Our national healthcare system needs a 'step-change', not incremental change. We are facing a vast and complex problem. Let's use it as an opportunity; rather than blaming our nation's health problems solely on corporations, providers, insurers, or the government, let's also think constructively about individual behavior and incentives.
Why do we stop at a red light? Why do we pay our grocery bill when we check out? Why are we compelled to 'service' our car when the red indicator light starts to flash? The simple answer is that if we don't we know we will incur a penalty. Either we have to pay to get things fixed later, or we pay extra financial fees, or we get nasty looks from our neighbors.
A behavioral sociologist would offer a more complex answer: such contracts form the heart of a civic society. We behave in accordance with laws and a sense of civic duty (we abide traffic signals) because we understand that preserving the community is ultimately self-preserving. We act in ways consistent with financial incentives, or disincentives (we service our cars) because it is immediately self-preserving.
Small, homogeneous countries like Denmark and Switzerland have a common historical thread -- the shame of the town square. That is, the personal accountability borne out of responsibility when using your fellow countryman's resources for you own good. Furthermore, citizens of these countries are inculcated at a young age to adhere to societal rules for the good and longevity of society.
The current US health care debate is starting to define itself by two rhetorical threads: finance reform and utilization/outcomes. The politico's wax and the physicians holler. Many cite the recent New Yorker article by Atul Gawande, "The Cost Conundrum", as the harbinger of the current crisis: procedure-oriented doctors as opposed to outcomes oriented doctors. There is plenty of mud being slung at the 'greedy' insurance companies, big pharma and the army of salesmen hawking questionably relevant middle-ware.
Nowhere in this debate is the patient, the consumer, and the citizen: the American! We lack accountability, responsibility and civic sensibility. It is Joe Diabetic that snacks on ice cream, misses appointments and doesn't take his insulin that increases the cost of health care. This diabetic will be admitted to your local ER with diabetic ketoacidosis and have many subsequent hospital admissions at our (read: your) expense, not his. This is a fundamental collective action problem.
Our town square is so big that we can get away with malfeasance to our village (and our country) with no shame. Yet, the forces of economics do not defy gravity and the cost of health care is now affecting all of us. Those of us that are untethered from the reality of cost are driving our health care 'car' into the ground.
Unless we get real foundational reform in health care, we will need to start a meaningful discussion of the "R" word as elegantly stated by Peter Singer, in his July 16th article in the New York Times, "Why We Must Ration Health Care." We are not a country used to contemplating rationing as an option. We're too great, we're too rich, and we're too smart. The reality is, if we don't get 'real' and individually 'responsible' in this great debate, we are really just too arrogant.
The only difference between our car and our body is that we don't have a flashing 'service' light -- and, more importantly, there is no consequence if we miss all our service checks. We can dismiss every doctor recommendation, ignore every 'annual appointment' and patently thumb our noses at our neighbors who watch us eat and not exercise. What's up with this? What happened to the ethos of World War I and World War II -- when we looked at our fellow citizens and made efforts to unload their burden? Now, the pendulum has swung wildly in the other direction -- numb, careless and self-centered. Civic duty is drowned out -- why? What happened?
I started thinking, where is the flashing 'service' light in our health care system. Where are the age-related, disease related or genetic reminders that could help us prevent illness, or at least, catch it early. The government has no problem regulating Wall Street, nuclear energy, the health care system and the legal system. Where are the regulations for maintaining personal health?
It is a privilege to drive a motor vehicle. We need to pass a test, show our competence and revisit this test at a government-determined frequency. If we get too many tickets, we lose our right to drive. Why can't we find the analogue for auditing personal responsibility in health care? The current system is basically like going shopping with someone else's credit card -- no limit, no penalty, no shame.
My solution is simple: match personal behavior with benefits. You either get with the health program or you don't get the benefits. Every patient should have the opportunity to meet with a physician which lays out a cogent, fair and meaningful plan for health. For example, if Joe Diabetic was given a road map of appointments (online) that meet the standard of care for diabetics, and he actually showed up, without fail, to the doctor, the podiatrist, the nutritionist and followed their subsequent recommendations, he would not need an ER visit and we would not shoulder his cost. If he misses these critical steps in his care, he pays, not us. Sure, there will be exceptions for missing appointments, but there must be the rule.
