The human condition dictates that we ascribe meaning - to everything. To moralise is to comment on issues of right and wrong, typically with an unfounded air of superiority. These traits are unfortunately implicit in healthcare - from all sides and during every aspect of it. Moral hazard can be defined as increasing your exposure to risk because someone else bears the cost of the risk; it is commonly applied in economics (Ref). Moral hazard can be an outcome under information asymmetry,
“ moral hazard can occur when the party with more information about its actions or intentions has a tendency or incentive to behave inappropriately from the perspective of the party with less information”
In the morally charged world of healthcare do we as conservative clinicians have a problem around moral hazard? Through this blog I will explore why this might be the case.
People with low back pain suffer for longer and in higher numbers than any other condition - amongst issues of healthcare, disabling pain is one of the biggest problems of our time (Ref). Disability can be defined as not just a health problem, but as a complex phenomenon reflecting the interaction between features of a person’s body and features of the society in which she or he lives (Ref). This definition reflects a multidimensional construct, which is amenable to many parties. Disability, then, is everybody’s responsibility.
For allied health, disability is a core concern. And if you’re an allied health practitioner things are booming. In Australia, there are a lot of us; 182,572 to be exact (Ref). There are more patients presenting to allied health for primary care than ever before (Ref). Yes general practitioners still have double the amount of first contact services, but our slice of the pie is not small and getting bigger. We are slowly becoming a significant part of the frontline of healthcare. This position brings with it great responsibility; are we aware of our place and the responsibility we have?
See more about Australian primary healthcare data here.
The responsibility we have for managing disabling pain in primary care seems to be overlooked by some. Campaigns, like Choosing Wisely, designed to improve the standard of care expected by patients and delivered by professionals have been rolled out for medical procedures not conservative allied health care. This may give an impression that no one is looking over our shoulder; and in fact they aren’t - right now. We have no measure of how we are doing, no guidance. This lack of checks and balances to the care we provide are exactly the conditions that lead to moral hazard.
We have a hierarchical medical system that is easy to hide behind. In hierarchies, the cost of risk is held by those higher in the chain. In healthcare this translates to medical professionals bearing the cost. You can argue that tests and treatments that medical professionals provide are subject to higher risk - for example death or maming. These are obviously bad outcomes, whether your stance is moral or not. However, in the context of our healthcare issues today, how much does that actually contribute to the global problem? We have poor data on how disability leads to pain, but mediators on this pathway have been shown to be self-efficacy, psychological distress and fear (Ref). These are surely everybody’s responsibility. Are we holding our risk to the same standard as medical professional’s? Does it need to be?
We have a system that protects us from risk and no measure for what care we are providing and what needs to change. These are the makings of a moral hazard; this hazard is far from recognised by many allied health practitioners, but it should be. If we judge our risk the same and understand our important role in the problem of disabling pain, then we can honestly appraise all forms of practice. The inertia in changing practice is no doubt a complex problem, not easily solved, but we should start by being aware of our moral hazard.