The Tragedy of the Commons is by no means a new theory, nor it is an novel discussion point within the healthcare system. It is, however, quite alarming that despite our awareness of the phenomenon, we continue to exploit it with little consideration for the future of healthcare.
Tragedy of the Commons
The Tragedy of the Commons was first described by Garrett Hardin [cite num=”1″] as a theory to explain what happens when individuals rationally utilize a shared, common resource. He provides the example of farmers allowing their cattle to graze on a shared pasture as much as possible (to their own benefit). Eventually, the land realizes its carrying capacity and can no longer support the herds to the detriment of all parties involved, resulting in the “tragedy to the commons” [cite num=”1″]. The argument presented by Hardin did not suggest that each farmer was a villain, but rather that they were doing what made the most sense given the system which allowed them to maximize self interest and required no accountability.
While this argument was initially presented in the context of population growth, it has been applied to the healthcare system as well [cite num=”2″]. Within healthcare, there are multiple participants; providers, patients and payers, each of whom typically seek to do what is in their best interests, regardless of cost or effectiveness.
Physicians as farmers
Physicians attempt to act in the best interests of their patients (an inherent ethical responsibility), and as a result, require the utilization of resources and uptake of cost. However, in a single-payer system like Canada, the shared pool of resources is finite. This creates an ethical quandary for physicians, as it can become difficult to fulfill their obligations to the patient, while simultaneously acting as custodians for these limited resources [cite num=”3″].
At the bedside, physicians may ignore the issue of the commons by trying to provide the best care possible as perceived by both provider and patient. For example, it is fairly routine for physicians to order tests and investigations that they suspect will not yield findings; while the value of a negative test is arguably beneficial for reassurance, it may not be the most efficient use of resources on a population level.
Unfortunately, there is a huge imbalance in terms of incentives: as previously discussed, external factors like patient expectations, fear of missing a diagnosis and litigation, or even personal financial gains often drive resource over-utilization. Similar to the Tragedy of the Commons, this system maximizes self interest with a lack of accountability towards better management of the “healthcare commons”.
The role of patients
As users of the healthcare system, patients also have a large role to play in the Tragedy of the Commons. The system is designed for end-users to seek maximal personal benefit with little accountability for the whole. Patients are typically not aware of the actual cost upon the healthcare system for unnecessary or inappropriate investigations [cite num=”3″]. Wanting “to be sure that everything is okay” can have significant consequences for the system, as there are costs to performing and interpreting investigations, treating their potential complications, and ordering further testing or treatment due to false positive tests. These costs and complications are not typically considered when “ordering a CT head, just to make sure it is normal.”
Much like the cattle, patients may have little awareness of healthcare resources or accountability, and see no benefit to restricting their utilization. Despite this, patients certainly are aware of the constraints within the healthcare system as reflected by prolonged ER wait times, surgical waiting lists, etc.. While they would like all of these processes to be improved, bitter complaints are heard if taxes are increased to pay for it. This creates a paradox, as patients want the best care possible for themselves, but want someone else to pay for it.
As stewards of the system, it is incumbent upon healthcare providers to ensure that they adequately inform their patients about indications, risks, and potential benefits behind any intervention. While physicians may perceive this to be difficult and arduous at times, this aspect of medical care should be incorporated into practice, to ensure we are meeting the medical needs of society and the healthcare system.
Healthcare expenditures make up a large proportion of the national GDP, and as a result governments have recently begun to cut funding (or kept payments stagnant). From their perspective, there are many inefficiencies within the healthcare system, and they are attempting to use these cuts to force more accountability by providers. While this is a reasonable means of attempting to force physicians and administrators to address the situation, there are other options. For example, the government could instead redirect resources and work with medical governing bodies to develop outcome-based metrics for physician evaluation and compensation that would encourage the use of cost-effective strategies and evidence based approaches [cite num=”3″].
For example, the government could necessitate that medical governing bodies make this a priority, develop outcome-based metrics for physician evaluation and compensation that would encourage the use of cost-effective strategies and evidence based approaches [cite num=”3″].
In his original argument, Hardin suggested that the solution to the Tragedy of the Commons had to be “mutual coercion, mutually agreed upon” [cite num=”1″]. Simply put, Hardin was suggesting that society needs to define rules or limitations to benefit the collective good (at the time the suggested punishment for breaking the rule(s) was death). From a healthcare perspective, this would require compromise between individual patient expectations and appropriate resource allocation for the system as a whole. Some potential solutions have previously been suggested [cite num=”7,8″]: consumers directly sharing costs, the government playing an increased role in controlling healthcare expenditures, or the limitation of available testing (i.e: we do not routinely order many MRI’s in Canadian ED’s, in part because they are difficult to obtain). Ultimately, the solution will require multiple strategies, in which all invested parties play a particular role.
Choosing wisely – a first step
The Choosing Wisely campaign is great example of the recent push for decreasing practice variation. Its published lists attempt to reduce inappropriate investigations and treatments by providing the best practice guidelines available. However, this is only one small step towards avoiding a tragedy of the healthcare commons. The majority of clinical practice guidelines focus heavily on pure clinical evidence, with very little research dedicated to robust cost-benefit analyses. Sometimes the most effective investigations/treatments for an individual patient may not be the best default gold-standard when it comes to the “biggest bang for the buck” on a population level. This supports the argument of having greater government guidance and input on these matters. No longer is it acceptable for the government to simply control the flow of money as a single payer without defining best practices based on robust cost-benefit analyses.
We are in this together
One of the guiding principles behind the Tragedy of the Commons is that individuals do not perceive that they can make a significant difference to the system. If an individual physician were to cut out unnecessary test ordering or treatments it would have minimal benefit for the whole. However, if we all did, we could begin to mitigate costs. Even better, we could likely do so without compromising care to patients, as increased spending does not correlate to a higher quality of care [cite num=”4-6″]. Minimizing the erroneous utilization of resources by physicians is one step towards curbing some of the significant wastes within our system.
It is important to acknowledge that the Tragedy of the Commons, as it applies to healthcare, is an inevitability unless we begin to take steps to mitigate an potential crisis. By examining our own practice patterns we can eliminate erroneous investigations and treatments. We must educate patients of the harms of over-investigation and rationale behind our decision making. Healthcare governing bodies and researchers need to further evaluate cost-effective strategies, and develop outcome-based metrics to enhance the delivery of healthcare. Hopefully, we can have these difficult conversations and develop a new way to share and preserve the healthcare “commons”.
- Hardin, G. The Tragedy of the Commons. Science. 1968; (162)3859; 1243-1248.
- Fadul, R. The Tragedy of the Commons Revisited. N Engl J Med. 2009;(361)105.
- Weinstein, M. Should physicians be gatekeepers of medical resources? J Med Ethics. 2001;27;268-274.
- Oanh Kieu Nguyen, Ethan A. Halm, Anil N. Makam. Relationship between hospital financial performance and publicly reported outcomes. Journal of Hospital Medicine, 2016; DOI: 10.1002/jhm.2570
- Canadian Institute for Health Information, National Health Expenditures Database (NHEX).
- The Conference Board of Canada. Health Spending: Do countries get what they pay for when it comes to healthcare? 2016. http://www.conferenceboard.ca/hcp/hot-topics/healthspending.aspx. Accessed April, 2016.
- Roman, B. On marginal health care – probability inflation and the tragedy of the commons. New Engl J Med. 2015;372; 562-575.
- Hassanally, K. Overgrazing in general practice: the new Tragedy of the Commons. British J of Gen Practice. 2015(65)631;81.