When the flashing 'service' light goes off, you must take care of the issue. If you don't, you risk being relegated to the "ration pool". We could have centers for nutrition, psychology and exercise that would award 'points' commensurate with your commitment to your health. Without fair and appropriate carrots and sticks, health care will become our Waterloo. Let's pick ourselves up, look ourselves in the mirror and pay attention to our individual health. Ultimately, our individual health is the best proxy for our nation's health -- it will save trillions of dollars over time. This plan will cost less than providing blanket insurance for all, and will provide tangible incentives to the millions of Americans committed to living healthy lives. If we don't, we'll just continue our slow decline from Pax Americana to Lax Americana.
Follow Dr. Jordan Shlain on Twitter: www.twitter.com/CurrentHealth
and how will this incentivized health behavior be monitored? by installing chips in people's heads? demerits for faulty thinking that leads to stress related illnesses? for who people sleep with? i pray that people who make a "modest proposals" like this are spared from tempting fate and living to eat their words when they come face to face the unfathomable mystery of life, death and illness.
not everything can be controlled by will and behavior. the author would be hard pressed show me 3 people of his acquaintance who actually have free will rather than being driven by complexes, compensatory drives, need and urges beyond their control and awareness. ask any psychologist or student of human nature! utterly ridiculous!
none of which is to say that people should not be empowered, educated, and encouraged to do their utmost to take care of themselves. but there is much that is outside of individual control including accidents, trauma, environmental toxins, genetic predisposition, quality of food and water available, wartime injuries, complicated childbirth, and last but not least iatrogenic disorders!
I also think that obesity has become a ridiculously simplistic cipher for the social darwinism that is coming out in the health care debate. If it was as simple as eating well and exercising, then many thin people who have horrible habits would be overrweight, and the many scrupulously healthy overweight people would get better returns for their efforts.
Then there is the issue of erroneous causality assumptions. It is my belief that the unfounded touting of the low fat (high in simple carb withouth sufficient fat and protein) diets of the 80s has contributed to the diabetes epidemic. Until recently doctors were telling their diabetic patients to eat white bread several times a day. So for a doctor to get on his high horse about behavioral causality with only a rudimentary knowlegde of endocrinological complexities or cutting edge nutritional epidemiology is just egregiously irresponsible.
Penalizing investors for making poor choices (microeconomics) doesn't help them when companies like Enron have carte blanche to lie about everything they're doing across an entire industry and are essentially unregulated (macroeconomics).
Raising tuition rates on parents whose children are doing poorly in school (microeconomics) is not a viable strategy to improving student performance, when the education budget for an entire state has been gutted and there are 45 students per teacher in every class in every school in a district (macroeconomics).
If the government mandates smoking cessation but does not make cigarettes illegal, all it has done is create a new way to tax smokers. But that would be okay from Dr. Shlain's perspective, because smoking any given cigarette is just a choice at the microeconomic scale, even though the addition of over two hundred chemicals to the tobacco in each cigarette will increase smoking with actuarial certainty across whole populations at the macroeconomic scale.
The problem with our health care system is not simply that patients make poor choices. The system itself is flawed.
Threatening people for failing to comply in a system that guarantees their failure is cruel. It does, however, get everyone else off the hook of feeling that there is shared responsibility for our mutual welfare, which ironically, is what he appears to be trying to promote.
Trust me the obese person is already punished by their own body.
I'm curious. In your practice do you:
-routinely screen patients for polycystic ovary syndrome (approx. 10% of women), subclinical hypothyroidism, many other metabolic conditions?
-warn patients when prescribing drugs that frequently cause weight gain?
-distinguish "apple vs pear" distribution's impact on cardiovascular health? Or that fat and exercising is often healthier than skinny and not exercising?
-take patients' financial circumstances into account when advising about improving diet, types of exercise?
-most medical schools include little nutrition instruction - have you educated yourself about high fructose corn syrup debate? Shared that knowledge with patients accessibly? Or our brains may overcompensate by overeating because food is literally less nutritious than decades ago?
