Patient responsibility

14

Category : Medical Rants

This rant and article will certainly cause controversy, as the West Virginia proposal already has caused. Medicaid Plan Prods Patients Toward Health

Ignoring doctors’ orders may now start exacting a new price among West Virginia’s Medicaid recipients. Under a reorganized schedule of aid, the state, hoping for savings over time, plans to reward “responsible” patients with significant extra benefits or — as critics describe it — punish those who do not join weight-loss or antismoking programs, or who miss too many appointments, by denying important services.

The incentive effort, the first of its kind, received quick approval last summer from the Bush administration, which is encouraging states to experiment with “personal responsibility” as a chief principle of their Medicaid programs. Idaho and Kentucky are also planning reward programs, though more modest ones, for healthful behavior.

In a pilot phase starting in three rural counties over the next few months, many West Virginia Medicaid patients will be asked to sign a pledge “to do my best to stay healthy,” to attend “health improvement programs as directed,” to have routine checkups and screenings, to keep appointments, to take medicine as prescribed and to go to emergency rooms only for real emergencies.

“We always talk about Medicaid members’ rights, but rarely about their responsibilities,” said Nancy Atkins, state commissioner of medical services.

As an economic and social libertarian, this experiment fits my world view. To paraphrase Spiderman, should one receive privilege without shouldering responsibility? If I support your right to health care, should you not have a responsibility to make the effort to improve your health and minimize suffering and expense.

Philosophers and ethicists will certainly debate this issue with long tomes. I suspect that one can develop logical and reasoned views on both sides of this issue. As one who claims common sense as his main philosophy, I want my hard earned tax dollars used wisely. If you have diabetic vascular disease and continue smoking, you will likely waste my contribution to your health.

Your rights exist only until they infringe others. You certainly have the right to ignore good health habits. You can smoke, drink, eat excessively and ignore your medications. At that point, I no longer have a responsibility to fund your health care. Your actions absolve me of that responsibility.

I like the West Virginia plan. It gives patients an opportunity, and only asks them to use that opportunity responsibly.

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Comments (14)

I’m not surprised that the NEJM looked down its haughty nose at the plan. I have come to expect that kind of hypocrisy from the self-appointed kings of medicine. Look at the West Virginia plan as P4P froma patients point of view. Why hold the physicians’ feet to the fire for poor outcomes if a large part of the responsibility belongs to patients? Living in a state (Minnesota) where there is a liberal paternalism practiced similar to Massachusetts, I doubt that West Virginia’s innovation will find its way to my area. But who knows? After the current P4P initiatives fall on their faces, perhaps a climate of realism will sweep through corporate and political leaders.

So DB, what is the purpose of having a state-run federally funded health insurance program?

Is it to make it easier for doctors to give up their obligation to have compassion for the sick and dying? If so, this program seems to be perfect.

If, on the other hand, such a system’s primary purpose is to make the poor and destitute, who already typically have a pretty difficult life, suffer fewer negative health effects from the socieconomic level they occupy, then this is a really inartful method for achieving that.

Your assumption, that your hard-earned tax dollars should be used wisely, certrainly makes a lot of sense — until we realize that a lot of your income comes directly from other people’s hard-earned tax dollars. In fact, it comes directly through Medicare and Medicaid … which if they were shut down tomorrow would grind medical care in America to a halt.

So sorry, I’m not someone who is enthusiastic about a fix to our healthcare problems that endorses a “screw the poor” approach.

Also, would you support such a system for Medicare, or for your own health insurance company?

While I think personal responsibility should count for something, even among the poor, I wonder about the whole concept of medical compliance, smoking cesession, and a healthier diet saving the healthcare system money. In the case of the diabetic who is a heavy smoker and eats what he wants, he and others like him will likely die before their time, won’t they? When death ultimately comes, their healthcare costs drop to zero.

it’s very interesting to read idiotic comments like Evan Allen’s. clearly, that opinion is not based on any experience of caring (or trying to care) for patients. contrary to popular belief, most doctors want their patients to do well. we are not simply money hungry jerks – otherwise we’d be lawyers or investment bankers. but we are only able to control a small portion of what patients do. if you prescribe a medication, and the patient never takes it, whose fault is that? if the patient waits to go to a doctor until they’re unsalvagable, why should the doctor bear that responsibility?

and BC, if that were the case, most public health initiatives wouldn’t exist. in reality, the overweight diabetic smoker doesn’t just “drop dead”. he has a heart attack, and goes to an ICU, and gets a cardiac bypass, and then another, and may develop renal failure, and then dialysis, and so on and so forth. it’s been studied with obesity, that it costs less to do a gastric bypass, than it does to care for the obese patient long term. (i.e. even though the patient lives longer, the health care costs associated with ongoing obesity are greater.) i’m sure the same holds true with diabetes and smoking.

