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.

Tuesday, December 12, 2006

More on "Patient Responsibility"

DB has rejected my counter arguments, and re-asserts what he is after with regard to patient responsibility:
If we just charged more for those who continue to smoke cigarettes, then our system would immediately have increased fairness.

Smoking cessation and weight loss are clear benefits. We really cannot debate the desirability of patients stopping smoking. We have no debate that obesity puts patients at risk for many problems.

Patients who continue to smoke and eat excessively spend more health care dollars. Now I understand that this is only on average, but I am happy to assert that the expenditure difference is great.

The esteeemed Dr. Dork -- of whose demise the rumors were, thankfully, greatly exaggerated -- also asks the good DB for clarification, and DB responds (in part):
Some commenters have argued that nicotine is addicting and smoking cessation is too hard. I do not consider that my problem. My problem is that your smoking causes my health care premiums to increase. Your smoking infringes on my financial health.


Smoking cessation is "not my problem?" You claim smoking increases your costs, and that increased costs are your problem. You can't have it both ways.

"Your smoking causes my health care premiums to increase." Where did that come from? Can you back up that statement? I don't think so. If that is the main support of your argument (which none of the rest of us can seem to grasp well enough for you to deem our concerns relevant) then I confess I am rendered speechless.

But let's set that aside. As it happens, I have no problem with setting health insurance premiums on criteria other than membership in a group (ie, sharing a certain employer) but, as one of the commenters to your response to the good Dr. Dork put it, you're trashing the concept of shared risk, which is the essence of "Insurance." I'm cool with that, though. Then again, remember that one of my proposals is to dispense with the present system -- which is basically health care payment brokerage -- in exchange for actual "health insurance," just like auto and life insurance (ie, that pays for catastrophes but not maintainence.)

Still, I would suggest being careful what you wish for.

Do you really think that the premium structure for auto and life insurance is based on "fairness?" Sure, that's how they sell it; but don't forget for a minute that all insurance companies are in it strictly for the money. Actuaries are only looking at the bottom line. Sometimes the outcomes are "fair" (smokers pay more for life insurance) but often they are not. Folks with family histories of cancer also pay higher premiums than those born into less risky families. They may not think it "fair" but they have no choice.

Auto insurance is no better in terms of "fairness," despite your blithe comments about higher rates for lousy drivers. My two sons, age 17 and 19, have never had a ticket or an accident, yet are charged the highest rates for auto insurance. Why? Because of the statistically bad behavior of their age- and sex-matched peers.

So by all means, let's get rid of group health insurance and let the actuaries set "fair" rates based on voluntary health habits. I think you'll find that because they're part of the insurance industry, they're going to be looking more at the bottom line than primarily at the health benefits. So in addition to surcharges for smokers and sliding scale premiums based on diabetics' A1Cs, don't be surprised to find runners being charged more than those who walk for exercise -- based on their actuarial higher risk of injury and greater use of (expensive) orthopedic interventions.

However this old saurian heart was also warmed by the following:
Thanks for reading oh dinosaur. Your blog is entertaining, and intellectually honest.
I thank you sincerely for the compliment. I enjoy your blog as well, and am trying to do my part to get you up over that 1 million mark.


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