-if not help, at least understand patients who may eat (rather than smoke or drink) during unavoidable stress (unemployment, caring for seriously ill relatives)
You say the obese are abusing their bodies. Perhaps, but often with help of heredity, medicine, corporate greed's effects on the food supply. Others also "abuse" their body, but without censure. Do you tell patients their knee replacements shouldn't be paid for if they abused their knees with high-impact exercise or sports?
Obese people have the misfortune to wear what others consider their vice visibly. They receive insults and patronizing, simplistic advice. If the medical community truly knew how to solve obesity there wouldn't be a diet industry worth billions. Now you'd like to add injury to insult by making them pay. IMHO - simplistic view /
We also obviously have a difference of philosophy. I tend towards John Donne's "No man is an island...Each man's death diminishes me". I certainly recognize personal responsibility, but also community responsibility. You lean in the opposite direction. A generalized observation from an outsider. Just as Americans seem to take patriotism to almost religious fervour, self-reliance seems to be glorified or mythologized. Part of your national character. Frontier spirit, etc.
FInally, as to why, as a Canadian, I weigh in on these discussions, the reason is twofold. First, based on, admittedly, my own priorities, I find it mind boggling that the US is the only major industrialized country to not have some form of universal health care. Second, both from politicians and journalists, a lot of misinformation about Canada's system, and socialized medicine in general, is being put forth, either through lack of knowledge or to deliberately skew the debate. I enter these discussion to give a more accurate view of our system. If one is going to debate an issue, one should at least have accurate information. Hopefully, despite our difference in philosophy and opinion, we can find common ground in favouring accurate debate and at least considering the issue of health care important enough to be worthy of substantive debate.
cont...
When I talk to my business friends about this, I use this illustration of Health Care they way it is practiced today: I propose to have them invest a million dollars with me on an invention I have. It has a 99% percent chance of failing, and if it does work it will only last for a short time. of course, my smart business friends pass on the investment...this is what we do in thousands of Hospitals, across the Country hundreds of times a day...the results are that predictable.
How's that grab ya?
Even if the patient does everything as required, the treatments are not cut and dried or foolproof. Some are barely effective and cause other problmes, as Zoe27 comments. Ask any mental health professional. Or any medical professional. Otherwise doctors would give money back gurantees.
It ignores the role of heredity, stress, mental health, mitigating factors going undiagnosed for years, adverse or atypical treatment results, conflicting expert opinion, etc. Truly individualized goals for patients taking everything into account would be beyond the scope of doctors. Two personal examples: I have sleep apnea and polycystic ovaries, both starting when I was a statistically healthy weight, both undiagnosed for years despite symptoms. These contributed to blood pressure and weight gain issues. Presumably I would have paid for my health care because I did not successfully address either issue, both attributable or mitigated by conditions undiagnosed for years. Personal responsibility is fine and healthy living should be encouraged, but bodies are too complex to reduce to simple goals/results. So is human nature. Take stress, which many can't avoid (unemployment, caring for ill relatives, etc.)...stress has physiological repurcussions, and telling people to just reduce stress ignores the unavoidable. Obesity is frequently mentioned by people who don't want public health insurance. So, when it's time for knee replacements, it's fine to decline payment because of obesity, but someone who damaged their knees exercising by jogging for years on hard pavement would be approved? Shouldn't they have chosen low-impact exercise - swimming, elliptical runners? How fine a seive will these "personal responsibility" judgments be put through. Universal health care is an ethical issue. To introduce punitive measures under the guise of personal responsibility lacks understanding of doctors' limitations and human nature.
So, be as 'complex' as you want--but stop making so many demands on my dime.
PS Most docs I know are single-payer advocates. are you?
"Empower nurse practitioners and public health nurses with more autonomy and establish community clinics at every elementary school in the country. Staff them for extended hours, 5 am to 11 pm or 24-7 if necessary, hiring security guards as needed. Make preventive care and home visits important parts of the clinic's services. That is the most immediate route to better health care."
My daughter said, "I know, mom, but I don't dare say anything like that if I want to be accepted."
I wonder -- Why should the notion that we all need to have skin in the health care game ruffle so many feathers on this site? Dr. Shlain's core idea isn't about carrots or sticks, or punitive frameworks, or complicated government incentives. It's about the simple idea of personal responsibility. Patients need to actively versus passively manage their own health-related outcomes. As Dr. Shlain explains, the protocol will vary from patient to patient, but by doing this more effectively, the country can potentially save billions in health related costs, and we can all begin to feel (and look) a lot better. So, remind me, what is everyone bitching about?
