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Personal Responsibility: A Thorny Issue in Healthcare Transformation

Posted Sep 24 2009 10:10pm

In my last post— Criteria for a Sustainable Health System —Cindy Weinmann made this excellent comment about personal responsibility.

Principles are interesting and to an extent transparent to systems. But focusing on individual responsibility has to take into account societal context of that responsibility. Want people to eat better diets and exercise more - well, Americans lose over 40 hours of vacation a year because they're afraid to take time off from work; average American commute is 3 hours. Add that up and you have a lot of stressed out Americans eating dinner in their cars - a recipe for hypertension, obesity, cancer, and heart disease. Oh wait! Isn't that part of the problem? I don't hear anyone agitating for more vacation days and shorter work hours!

Just as important might be: reducing the 50% of health care costs attributable to waste, according to Price Waterhouse Coopers - out of $2 trillion plus - over $1 trillion wasted. About the same as insuring everyone, huh?

As Cindy points out, personal responsibility is a thorny issue. I've written about this several times in the past, including these four blog posts:

In the first post (Apr. 2007), I discussed the dilemma modern consumers confront in this era of "personal responsibility" by presenting three stories about the difficult position patients and other consumers face: One has to make difficult treatment decisions when there are no clear-cut answers, another has to decide on a health insurance policy from among dozens of confusing alternatives, and a third is being treated in a trauma center after a catastrophic event. The conclusion:

…consumers need valid, understandable information about the risks, benefits, and costs of different treatment options. But often that's not enough. Consumers also need the motivation, resources and skill to comply with chosen plans of care. In other words, they must be mentally, emotionally and physically able and willing to carry out their healthy living strategies, and do it effectively and efficiently.

Obtaining the needed information can be difficult because information found on different web sites, instructional pamphlets and expert opinions often offer conflicting, inadequate, irrelevant, unclear, and/or invalid information.

In the second post (Sep 2007), I followed up on a discussion that offered answers to the questions: Who is worthy of having adequate health insurance and high-value (safe, cost-effective) care; what makes them deserving? And who, on the other hand, is unworthy; what makes them undeserving? Following are excerpts from a subsequent conversation with a reader who commented:

Everyone deserves unobstructed medical attention for illness and injury; curable, chronic, and/or terminal. In that I see an absolute fulfillment of the constitutional mandate to see to the 'general welfare'. One step beyond that is preventive care, more opinionated and intellectually based; but I none the less would consider that the 'general welfare'. Every other service for everyone associated as medical service should remain privately financed and marketed (like child bearing and voluntary procedures).

The critical issue within that position is how to deal with self induced health impairments. This health class should have a name, definition, and social remedy. Let's call it IHIs. It's tough because it's smoking, poor diet, drug addiction, STDs, poor dental care, high risk sports, etc. I'm thinking IHI classification puts an individual into a special insurance category requiring addition premium or mandatory savings both during and for some time after such circumstances.

I replied:

Yes, dealing with the kind of self induced health impairments (IHIs) is a thorny issue.

A logical case can be made for having those with the financial means pay out of pocket for at least a portion of treating health problems clearly determined to be voluntarily induced. That is, delivering care to people with adequate maturity, knowledge, intelligence and rationality, but who make a conscious decision to engage in high-risk behaviors and suffer the consequences, would cost them more, so they are held accountable for their actions.

Unfortunately, many (most?) of these people are either (a) immature (e.g., teenagers enticed by tobacco and alcohol marketing, as well as peer pressure, and then get hooked); (b) ignorant, confused or unintelligent (they don't fully realize or understand the risks of eating too many greasy french fries and failing to exercise regularly, or they have trouble self-managing a chronic condition requiring a complex medication regimen and lifestyle changes); (c) irrational (e.g., they deceive themselves into believing they can stop taking drugs, or they are self-destructive due to a psychological problem); or (d) they lack the funds and support needed to live a more healthy lifestyle (all their time is taken working day and night at minimal-wage jobs, or they lack affordable transportation, to visit the dentist every 6 months, or they can't afford fresh fruits, vegetables and lean meats when pasta is a fraction of the cost). Or, they just might be unlucky (e.g., the got an STD because the rubber broke).

