More thoughts on personal responsibility


Category : Medical Rants

As I read the comments on the WVa plan and personal responsibility, I am struck by two phenomenon. Many commenters engage in Fisking. These commenters put all their focus on potential problems in the plan.

Most commenters avoid the question that I raise. 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?

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Comments (21)

“Fisking” is fair play if not relying on misquoting, or selected quotes made to imply something different to the context in which they were clearly used. Deconstructing an argument of another and criticizing its assumptions piece by piece is fair argumentative and debate technique. It is the burden ot the initial poster to defend why an argument should be thought true in its whole when it cannot be seen to be true in its parts. Labelling a reply as “fisking” slyly implies that the technique is an attempt to turn truthful assertion on its head when that is not the case. It is little more than a sloppy way of avoiding the rigor of an equally disciplined defense of the parts of the argument.

I suppose one could argue that those who “do the right thing” by maintaining or trying to improve their own health are “rewarded” with better health as compared to those who are irresponsible. While it may not be feasible or politically acceptable to charge Medicaid (or Medicare) beneficiaries who smoke, are overweight, etc. higher premiums or give discounts or enhanced benefits to the more responsible beneficiaries, such price discrimination is feasible for employer plans and for those who purchase health insurance in the individual marketplace. Philosophically, I have no problem with penalizing unhealthy behavior via the price mechanism or rewarding healthy lifestyle choices.

As for medical interventions, required or otherwise, I do not think periodically checking blood pressure, weight / BMI, cholesterol levels or blood sugar is invasive or expensive. For those with elevated cholesterol, blood pressure, or blood sugar, appropriate medication would likely be beneficial and could save money for the healthcare system by reducing hospitalizations and ER visits. It may or may not result in lower per person medical costs over a lifetime, but if it results in longer, healthier lives on average, such disease management is probably well worth its cost.

I was going to post my negative reaction earlier, but all your other commenters had made my points quite eloquently. I can see you still don’t “get it”: “Patient Responsibility” is P4P for patients, with all the attendant fallacies. What you call “choices” are often not nearly as facile as you seem to believe; and they frequently fail to have the healthful benefits you ascribe to them. What do you intend to reward? Effort or results? I shall go back to my draft and post forthwith, as I think this is a discussion that deserves wider exposure than that available in a comment trail. (Going away for the weekend, though, so it may not be til Monday.)

My question is at what point does better health not be its own reward? Idealistic, true, but the American ideal is to never die. So, better health is granting that. I don’t know where it can get better than that.

Following along with some of the above comments. I cannot point to hard numbers, but in discussions with people from outside the US, the feeling I get is lifelong health cost are about the same for the bulk of people. that old 80/20 split.

We spent a wonderful evening some time ago with a couple who were both doctors from Germany. The issue of smoking came up as a topic of discussion. They did not see what the big deal was given that smokers pay a very high tax on cigarettes and thus compensate the system. Other major health problems were also dismissed as with early death comes the elimination of medical cost.

My wife and I had Thanksgiving dinner with a couple from Quebec and another from Scotland. Both couples acknowledged the slow response of their care systems, but felt the lower cost and population coverage outweighed the disadvantages. At no time was there talk of who should receive what, or pay more for “bad” behaviors.

It is interesting to note both couples spoke glowingly of their GP’s and their involvement in their lives and community.

While we wish to encourage positive behaviors we must be willing to accept a certain percentage of people will engage in behaviors some will feel are detrimental to their health. Often those who lead the most unhealthy lifestyles out live their peers who die of accident or unrelated illness.

Steve Lucas

Two comments: first, on fisking. I’d seen the word used, but never really saw the derivation and explanation. In my opinion, the most expert fiskers operate in the political arena and often are very powerful and visible people: dictators like Fidel Castro and Saddam Hussein come to mind. When they are interviewed by journalists about their misdeeds, murders and human rights abuses they have an extraordinary talent to reverse the question and answer process so that the interviewer is swiftly back on his heels defending himself. Ahmadinejad of Iran has shown himself a master of this technique when questioned about his denial of the Holocaust. But, enough of politics for now!
There is of course a moral dilemma for us as physicians concerning denying care to individuals who are sick whether their lifesyle choices contributed or not. I do not think it right for third party payers, government or private, to punish the care giver financially because he was not able to influence his/her patients to adhere to guidelines. Should the fire department be held accountable because a smoker throws a lit cigarette into the brush that starts a fire? Are the police responsible for the social conditions that lead to criminal behavior? OK, maybe I am stretching the point here, but the reality of medicine is that evolved as a profession to care for the sick. Modern thoughts about disease prevention didn’t really apply. If you want a good laugh, read a 19th century medical text for its ideas on the prevention of disease. Medical science knows a lot about intervening after the fact and new technologies are extremely expensive as well as effective. I’m skeptical that coercion will ever be successful in making people change behavior. The patients in my practice who eat sensibly, exercise and avoid tobacco do so not under threat of dire consequences but because they like the way it makes them feel. For our non compliant patients I fear there are incentives and rewards that for them are more powerful molders of behavior.