Had anybody even noticed that the plan includes things like routine checkups and screenings as well as “following doctor’s advice”?
Would you mind showing me some evidence that routine checkups of healthy people are beneficial and save money? By the way, there have been a study recently that showed how most of annual physicals of healthy people included tests USPSTF recommends against. Would this plan penalize the patient for “not following doctor’s advice” in this case? More importantly, how would making a 30-something person’s (what is the average age of people on medicaid?) going to doctor’s office everyyear and submitting to a bunch of non-recommended tests be cost-saving?

Also, does personal responsibility now mean one is going to be penalized for exercising one’s right to ‘informed refusal”? Or even consent: Why bother informing the patient of risks if refusal would result in cuts? do it or else certainly leads to a truly “informed” consent.

I don’t want to go off topic and discuss benefits/risks of screening, but the fact is screening is neither risk- nor harm- free. And many preventive drugs have side effects. So according to you a payer (be it a government or an insurance company or employer) can require people to submit to potentially harmful interventions and the people who refuse can be penalized?

As far as cost is concerned, in many cases of screening and drugs for primary prevention a lot of people need to be tested/treated for one person to benefit. Tests have false positives that need to be evaluated; tests can lead to overdiagnosis so more people need to be treated; if tests don’t help, people need to be treated for longer period of time. Preventive drugs involve monitoring, extra office visits and labs. In some cases costs may be much higher than the savings. Of course, we can trust the government to always make sound fiscal decisions.

Anyway, are people allowed to decide if 2 or 3 percentage points risk reduction is worth risking side effects? And what is true today can be wrong tomorrow. If not following doctor’s advice is to be penalized, 5 years ago a healthy 60 years old refusing HRT could fall into “non-compliant” category. Virginia plan doesn’t seem to differentiate cases of serious non-compliance of say a transplant recipient not taking anti-rejection drugs and using drugs from a healthy person’s refusal to take drugs for a small risk reduction of something bad happening in future. I don’t see in the plan even patient’s right to refuse defensive or “ancillary” tests.

I also have similar reservations as those of BC. One example is my cousin’s husband who was obese, had high blood pressure and a father who died from heart attack at a young age. He hadn’t taken any medications, hadn’t seen a doctor for 5 years when he collapsed and died from the immediately fatal heart attack at the age of 52. The ironic thing is that he had lost some weight in his last year of life. Had he controlled his blood pressure and took statins maybe he could’ve lived longer. But would he have saved money? He was dead before the ambulance arrived, so his healthcare cost for the last 5 years of life were zero.
The most money-saving thing everyone can do is jump from Empire State Building at the age of 50. But I don’t think anybody would give the government right to tell us to do it.

Punishing flakiness and smoking will certainly help solve the schizophrenia problem.

Dan, nice that you think I’m an idiot who has never cared for a patient. Curiously, I’m neither, but it does keep you from addressing the substantive question that I raise which again is:

What is the purpose of the medicaid program?

I would think that the person who was calling me an idiot would be with it enough to answer a simple question like that.

If you prescribe a medicine and the patient never takes it, it means you didn’t get the patient to understand why it was in his/her interest to take it, it was too expensive, it caused side effects, or the patient has other problems that were not addressed that were preventing its use.

It must be nice to think you have no responsibility for your own work, but I think doctors have some responsibility for their patients, and I have managed to maintain this belief while practicing primary care medicine for 16 years.

Yet, that gives me no credibility with Dan, who without knowing a thing about me calls me an idiot.

It seems easy to imagine someone who was cared for by Dan not taking their meds.

According to the Chief Medical Officer of Medco Health Solutions, 20% of all medications prescribed are never taken by the patient. As good and as smart as the docs may be, they can only lead the horse to water. Personal responsibility has to count for something. In the case of Medicaid patients, however, since they are poor, they have no financial “skin in the game.” This makes it extremely difficult to change their behavior in a beneficial way as compared to middle class or wealthy patients who can be influenced by changes in co-pays, deductibles, coverage of preventive services and the like.

The bottom line is that if Medicaid patients can be induced to change their behavior in ways that will improve their health and make them less costly to the system over the longer term, it would be a good thing. Since we probably don’t know precisely what will work and what won’t, some experimentation (within reason) is appropriate, in my opinion.

Diora, you make an excellent series of points in your comment. Too bad the people in charge aren’t listening. My business manager has been brainwashed by the corporate health care purchasing cartel into believing that P4P programs will actually save money. Even if that is true (and I mean long term, not a six month high intensity study) the savings will not flow back to the employees or to the physicians. Think of this fact: in the days before Medicare,best practices algorithms and P4P, were health care costs out of control? In spite of all the anectdote based variable care they were not. Now I whole heartedly subscribe to the idea of practicing high quality medicine and educating physicians to stay current with new trends in treatment, but will it make a dent in medical cost inflation? It’s not going to happen unless the root causes of the problem are attacked.

