evidence of depersonalization in health care research can be a proxy for a lack of compassion. Researchers have found a clear signal in the data that this lack of compassion is associated with increased medical errors. It might not surprise you that clinicians who are less caring in general may also be careless in the technical aspects. On the contrary, more caring may translate to being more careful. Unfortunately, medical errors have direct and widespread financial consequences that extend far beyond the walls of the organizations where those providers practice. Medical errors adversely affect the whole U.S. health care system.

According to a 2010 study sponsored by the Society for Actuaries, medical errors cost the U.S. $19.5 billion annually, with $17 billion in avoidable medical costs directly attributable to the errors, $1.4 billion due to increased mortality rates, and $1.1 billion due to lost productivity from missed work; according to recent research, that may actually be a gross underestimate. In a study in the Journal of Health Care Finance, researchers consider more recent data that suggest a much higher rate of medical errors. The new annual U.S. estimate is between $735 billion and $980 billion. If an increase in caring were to increase meticulousness and reduce medical errors in such a way that recaptures even a small fraction of that lost revenue, it would be an enormous windfall indeed.

What about the costs associated with malpractice cases? Malpractice costs do not comprise as much of the spending on U.S. health care as many clinicians believe, but the costs are still significant. According to an article published in Health Affairs, the annual cost of the U.S. medical liability system - excluding the cost of insurance premiums but including the cost of “defensive medicine” (e.g. tests ordered by doctors simply to reduce risk of malpractice litigation) - is $56 billion. While that is a hefty price tag, those costs might be worth it if the medical liability system was achieving its goals of making whole those that are wronged and deterring negligent behavior. 

Interestingly, the research shows two intriguing data points. The majority of people that are injured by acts of malpractice never receive any compensation, and at the same time, the majority of cases that do receive compensation have no evidence of malpractice.  We make no judgement of the system other than to point out the evidence of the impact of compassion for patients: it makes a clear difference. In fact, in one study of plaintiff depositions for malpractice lawsuits that were settled against a large metropolitan medical center, researchers found that, in general, patients and families decided to litigate because they perceived their doctors did not care. Specifically, they complained that doctors were unavailable, discounted their concerns, communicated poorly, or just failed to understand the patient’s or family’s perspective. It wasn’t the technical part of the medical care; it was the caring part of the medical care. 

Of course, the natural reaction to a call for strengthening the relationship between clinicians and patients is that the business efficiency pressures in our health care system do not leave sufficient time.  And according to one Harvard Medical School study, 56% of physicians believe that they do not have enough time to treat patients with compassion. However, the data show it's not about quantity of time with patients; it's about the quality of that time. It doesn’t take as long as people think. Studies show that communicating compassion to patients takes less than one minute. We found five separate studies on the time it takes for compassion and the median value was 40 seconds. But will that connection with patients lead to appointments that last longer due to more questions and conversations? Not according to the data. 

In a Johns Hopkins study supported by the National Institutes of Health, researchers found that primary care physicians trained in compassionate communication had clinic visits that were slightly longer (compared to a control group of primary care physicians who received no special compassion training), but the time increment was so small that it was not statistically significant. Again, the extra care took less than a minute.  

We have to find ways for clinicians to have more meaningful connections with patients. The scientific evidence — from more than 250 original science research papers laid out in our book — shows quite clearly that compassionate care is vital for patients, for patient care (including the quality and costs of care), and for those who care for patients. In our examination of the medical literature, we found that the scientific “bar” for evidence is very high. It’s the same bar for the evidence used to prove the benefit of any medication you took this morning, or the surgical procedure that your family member underwent recently. And if you are a clinician, it is the same bar used to establish the standards of medical care in your specialty. Rigorous research shows that compassion is not just a “nice to have” —it’s essential. We must make sure our medical schools, nursing schools, and allied health schools incorporate this science into the rest of their evidence-based curriculum.

Let us be clear — increasing compassionate care cannot be the only solution to our incredibly complex health care problems. By no means is it a silver bullet. However, it is an incredibly impactful solution, one grounded in science, that can dramatically improve outcomes, cut costs, and improve our entire system of care. 

Anthony Mazzarelli, MD, JD, MBE, is Co-President of Cooper University Health Care, and Associate Dean of Medical Affairs at Cooper Medical School of Rowan University, Camden, NJ

Stephen Trzeciak, MD, MPH, is the Chief of Medicine at Cooper University Health Care, and Professor and Chair of Medicine at Cooper Medical School of Rowan University, Camden, NJ 

Drs. Mazzarelli and Trzeciak are co-authors of the new book: Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference