Saturday, December 9, 2006

Responsibility, Choice and Compliance.

Dr Dork has been following with interest some posting earlier in the week by DB over at medrants, here and here...and here. More recently, #1 Dinosaur has thrown in his two cents with a thoughtful post on the topic.

Some interesting discourse has ensued in the comments section of DB's postings.

Essentially this is a discussion on the concept of a "reward" system for demonstrating personal responsibility in healthcare. The debate was sparked by this story.

As far as Dr Dork can tell, there appears to be considerable support in the US for such an approach in terms of health economics.

"Cost effective distribution of finite resources"
"Helping those who help themselves"

And so forth.

Dr Dork finds such a proposal....disturbing. This is not a question of economic principles.

If we reward only those able to comply with recommended treatment and lifestyle regimens, we are in effect punishing those unwilling or unable to comply.

As Dr Dork commented on the original debate on DB's medrants:

"In otherwords…punish those who do not, or are not able to, comply with recommended medical treatment ?

What of the doctor or business executive who develops a stress related cardiovascular problem and refuses to reduce their working hours ? Should they be refused treatment ? What if someone is non-compliant because they are unable to afford the medication ? What of the impoverished who are only able to afford junk food to eat rather than a broad healthy diet ?

In terms of personal responsibility, what if you cause a car accident(eg from fatigue, inattention) and suffer serious injuries - should your insurance be entitled to refuse you treatment?

Where do you draw the line ?

By this line of reasoning, are the homeless and poor in dire straits purely due to laziness ??

Are not mental health disorders, including alcohol and drug addictions, by their very nature characterised by poor insight and hence difficulties with compliance ?

Wolves may cull the weak from the pack…but we are human beings."

Such an approach raises profound philosophical, political and moral questions. It also reeks of countertransference towards "difficult patients".

This was brought to mind by one of Dr Dorks recent patients, Stan. Though seen by Dr Dork for another matter, Stan has been plagued by severe hypertension for years.

Stan is in his late 50s. He works a physical job. Long hours. Work is a bit sporadic, and Stan walks a financial tightrope. He takes several medications, for his blood pressure amongst other things. Some of these are not cheap.

Stan earns just above the low-income pharmaceutical concession threshold. Not by much. With all his health problems...he could probably go on disability if he wanted to. This would greatly lower his medical costs, and he would probably be fiscally better off. His medical costs are, almost entirely, his medication costs.

Stan is bulk-billed by his GP and specialists all. He is not charged anything out of pocket to see Dr Dork.

This week, Stan was waiting for a new job to start. He had to choose between paying his mortgage, and buying his blood pressure medications.

He chose the former.

Whilst not as astronomical as before treatment began, Stan's blood pressure was again high. Quite high, really. Not good. He already has a dodgy ticker.

Should Stan be refused followup and treatment from his cardiologist as he is a 'noncompliant' patient ?

Dr Dork doesn't think so.


angry doc said...

An interesting development, and one I would do well to monitor as it may not be long before a similar system comes to these shores.

We have recently implemented a scheme where patients with diabetes may use the money in their compulsory medical savings account (Medisave) to pay for outpatient fees - Medisave was previously limited to inpatient and day surgery use only.

Clinics participating in this scheme are required to return figures (costs, reduction in HbA1c, etc.) to the Ministry of Health, which intends to publish the statistics as performance indicators, ostensibly to allow patients to make informed choices on which clinic to go to. So in a way, clinics and doctors will be 'punished' or 'rewarded' as a result.

The scheme will be extended to include hypertension, hyperlipidaemia, and strokes from next year.

There is so far no indication that patients will be 'punished' or 'rewarded' for their performance though.

While your post has softened my position somewhat, part of me still feel that patients should take more responsbility for their own health.

The fact is we know that lifestyle and behavioural modifications are cornerstones in management of the chronic illnesses in question (diabetes, hypertension, hyperlipidaemia).

We know that there are effective screening tests to detect and diagnose these chronic illnesses, which will in turn allow intervention and treatment.

We know there are known effective treatment for these chronic illnesses.

The concept of 'patient autonomy' means that the decision on whether or not to take up the intervention measures listed above is left with the patient.

While what we 'know' may change with new research and findings, we must in the meanwhile (as we always have) practise base on 'best current evidence'.

So yes, I believe that patients can to a degree (but what degree?) affect the outcome and progression of their illnesses, and that they should be made to understand that in the context of a healthcare system where resources are pooled and finite, and that they should feel a moral obligation to take better care of themselves, not just for their own sakes, but as the decent thing to do.

But whether this responsibility or lack thereof should translate into a system wherein patients are rewarded or punished in monetary terms (surely no one is thinking of denying them healthcare?), and what form that system should take to ensure that the effect is to incentivise them into complying with our healthcare plan rather than make it harder for them, I guess I will need to hear more from both camps.

Sid Schwab said...

It's a really interesting topic, and one which I'd missed on the other blogs you mentioned, having been a little spotty in my spotting lately. My first instinct was to think it's a good idea: we've accepted for a long time, after all, that non-smokers get a premium break. But if it's true that bureauocratic attempts to measure and fairly reward (or punish, more likely) docs in the compliance arena are fraught with stupidity, then it will surely be so for patients as well. One could also say people who comply get their own rewards (all of this, for all I know, has been said in the other comment-streams). So after due consideration for about two minutes, I find I feel strongly both ways.

potentilla said...

