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The Keckley Report

Core Beliefs about Healthcare: The Generational Differences Matter

By January 15, 2018March 1st, 20232 Comments

Attitudes matter, but beliefs matter more, especially in healthcare.

Milton Rokeach, a famed 20th century social psychologist, studied the relationship between attitudes and the beliefs on which they’re based. In his books, The Open and Closed Mind (1960), Beliefs, Attitudes and Values (1968), The Nature of Human Values (1973), he demonstrated that attitudes can be understood by ascertaining why people believe as they do. He found that attitudes/opinions change as individuals absorb new information or have new experiences. And he found beliefs are strongly held, slow to change and reinforced as individuals selectively filter facts that support their predispositions.

Understanding underlying beliefs is vital to public discourse in healthcare. Trade associations base their advocacy efforts on a thorough understanding of their members’ beliefs. AMA, AMGA and other groups representing physicians build on a strong underlying belief among their members that the profession is threatened by outside influences and ill-conceived public policies ruinous to its future. Surveys of hospital leaders by their trade groups– AHA, NAEH, CHA, FAH, AAMC and others– reflect widespread belief among hospital leaders that reimbursement cuts and regulatory compliance are compromising care, impairing medical training and harming communities. Surveys of insurers by AHIP, BCBSSA and others indicate their members hold strongly to the belief that they necessary superintendents over waste and inefficiency that’s rampant in the system. Surveys of drug manufacturers by Bio, PHRMA and other groups tap their strong belief that their novel therapies are unavoidably costly to develop, proven effective and worth the price. Device manufacturers, information technology providers, post-acute operators and other stakeholders similarly build their programs on widely held beliefs of their members.

But understanding beliefs about healthcare held by the general public is tricky: their core beliefs are not homogenous. Public opinion surveys query attitudes about policies, events and issues like individual and employer mandates, drug costs, the government’s role in regulating the system, access and affordability, trust, universal coverage, insurance premiums and other topics. Pollsters know wording impacts the responses they get. For example, ‘Medicare for all’ gets a higher rating than ‘single payer system,’ ‘not-for-profit’ gets higher marks than ‘tax exempt,’ ‘quality of care’ means something different to everyone and so on. They measure attitudes using scales like for/against, favor/oppose or agree/disagree scales to gauge the direction of these opinions. Some probe further: ‘why do you feel this way’ to gauge the intensity of the opinion expressed. All report differences in opinions based on characteristics of certain cohorts: age, income, insurance status and so on and many explain differences based on the underlying beliefs held strongly in certain groups.

Case in point: opposition to the Affordable Care Act galvanized around the belief that the ACA would result in ‘government run healthcare’ or ‘socialized medicine’ strongly opposed by some based on their belief that healthcare is a personal choice. By contrast, supporters of the ACA believe healthcare is a fundamental right in which the government’s role is central. Conflicting beliefs on the ACA have not changed since 2010, and the current debate about its Repeal has resurfaced this fundamental conflict of beliefs.

Beliefs about healthcare vary widely. They’re complicated, sometimes well-informed and always slow to change.

So, what? Everyone knows that as we age, healthcare becomes more important. And we’ve learned through the years that aging prompts mindfulness about finances, family, faith and the future.

But generational differences also reflect a major shift in beliefs about the health system. Younger generations, socialized through social media, expect a system that’s personalized, digitized, transparent, convenient, affordable and predictable. They value brands that have changed their lives—like Apple, Amazon, Uber and Netflix—and believe most healthcare organizations fall short in delivering the same. Older generations are more thoughtful about healthcare, fearful of its expense and anxious about the healthiness they, their family and closest friends enjoy. Their beliefs about healthcare are experience-based and slow to change.

Understanding the core beliefs of consumers about healthcare held by each generation should enable stakeholders to understand their expectations and meet their needs more effectively. Clearly, the differences across generations are profound: all recognize the importance of the health system, but each has a different view of the direction it should go to serve their needs.

In healthcare, attitudes matter, but beliefs matter more. Understanding how others think and the underlying beliefs that anchor their views is necessary to a rational discussion about the future of our system.


P.S. Last Tuesday, CMS announced its new voluntary bundled payment model, the Bundled Payments for Care Improvement Advanced, which includes 29 inpatient and 3 outpatient episodes. Provider payments will be based on quality performance during a 90-day episode of care starting at inpatient admission to an acute care hospital (the anchor stay) or the beginning of an outpatient procedure, (the “anchor procedure)” and end 90 days later. Participants in the BCPIA program, which starts October 1, 2018, will be eligible for bonuses in the Medicare Access and CHIP Reauthorization Act.(MACRA) quality payment program. Applications to participate in the new BPCIA program are due March 12. 

Context: Voluntary bundled payment programs were launched in 2013 as part of the Affordable Care Act. Per a study of participants in the Model 2 BPCI program released last week in the Journal of the American Medical Association, only 12% of eligible hospitals signed up and 47% of these dropped out within two years. “Patterns of participation and dropout in the BPCI program suggest that for voluntary alternative payment models to have a broad effect on quality and costs of health care, barriers to participation and strategies for retention need to be addressed,” the authors said. Participation and Dropout in the Bundled Payments for Care Improvement Initiative Karen E. Joynt Maddox, MD, MPH; E. John Orav, PhD; Jie Zheng, PhD; et al. JAMA. 2018;319(2):191-193. doi:10.1001/jama.2017.14771

Also, I highly recommend Deloitte’s new report, 2018 Global Health Care Outlook: the Evolution of Smart Health Care. It’s a solid, well-documented assessment of the trends and challenges in healthcare settings worldwide.


  • Julie says:

    On the topic of "understanding underlying beliefs is vital to public discourse in healthcare," readers may also enjoy the following insightful read: The Righteous Mind: Why Good People Are Divided by Politics and Religion by Jonathan Haidt.

  • Rob Tholemeier says:

    For a while now I have been recommending that CMS gets out of the price fixing business. The new bundled payments could and should be the start. Set a maximum reimbursement but let providers advertise their prices and compete. This is a much better approach than so-called "quality performance". Let the consumer decide. Not all procedures and admissions will fit the scheme immediately but some do. Let the market work.

    BTW, it is time to end MSSP ACOs. It is pretty clear to me they are costing more than they are saving. If someone can show me numbers that counter this observation I’m "all ears." Creating a more competitive market based solution to the high price of Medicare would be much more effective and a lot less costly.