As Jane Diabetic who is uninsureable because of my autoimmune disease, and who does take personal responsibility for checking my blood sugars frequently throughout the day,complete with the multiple shots required and attention to diet/exercise, yet still on occasion need the ER, managing to pay for it all by myself, I admit I took great exception to his example.
Plus, if the tools/medicine required to manage any disease is prohibitively expensive, it can make it a bit difficult.
If he was my dr and copped the attitude displayed in his writing, I'd have to fire him.
- If I get a second opinion, who decides which plan I have to follow and how much I have to "pay" based on not following which plan?
- If I'm particularly dumb and don't go to a physician when the infirmities of age creep up, will the payment I have to bear include denial of care because of my "dumbness"? (I'll be on Medicare and have no income except Social Security.)
- Dr. Shlain's plan puts extraordinary power in the hands of physicians, when they make mistakes will I get a refund of my "extra" payments???
My point is that Dr. Shlain's plan is unrealistically simplistic. We, as Americans, have a birthright of Freedom. Shackling us to a "plan" is not OK. At present, the consequences of poor lifestyle choices are poor health and a likely early death. Denying care by making it more expensive if you are sick or haven't followed "the plan" are not alternatives I will accept.
The poor will be cared for, the rich will be cared for, the working guy with a "getting by" job will be the only one punished for his poor choices. Kinda like the system we have now. ... .. isn't it?
I think that any 'plan' should be mutually agreed upon by doctor and patient. If someone wanted a second opinion, they should get it and be allowed to get it.
No one should be "shackled", but no one should also spend someone elses money without having some level or form of accountability.
My next post will be about 'physician responsibility' - and I will address your 'refund' question.
Thank you.
Maybe we should send all the sinners to France! ("Please don't throw me in the brier patch!!)
Another comment stresses that incentivizing patient to live healthy is an unacceptable limitation to his freedom and leads to tyranny. I disagree since you can opt out from the requirements of the system, but at your own cost. And what is that concept of freedom for which others have to pay for! Furthermore, if the US government want to get serious about a health care system that covers every residents with a solidary aspect, some requirements over behaviors is a political necessity. Without it, it is politically hard to sell any welfare program.
I do believe, though, that such a dramatic change (personal responsibility and rewarding/sanctioning behaviors) would require a lot of policy adjustments. Citizens and patients are put in front of contradictory pressures. But it is not because the task is considerable that we should give up on working on it. The US health care system is indeed in deep need of a radical turn.
I've always worried that this is the real problem with socialized medicine, be it single payer or 'public option'. I'm afraid I'm just not going to be able to see any system that doesn't allow me to continue my self-destructive behavior unmolested as anything but tyranny. I mean, I'm mostly a liberal, but I don't think it matters how gently you try to 'incentivise' one behavior or 'disencourage' another, you just end up demonizing "the weak" and blaming the poor for their suffering.
Seriously, I haven't seen one person, Democrat or merely liberal, ever once address the danger of this "we can control your behavior because you're costing us money" aspect of public health insurance. And that concerns me.
(Setting aside the fact that many encounters with the health care system are not due to poor lifestyle...)
I think that last thing we need to do is adopt a punitive model for health care.
We are already paying for results of bad behavior. Only we're paying at the most expensive level!
It's time we try to act like adults and face the facts that these people exist and won't go away because we punish them.
We need to leave the punitive mindset behind and deal with these issues as the public health problems they are. Put together a system that supports good decisions rather that punishing them by taking away the very thing that could help them. Compassion is needed not a puritanical approach.
There is only one solution that delivers the goods and it's simple...
Single Payer.
Put the entire country (including people on Medicare and Medicaid) on the same plan as congress. One bill from providers a month, one check issued per month. Everybody plays by the same rules. Problem solved. Billions saved.
http://www.pbs.org/moyers/journal/05222009/watch2.html
http://www.pnhp.org/news/2008/february/10_myths_about_canad.php
http://www.foreignpolicy.com/category/section/the_list