"Patient Responsibility"

Prompted by West Virginia's plan to incentivize Medicaid patients, DB has a great discussion going on here and here about some of the philosophical, ethical and economic aspects of "Patient Responsibility." At first I was going to join in the fray, but then I found that his commenters were all making my points -- many of them far more eloquently than I could.

Nevertheless, DB appears unswayed by their arguments. He accuses his commenters of avoiding his question, and then rephrases it. Before I address it directly (since it's a terrible mish-mash of a non-question) let me begin with my take on "Patient Responsibility" and why, with regret, I cannot support the concept. (Philosophically, DB. No Fisking here.)

Essentially, we are talking about "P4P for Patients", and every single argument that we legitimately make against P4P for physicians also applies to this.

Several conditions would have to be met for a Patient Responsibility/P4P program to be fair:

1. Patient choices would have to be the direct and only cause of whatever poor outcome you are trying to prevent.
2. "Good choices" made by patients would have to reliably lead to health improvement.
3. "Choices", which imply free will, need to be behaviors or actions that a patient has the opportunity and resources to undertake.

Unfortunately, none of those conditions apply; either in West Virginia, or anywhere in the world, because of the nature of the complex interaction between health and human behavior. Taken one at at time:

It's oh so easy to talk about diet and exercise in the context of things like diabetes and body weight. Unfortunately, the ability of diet to influence serum cholesterol levels, body weight and glucose levels -- among dozens of other parameters -- is tremendously dependent upon individual genetics. We all know 300 pound carnivores with LDLs of 90 and 120 pound vegetarians with triglycerides of 400. Insulin resistance is a necessary precondition for the development of diabetes in the presence of carbohydrate overload and a sedentary lifestyle. Despite all the hype about the "diabetes epidemic", it is clearly not true that everyone who overeats and gains weight will become diabetic. "Ideal body weight" is variable enough across the population so as to make the Metropolitan Life Insurance Tables meaningless from an actual health standpoint. And as long as non-smokers continue to be diagnosed with lung cancer, no one is ever going to be able to make a cause-and-effect argument effectively enough to make "Patient Responsibility" morally feasible.

So-called "good choices" must show reliable and postive results. If we're including medication complaince under the heading of "good choices", are we looking merely for compliance, or for outcome? I don't know about you, DB, but I have plenty of patients who are very compliant with all the antihypertensives I can throw at them whose blood pressures are still not optimally controlled. Just as I would object to having such a patient "count against me" in a Physician P4P program, I would imagine the patient would object to being penalized for "not getting his blood pressure under control." Weight loss is an even stickier subject, especially for the perimenopausal female population for whom maintenance caloric needs drop precipitously. They can truly follow an 1500 calorie diet without meaningful weight loss, even with vigorous, regular exercise. And of course, before leaving the subject of compliance it must be pointed out that the only interventions you plan to reward or penalize patients for must be thoroughly evidence-based. As Diora put it, 5 years ago a woman who refused HRT would have been considered non-compliant. Who knows what interventions we insist upon today might be shown to be either meaningless or even harmful sometime in the future?

Finally, are those things you designate as "choices" really things patients have a choice about? You may be rightly proud of yourself for your regular exercise program, but what about the arthritis patient? The plantar fasciitis sufferer? The busy mom who has to get three kids up and out to school before work, then has to supervise homework, dinner and baths before collapsing herself? You may "choose" not to smoke, but plenty of smokers struggle with addiction, depression, anxiety and other mood disorders. The argument, "I can do it; so can you" can be seen as analogous to telling a person with major depression to "just snap out of it." ("I have bad days, too; why can't they 'choose' to cheer up and look at the bright side.") Perhaps the best way of formulating this is the principle of walking a mile in another man's shoes before judging him.

Believe me, I'd love to lose this debate! I'm just as frustrated by what appear to be willfully self-destructive patient behaviors as you are. Sure, it would feel good to see them forced to "take responsiblity for their actions," which of course boils down to punishing them under the guise of "rewarding good choices." I agree that it sounds like a good idea intuitively, but examining the implementation requirements reveals the weaknesses of its philosophical underpinnings. (And that's not Fisking, DB.) Just as it makes intuitive sense that chest CTs are better than CXR at finding early lung cancers, I believe it was DB himself who correctly called upon us to wait for the evidence. Banal as it sounds, good health must remain its own reward for good health habits; just as the only appropriate measures of physician quality must ultimately remain patient opinion.

Now, let's see how DB rephrases his original question:

Should we reward those who work to improve their health? If we do not then those who ignore their health (by continuing to smoke, show poor adherence, avoiding exercise and not avoiding high calorie diets) are subsidized by those who do the “right things”.

We have a challenging philosophical question. Treating all patients financially the same means that we penalize (financially) those who take care of their own health. That is hardly fair in my mind. Why should my insurance rates go up because obesity is increasing, and therefore diabetes is increasing?

Our current system is financially disadvantaging the normal weight, non-smoking exercisers. Is that fair?

What are you talking about, DB? What the hell does "treating all patients financially the same" mean? Charging everyone the same amount for health insurance? Do you really think your insurance rates are going up just because there are too many other fat slobs (who happen to be unfortunate enough to carry the insulin resistance trait that renders them susceptible to diabetes) who can't get their asses in gear and never met a Big Mac they didn't eat? Don't you think the William McGuires of this world, who never met a legislator or insurance commissioner they couldn't buy, have something more to do with it?

As it happens, there are already plenty of rewards available for good health behaviors. BC/BS programs to reimburse gym membership costs exist. There are partnerships between Weight Watchers and other insurance plans for similar financial incentives. What you want to add now is the stick: punish those smokers who "refuse" to quit. It's a lot easier to do that than to sit down with them time and again over years and years and years as you patiently persuade and cajole and encourage. I fully understand the urge for the former, but the latter; well, that's our job.

(Read more of DB's comments here. They continue to expand on my points with great eloquence.)