In other words, this is a complex issue and a great deal of thought should go into defining the conditions for the kind of punitive costs you propose.

Also consistent with your suggestion would be a policy of taking punitive action against the manufacturers, distributors, retailers and marketers of unhealthy foods and ineffective medications and supplements. And what about tobacco companies and alcoholic beverage producers who promote their products to college students, and even the promoters of dangerous sports?

It seems to me, therefore, that establishing a reasonable two tier system--one for folks who self-manage their health effectively and another for those who don't--is a daunting task, but one worth examining.

In the third post (Nov. 2007), I wrote:

Turing to personal responsibility. People who abuse drugs or alcohol start do so for many reasons--often due to psychological problems, bad living environments, genetic predispositions, family problems, marketing & advertising influences, peer pressure, our society's worship of short-term hedonism and self-indulgence (conspicuous consumption that drives our form of capitalism), and other such factors related to human frailties. And these folks tend to start down that negative path when quite young and more susceptible. A similar case can be made for smokers and even obese people. This doesn't "excuse them" for their poor decisions, but it does explain why humans sometimes act foolishly. That is, there's a heck of a lot more to it than can be attributed simply to "personal choice," like choosing a Coke over Pepsi (or visa versa). What we should be doing is working to change the things in our culture that precipitates such self-destructive behaviors, providing more effective psychological and rehabilitative services, investing more in preventive care and ways to motivate adherence to healthy lifestyles, etc. I find it rather heartless to say: "Too bad…it's your fault you're sick and can't afford excellent healthcare…we don't care why…but since you can't afford it, you don't deserve the same level of care that I do!"

Now, I'm not dismissing the claim that there may be some "deadbeats" out there who are psychologically stable and able to work, but wish to live in poverty just to get free medical care and be able to sleep all day, even though their health is more likely to be worse than others and they must do without the pleasures money can buy. But since 80% of our healthcare costs are for 20% of the population (i.e., old people near end of life and folks with certain chronic conditions), I don't think the deadbeats account for much of the utilization, even though you can certainly make a case that they are "playing the system" and ought to be required to pay back any publicly funded care they receive.

In the fourth post (Dec. 2007), I wrote:

To be responsible, people ought to take good care of their health by, for example:

  • Eating foods lower in fat and carbohydrates, not smoke tobacco, avoid drinking much alcohol and using dangerous drugs, breath clean fresh air, stay out of the sun, exercise, etc.
  • Earning good money, invest it wisely and save in order to afford treatment should they someday have a catastrophic or chronic condition.
  • Rejecting short-term pleasures that have a potential negative health consequence.
  • Going to the doctor, dentist, therapist, etc. only when necessary and selecting providers and treatments that are the most cost-effective.

And, it is only sensible that our culture, government, and economic system more likely that our citizens do such responsible things by making radical changes, such as:

  • Making junk food more expensive than high-quality food
  • Making tobacco and alcohol extremely expensive, while discouraging advertising to young people
  • Putting businesses that blatantly pollute our air and waters out of business
  • Down-playing the vanity of a sun tan
  • Stopping the use of TV as the opiate of the masses, which creates so many "couch-potatoes," and start promoting more physical activity
  • Rewarding healthcare providers for delivering high-value (cost-effective) care and preventive services, and insurers for offering high-value policies, as well as enabling consumers to select them through robust transparency of quality and cost
  • Being role models of responsible money management, such as balancing the Federal budget rather than pushing incredible debt onto our children
  • Making wise investing something that anyone can do rather than making the system so complicated and full of underhanded practices that it's so easy to get ripped off and make poor financial decisions
  • Encouraging business to focus on long-term societal benefits rather than short-term investor returns
  • Increasing the incomes of the working poor, so they have a chance to save for the future and purchase health foods, etc.
  • "Leveling the playing field" so the disparity between the haves and have-nots aren't so drastic (the top 5 percent currently have more wealth than the remaining 95 percent of the population combined)
  • Linking profit to value for the patient/consumer
  • Putting at least some of the money currently being spent on political pork (estimated to be over $50 billion per year) and war (now about $500 billion and expected to go to $2 trillion) into improving our healthcare system.

Bottom line: There's a heck of lot to consider concerning when judging healthcare reform policies in terms of their focus on promoting personal responsibility!

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