As tax payers, we fund the health consequences of other people’s unhealthy lifestyles – that doesn’t sit well with me. A change to medicaid like this seems to be a good step in the right direction. But it strikes me kind of strange that they’re doing it with Medicaid first. It seems that the critcisms in the NEJM editorial (access to transportation, hurting kids, etc.) would be less of a concern if this was done with Medicare. I hate to be cynical about this, but are they trying this out with Medicaid first because lawmakers know that Medicaid recipients probably don’t vote. I’d like to see them try this with Medicare. But I don’t think the AARP would stand for it.

DCS, thanks, who will listen to a simple layperson like me? If I may rephrase an idea expressed on one of the JAMA virtual mentor articles, prevention is today’s religion.When you believe in something, why bother to do math?

P4P is really just another side of Virginia’s plan, IMHO. P4P rewards doctors for ensuring that every patient is following guidelines. Virginia plan penalizes patients for, among other things, refusing to follow these same guidelines. German plan proposes to penalize cancer patients who don’t participate in screenings. American employers give incentives to employees to participate in preventive care plans. At first these plans only included exercising and non-smoking, but in the last few years they started to include annual physicals (?!), screenings – including, I am not kidding, PSA; cholesterol numbers, glucose, and blood pressure. At the moment these plans are voluntary and trust-based, but can we be sure they are not going to be made mandatory? They are not going to save money, but does it matter if they believe they will? If Virginia can make its plan mandatory, why can’t they? BC thinks we should experiment, but the trouble is, you are experimenting on people and without their consent. If I am not mistaken, this is against the law.

For doctors as well – this type of belief in magic of prevention and early detection doesn’t work well in a court when something “hasn’t been detected early enough”. But this is another subject.

Now, I am all for responsible behavior, but for me it stops at the moment where it interferes with my rights to decide what is best for my body. The only exception is when my actions clearly affect public health i.e. when I can infect others. If I feel that for me the risks of a test/treatment is not worth the benefit, it is my right regardless if the guidelines. I wonder what ACLU has to say about Virginia plan. Or maybe they are also believers.

I think some of these plans clearly do. “If you do it, you are a nice and responsible person and get rewarded, if you don’t you are irresponsible and may be penalized”. As I said, is it today’s version of informed consent?

Evan,

I was a little worked up, and so I apologize for calling you an idiot. I still strongly disagree with your comments, but that’s ok.

Dan, thanks for the apology.

If you disagree with me, I’d love to see a little more substance about the disagreement. But I will settle for the apology, thank you.

What if the government were going to pay for auto insurance for those who needed coverage in order to drive to work, but could not pay for it. Would there be outrage for certain requirements to be met for someone to receive this paid-for, free coverage? What if there were a rule that in order for the insurance to pay medical costs from an accident, the insuree would need to be wearing a seat belt. Would that seem unfair?

I found this site while looking for “Patient Responsibilities” write-ups I could hand a patient of mine. As a family physician in solo practice, I only see 10 patients a half day to allow a lot of time for patient education. We discuss their medical conditions in layman’s terms including causes, treatment, alternative treatments, non-phamacological treatment. We discuss current standard of care, goals for treatment, complications of not treating, side effects from medications. We discuss step approach to care, starting at simple, less expensive, less invasive treatments and diagnostic studies and progressing as needed to more involved, expensive, invasive studies/treatment. I tell patients after I prescribe a new drug, “Always call me if I ever put you on a medication and you have problems or questions later.” In addition, I tell patients, not just in regard to new meds but in other situations, “Many times patients do not want to call and ‘bother’ the doctor. However, it is a bigger ‘bother’ to me to not hear from a patient than if he/she calls. Therefore, please call.” I explain to all new patients (and to established patients who have symptoms that might worsen before their next visit) how to get ahold of me after hours. I take my own call all the time, except a few times a year a nurse screens the calls before notifying me on the cell phone.

Yet this patient yesterday came into the office stating she stopped all of her meds that she had been previously been taking regularly. I always try to find out a patient’s point of view when a patient is non-compliant. (Regarding cost, we hand out lots of free samples, have pamphletts in the waiting room on getting help with meds, and do a lot of paperwork to obtain free meds from drug companies.) A patient has a right to refuse a med or stop a med for any reason. However, IT IS A PATIENT’S RESPONSIBILITY TO LET THE DOCTOR KNOW HE/SHE DOESN’T WANT OR CAN’T TAKE A MEDICATION. After all, it is a patient-physician RELATIONSHIP, and that requires two-way communication.

I ended up spending an hour with her educating her on how to be a “good” patient: one who questions everything, asserts herself, demands good care, expects respect, but also one who works with her physician.

After 24 years in medical practice, I realize I can only do so much. Patients have to take on responsibility .
. . . and so do drivers.

Respectfully,
np

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