I don’t mine the idea of personal responsibility based costs. I am a wretched driver (I seem to rear end people a lot) and thus get to pay high auto insurance rates. It’s the price I pay for my lack of skill and attentiveness.

As I understand-always possibly flawed-when applying for health insurance independently your rates are based upon your health.

My brother tried to get independent coverage but was quoted very high rates as he is computationally obese. At the time he was running about fifteen miles a week. The numbers crunch to being very unhealthy but he really is a short, stocky, barrel chested guy who made a great linebaker in high school.

As for the fisking, I think you should be open and accepting of any commentary to find a real, effective answer. We all differ in the way we understand and think about a potential topic. I tend to approach topics in a very global, open ended, emapthetic way. I consider how it will effect people-sometimes admittidly at the expense of logic. Some people will be open ended yet possesss razor like logical analysis and piece by piece dissect your argument. Very detail oriented, static folks can’t ususally see the forest for the trees and will just balk at any change as they lack the ability to think in a global abstract fashion. All they CAN do is point out all the problems. Sometimes I would like to cut open thier haeds and see if they have cherrios for brains. A chunck of people are so trapped in the fun moment of the present they don’t even care about the topic-or quitting smoking-or paying your bill. They have no long term planning capabilities.

Now the real issue is that our society is made up of ALL of these people. If it was people just like me-well of course everything would be perfect! However we are a big mix of very different ideas, perceptions, and attitudes. So it perhaps most important to look at the comments who differ most greatly from the way you think about a problem and try and understand those view points. Even if you don’t agree you will learn better tools for dealing with the way they think.

The only way effective changes can be made is by convincing our societal blob of personalities. Otherwise you are just singing to the choir.

I think pointing out specific problems of the plan is important because it illustrates a generic problem with such plans: they are made by people. People are fallible. They start with obvious life style choices such as smoking, and then they want to “improve” the plan and items that at present are “believed” to be healthy. Beliefs can change, some guidelines are controversial, doctor’s advice changes with time, but the powers in charge aren’t aware of it. You start with “obvious” unhealthy behavior such as smoking, and you end up with making potentially harmful intervention mandatory.

Here is an example of such thinking – I have to comment on this line even if one could consider it “fisking” (thanks for teaching me a new word). I think it shows how easy it is to cross the line from fairness to paternalism:
“As for medical interventions, required or otherwise, I do not think periodically checking blood pressure, weight / BMI, cholesterol levels or blood sugar is invasive or expensive. “
They are not invasive and they may even be life-saving for some people, but unless you can prove that people who don’t do them are hurting you, you have no right – either legal or moral – to impose these measures on others. As far as not being expensive, you are not considering how many people need to be treated for, for example, blood pressure to reduce one person’s risk (consider primary prevention). Also, drugs have side effects. It is not your or any policy-maker rights to dictate to an individual at what numbers reducing her risk of future heart attack in future is more important than the risk of side effects at present. If you start forcing medication on people, be prepared to be responsible if any of them has a serious side-effect however rare it might be. Don’t forget to factor in the cost of lawsuits as well. Also, once you come to a doctor’s office for a “physical”, he is likely to order a bunch of non-recommended tests (based on a recent study) further driving up the cost and increasing the risk of harm.

I might be engaged in “fisking” here, but I just wanted to comment how some things are not as obvious as they seem.


I appreciate your comments even when they’re critical of me, so keep them coming.

With respect to the discussion about periodically checking weight, blood pressure, sugar levels, etc., I have no interest in being a sanctimonious nanny. My interest, at least as it relates to Medicaid (and Medicare) beneficiaries, who are receiving their healthcare primarily at taxpayers’ expense, is to keep costs within a range that society can afford and sustain. For those who are paying for their own healthcare out of pocket or buying health insurance in the private market at a price that fully reflects their own individual risk factors, I say let freedom reign. Be as responsible or irresponsible as you like.

All medical interventions, no matter how minor, carry at least some risk. If the best information available to the experts suggests that the interventions I alluded to will save the system money, I support them. An earlier comment that smokers (at least overseas) pay very high taxes, presumably sufficient to cover the full social cost of smoking, makes perfect sense. If irresponsible behavior causes people to die sooner and incur lower lifetime medical costs than those who maintains a healthy lifestyle, that’s OK by me too. However, for those who are imposing most or all their healthcare costs on society (Medicare and Medicaid beneficiaries), if there are simple interventions and checkups that can reduce those costs, I don’t think it is unreasonable to expect some cooperation in stretching our finite financial resources as far as possible.

Rant is up.

On January 1st, 2005, I decided it was time to turn my life around, healthwise. I was a diabetic (type 1), insulin-resistant on top of the D, morbidly obese, pack-a-day smoker, sedentary, and so on.

