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.