The Catholic Social Teaching principle of Stewardship reminds us that we human beings have a duty to safeguard God’s creation. While this principle is often applied to our relationship to the natural environment, the same principles can be applied to all resources bestowed by God for human flourishing. Just like natural resources such as air, water and land, other gifts such as human talents, material and financial resources are God-given and ought to be employed in a way that respects their provenance from the Most High, as well as their natural end to further the common good—not only for those living today, but also keeping in mind the welfare of future generations.
Extrapolating this line of thinking to our use of resources in the development and delivery of medical care, we see that several types of resources are required in order to provide such care. Financial investment, material resources and human ingenuity and intelligence go into the development of diagnostic tests, treatments and techniques that are used to further human health and healing. We should all be profoundly grateful for the bountiful gifts that produce such innovations for the purpose of restoring and preserving health.
However, it should be obvious to anyone who has had an interaction with the healthcare system that the delivery of healthcare is permeated with a vast amount of wastefulness. The medical field is consumed by an overgrowth of regulation resulting in byzantine payment models and delivery mechanisms that inevitably lead to a great amount of waste—waste of money and diversion of human talents in the service of bureaucratic and managerial functions that perpetuate many of the wasteful systems and practices that do nothing to advance the ostensible aim of the healthcare system (ie, treating and curing illness and furthering health).
The natural end result of the addition of a vast workforce of functionaries who are removed from actual patient contact by orders of magnitude is an inflation in the cost of care. This increased cost is baked into the price of goods and services produced by the healthcare apparatus. Governmental payors (namely, Medicare and Medicaid) place caps on what they will pay for services; commercial insurers negotiate rates with service providers (doctors, hospitals and the like). Only the uninsured patient is made to bear the list price of the medical care provided to him—in other words, the very person who is least able to pay the full ‘rack rate’ of his medical care is the one who must negotiate on his own behalf with the healthcare provider (hospital, clinic) for a resolution to the inflated prices for which he is held responsible.
Returning to the concept of Catholic Social Teaching, the scenario described above is a tremendous affront to the principle of stewardship on many levels. First, it is not a prudent or judicial use of the economic or material resources given by God for the promotion of health. A recent study found that up to 30 percent of US healthcare spending was spent on administration, and that at least half of administrative spending was wasteful.
Aside from wasteful spending, there is a large contingent of people whose positions serve primarily to maintain the existing system’s bureaucratic infrastructure without directly benefitting patient care. One could argue this represents a misapplication of human resources that could better serve the care of patients in some other way (or be directed toward some other pursuit outside of healthcare—think of retraining large numbers of billing auditors and referral coordinators).
Another way that the current healthcare system works against the principle of stewardship has to do with the way financial resources are applied within the system. In order to capture revenue from governmental payors and commercial insurances, providers must ensure adherence to measurable “metrics” and protocols. Administrative functions designed to comply with these directives result in a higher price for medical care—and they skew the aim of the care from being solely focused on the patient to being directed toward fulfilling regulatory and financial mandates. This works against the common good by diverting resources away from real care, inflating the cost of care, and increasing the dependence of individuals and families on third party payors for all their healthcare needs. In CST parlance, the current system undermines subsidiarity (ie, local control in decision-making) and solidarity (joining of justice and charity), by working in detriment to the common good.
How can we reverse some of the erosion of poor stewardship that is inherent in the prevailing healthcare system? For one, it is important to bear in mind that the material and personnel needs of different specialties and care settings are markedly different—think of the differences between the needs of a primary care office and those of a liver transplant service. For the purposes of this article, I will focus exclusively on stewardship in the primary care setting.
Unfortunately, the prevailing insurance-dependent economic model which is used to finance nearly all healthcare expenses (see my previous blog on “subsidiarity”) has plundered economic and organizational resources in primary care. The reason for this is manyfold—first, primary care is not an ‘insurable’ event in the same way as trauma or emergency room care are. This is because, unlike emergency room care, the majority of primary care is predictable and foreseeable. Most people expect to see their primary care physician at least a handful of times a year for preventive care or a random episode of relatively mild illness, or to monitor chronic conditions such as diabetes and hypertension. By contrast, people generally do not anticipate having a major medical event such as a heart attack or stroke that leads to an ER visit or hospitalization.
The second way in which the insurance-payment model has hurt primary care is by treating the primary care practice as a “loss leader.” This means that large healthcare systems prefer to treat primary care practices under their umbrella as a financial liability, for the purposes of driving patients toward more lucrative services and specialties. The enormous overhead saddled on primary care practices—who are responsible for such tasks as requesting insurance authorization for subspecialty referrals, imaging studies and the like—makes primary care practices appear to operate at a loss. For primary care practices that are owned by larger healthcare systems, referrals for ancillary services such as labs and imaging are routed to the larger system without regard for cost of the service.
A reorientation of focus on stewardship in primary care is best achieved by decoupling primary care from large multispecialty health system care, and even from the insurance/government-payment mechanism entirely. Because of its relatively predictable and low-cost nature, primary care ought to be accessible to the average American without resorting to the pre-paid money laundering scheme that is the insurance industry operating in tandem with monopolistic healthcare systems. In the end, the goals of primary care are at odds with those of the hospital system—at its best, primary care obviates the need for higher-level medical care, while hospital-based care tends to incentivize more costly care. Even newer schemes such as ‘value-based care’—the newest iteration of the failed managed care policies of the 1990s—face a large burden of regulatory costs and metric-driven protocols that work at cross-purposes.
In summary, the CST principle of stewardship is intimately related to the principles of human dignity, solidarity and subsidiarity. When applied to primary care, stewardship promotes human flourishing through a judicious use of economic and human resources in the promotion of the common good—relying on local autonomous control over the delivery of care in response to the demands of justice and charity.