Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, December 08, 2006

"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.)

11 Comments:

At Sat Dec 09, 12:53:00 AM, Anonymous difficultpt said...

hmmmm, they could be dismissed for their bad behavior . . .

 
At Sat Dec 09, 03:33:00 AM, Blogger Dr Dork said...

Very well put.

 
At Sat Dec 09, 06:50:00 AM, Anonymous Anonymous said...

Very nice post. Yours is a voice of reason in a time of hysteria.

 
At Sat Dec 09, 04:36:00 PM, Anonymous cathy said...

Dr. Dino, I havent been to DBs and read anything yet, but this post of yours is about one of the best I have ever read.

I worry about this attitude of DBs spreading in the medical community. On various med blogs,, you can already hear some physicians ,talking horribly about what they consider non-compliant patients. They almost sound to me, as though anyone, who is sick with anything, are non-complaint for being sick in the first place and they want to not treat them. Is this going to lead to patients who need medical care the most, refusing to seek it, because of doctors who will blame them for their own conditions?

When did physicians become so judgemental?

 
At Sat Dec 09, 10:59:00 PM, Anonymous Diora said...

Absolutely brilliant. Must read for everyone with any interest in the subject.

Cathy, you are right it's not just db. Kevin posted about the West Virginia plan that "it should be universal" even before db did. I am seriously scared too which is why I was so active in virtually every thread on this subject.
I am really surprised that lawyers are staying out the whole discussion. I would be really curious about ACLU take on this.

 
At Sat Dec 09, 11:40:00 PM, Blogger Cathy said...

Diora, I'm with you all the way on this one. I RARELY go to Kevin's anymore, because honestly, I get almost sick to my stomach reading how many of his commenters (doctors) feel about patients.

 
At Sun Dec 10, 07:38:00 PM, Blogger Bohemian Road Nurse... said...

Thank you for confirming my belief that we ladies have a very difficult time losing weight! I always thought it was my imagination....

 
At Tue Dec 12, 12:05:00 PM, Anonymous difficultpt said...

FYI: you have been officially nominated for "best new medblog"

http://www.medgadget.com/archives/2006/12/the_2006_medical_blog_awards.html

 
At Tue Dec 12, 12:07:00 PM, Anonymous difficultpt said...

One more thing . . . you are up against Sid and Dr. A.

 
At Wed Dec 13, 12:19:00 AM, Blogger Dreaming again said...

These arguments scare me. For years,I've fought with my weight ...taking massive doses of prednisone for long periods of time (80 to 100 mgs for up to 9 months at a time) certainly did not help matters.

I was told (and didn't believe) that I had to have a metabolic disorder ... but I for some reason decided to believe Dr. Phil and the ilk who said those disorders almost NEVER happen.

Only ...when they did the full work up on me ... it DID happen.

My weight is not my eating. My weight is metabolicly effected and ..with medication, exercise and eating right has been coming off SLOWLY (60 lbs in 27 months, but a steady downward stepping, without any going back up)

Add to that ... PCOS ... and I've got one tough battle on my hands.

But .. .I was 40 before it was found. So ..by this guys standards because I was obese, it was assumed (falsely) that I drastically overate all the time therefore should pay more.

I actually eat more NOW than I did then!!! (partially, because if I ate, I'd balloon up in weight, with medication, exercise etc, I'm stable at worst)

Yet, the average person can't tell me from anyone else that's overweight ... and my disorder wasn't found for years ...so ... what would the medical community do with people like me? Reimburse when they find out it's not the patients fault?

 
At Fri Jan 05, 11:57:00 PM, Anonymous Anonymous said...

Patients who have difficulities such as smoking or weight issues are punished far more for their actions then any doc could ever come up with. Or ins for that matter. If you think they aren't already peanlized for there actions then try being an overweight smoker who is trying to get ins outside of a job or treatment for a pre existing contion. If the doc hates the patient that much that perhaps he should ask that patient to leave his practice. Or perhaps consider chaning professions. Im not trying to be rude or offensive to you in any way, just a thought to some of the thoughts you posted. By the by, thanks for being understanding for those of us who want to change our habbits but aren't able to do it as fast as we ourselves would like.

 

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