I have been having a similar debate with a suporter of the British National Party in the comments to this this post.

It is actually, as you say, very complex. I have been trying to make a purely economic case for it being a bad idea.

I think you are traducing wolves, btw.

Mother Jones RN said...

I agree with you Dr. Dork, the idea is very disturbing. President Bush is in favor of this concept, which just confirms that the idea is stupid, as well as harmful.
Mentally ill patients who are unable to "help themselves" because of their illness are going to get the shaft. I get angry thinking about what will happen to my patients.


NeoNurseChic said...

This reminds me of what our university has done - we are now offered the same 4 health insurance choices as before but with the addition of United which is one of those employee reimbursement type health plans. It's like a risk gamble. You put aside so much money and your copays and the like come out of there. If you are to suddenly fall ill, then you gambled wrong indeed! You only get what you give. It slights those who fall ill - no matter whose choice it was. This was advertised as this great new plan, but I was skeptical right from the start.

Afterall, when I started nursing school, I had gone onto an HMO (Health Maintenance Organization) through Aetna which was promised to be much cheaper. The PPO (Preferred Provider) offered through the univ for students didn't have prescription coverage, and mine were around $700 a month at that point. But whilst I joined the HMO to save money for my parents since they were losing a lot in cobra'ing me on my mom's health plan, I ended up going bankrupt. I sold every share of stock I had had in my name since birth. I had to get postponements on my rent until my next student loan would come through. It was by far the most stressful time of my entire life.

I go back to a single concept: Those who need health care the most are the ones who are often least able to afford it - and the system demands that you be proactive, but when you feel like crap and avoiding stress is important, the last thing you feel like doing is spending all day trekking to the pharmacy, the insurance company, the doctor and playing pingpong between all of them. At one point, I actually walked to the Blue Cross building at 17th and Market Streets in Philadelphia to get a form - I'd left straight from the pharmacy who had charged me over $300 for naratriptan. I was receiving over $800 bills for home oxygen.

What was I to do?

I took a job while a full time 2nd degree nursing student in an accelerated program. I was the last person in the world who should have worked while in this program. Yes, it did exacerbate my conditions to work, but if I didn't take a job, then I couldn't have paid for my health care. So what was I to do?

It was a rough time.... I shudder when I think back on it!

Take care,
Carrie :)

Rob said...

I actually posted on this last month, coming from a couple of articles in NEJM. While it is nice to have a system that does not give people accountability for their bad decisions, it is probably more troubling for a system that penalizes ones who cannot comply. We cannot systematize this solution. It is something that we have to fight on a societal level, not on a legislative one. Otherwise, as you said, the real victims will be the ones who are most needy.

Thanks for the link, by the way.


Rob said...

I meant to say "While it is nice to have a system that holds people accountable for their bad decisions..."

What a goof!


Dr Dork said...

I think what was concerning, most of all, in regards to this plan, is that the plan doescontain punitive elements,

To quote:
"Those signing and abiding by the agreement (or their children, who account for a majority of Medicaid patients here) will receive “enhanced benefits” including mental health counseling, long-term diabetes management and cardiac rehabilitation, and prescription drugs and home health visits as needed, as well as antismoking and antiobesity classes. Those who do not sign will get federally required basic services but be limited to four prescriptions a month, for example, and will not receive the other enhanced benefits.

In future years, those who comply fully will get further benefits (“like a Marriott rewards plan,” Ms. Atkins said), their nature to be determined but perhaps including orthodontics or other dental services. "

That's worrying.

Hi Sid, Potentilla.

I had to look up traducing...ha! I'm not an economist by any stretch, but it doesn't seem viable to me in that aspect either, especially in regards to limiting/denying services to the noncompliant. These are the sicker, who will only get sicker. At greater cost, not just directly, but indirectly, such as in lost productivity.

Mother Jones
I'm on the same page with you there. The most vulnerable will be most harmed by such approaches.

What a terrible time.Glad things are better for you - I hope!

Hi Rob
No probs, I'd missed that.


Health Psych said...

This is worrying. There's a difference between people who willfully, for whatever reason, elect not to comply with medical treatment and those who are unable to follow their health regimen, whether it be for financial, cognitive or other reasons eg. mental illness. I blogged a while back on how the physical health of the mentally ill often gets overlooked. This sounds like a recipe for distaster. Yes, people should take responsibility for their health but we also have to accept that for some people that will be difficult for genuine reasons.

Cathy said...

Dr. Dork, I completely agree with you. This is scary stuff these Doc's are considering. We alrady have many people here who cannot afford healthcare, and so therefore they are NOT compliant with their Doc's wishes. What are we becoming when we want to further punish
these people..

I just did a post, about disability and American Medicare, and how my healthcare actually increased after going on disbaility and medicare. It is interesting that where you live that isn't the case.

Dr Dork said...

Healthpsych, cathy,

I agree this is very worrying. It is discriminating against those currently unhealthy, financially disadvantaged or with chronic health issues. Health problems are multifactorial and 'biopsychosocial' in nature, and those who tout this as a 'reward' system only neglect that punitive measures are clearly stipulated for events not entirely under a patients control by any stretch of the imagination.

Surprising, and dissappointing, to see some docs coming out in support of this.


Prudential Life said...

I find this a little bit concerning and quite disturbing.

Thanks for sharing Doc.

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