Conflicting incentives are built into the American health care system. On the one hand, many patients depend on insurance companies to pay their bills, and come into a health crisis with a “no expense spared” mentality. On the other hand, doctors and hospitals, despite the millions they pull in, are practically hemmed in by limited resources and personnel - only so many nurses, machines, rooms, and medications are available. Patients come for a free lunch that doctors know they can’t provide.

One result of this is that patients suspect that physician decisions are not always aiming at the health interests of patients. Another is that doctors and hospitals have to frame their decisions in quality-of-care terms that may not reflect the actual basis of their decisions.