In the past nearly two years, I have dropped more than a hundred pounds of weight (I’d like to drop another 40, which would bring my body fat to 12%); I stopped smoking; took up regular work-outs six days a week; and started bicycling everywhere — and I do mean everywhere, as I neither have nor want a car. (Not to mention I never had a license in my life.)

And you know what? My employer, self-insured, shelled out more than $45,000 this year for sports-related injuries: surgeries after some jerk driver ran me over when I was biking and didn’t even stop; overuse injuries like a tear in the acetabular labrum; right shoulder joint SLAP tear repair; the list goes on.

Tell me a fairy tale from the Grimm brothers, but do _not_ tell me that a healthy lifestyle lowers healthcare costs — in 2006 alone, mine were ten times higher than in 2004, before I got on this trip.

(And no, I am not going to quit; despite getting run over by jerks and cut open by orthopods, I like being fit. I may not be in good health, but at least I can bike a few hundred miles without dying in the saddle.)


Fisking is, to my understanding, simply deconstructing a faulty argument. It is not, by definition, fallacious or misleading.

Perhaps people focus on the negatives because there are such gaping holes in such a stance as you have taken ?

A variation on: #1 Dinosaur rant is: Who will benefit? In Econ 101 we learned that money is made on change. In P4P the physician is made responsible for patient outcomes and their income is based on this parameter. I will guarantee doctors will not make more under this system.

When we shift this responsibility to patients they loose for all of the commentators reasons. We will also see doctors loose since they will have increased paperwork and I am sure they, in time, will again be made responsible for patient outcomes.

So who wins? The insurance companies and government through increased premiums and denial of coverage. Due to the large numbers even a small shift in increased premiums will result in financial change in the billions.

While we patients, and you doctors, would like to see everyone lead long healthy lives the reality is, in a complex world, we all make decisions, or are place in situations, where our health suffers.

Steve Lucas

BC, I always read your posts as well, I do respect your opinion and often agree with you. There is, however, no evidence that the measures you mention are cost-saving. Checking for cholesterol for example leads to treatment when the numbers exceed those in the guidelines. As a result, you end up paying the cost of drugs for many people with only savings on very few of them. Consider for example somebody whose 10-year risk of heart attack is 10% which is pretty high and assume 30% risk reduction as an example. In this case, you have 3 percentage points chance that statins will prevent a heart attack. It also means that in this group 97 people out of 100 will take drugs that wouldn’t benefit them. But there are doctors who prescribe drugs not based on risk but based on LDL values. In this case, you may end up with a middle aged healthy woman with 10-year heart attack risk under 1% being put on drugs. Almost happened to me.

Cholesterol treatment is not cost-saving except for maybe in secondary prevention and even then not for everyone. At least not according to this (read last sentence and keep in mind that cost-effectiveness is not the same as cost-saving.) I am not sure about blood pressure, but I imagine it also depends on one’s risk. There probably are other articles on the subject, but I don’t have time to look.

You also mention that if some preventive measures save money, it’ll be OK to penalize people for not doing them. In this case, wouldn’t it be logical to go the other way and to penalize people for taking preventive measures that are not cost-saving and only have a small chance of individual benefit? Many of recommended preventive measures fall into the latter category. Seems logical.

The reason I don’t see it for “medicaid-only” plan is that one could make similar arguments for employer-sponsored plans. You only need to substitute “shareholders” and “employees” for “taxpayers”.

So who wins? The insurance companies and government through increased premiums and denial of coverage. Due to the large numbers even a small shift in increased premiums will result in financial change in the billions
Pharmaceutical companies come to mind. At least in some reincarnation of such plans.

BC, one time I had a similar problem with posting was because of a character in the post. Check out what character follows “for” in your post. This could be a reason it gets truncated.


Thanks Diora. Let’s see if this works.

Thanks for the link to the NIH cholesterol study on the cost-effectiveness of various treatment options. If I were spending my own money, I would probably conclude that an investment in treatment that could extend life for less than $50,000 per QALY would be money well spent, if the objective is to actually save money for a program such as Medicaid, requiring treatment like this is unwise if it will not save money.

I also thought that you made a very fair and excellent point about often having to treat a very large number of people to avoid one heart attack or stroke. I am looking for opportunities to save money, while your emphasis is more toward freedom of choice and minimizing the risk of side effects from drug interventions. I would be the first to suggest, however, that if there were to be a policy to require Medicaid beneficiaries to agree to be checked for cholesterol, blood pressure, glucose, etc., we need to be able to demonstrate clearly to everyone’s satisfaction that such an approach, would, in fact, save money for the system (and taxpayers).

In the private sector, at a recent investor conference, Cigna noted that it now offers 19 separate disease management (DM) programs that employers can buy as part of the health insurance package they provide to their employees. Two companies they cited that have embraced this approach (Whole Foods and Safeway) say it is saving them money. Cigna claims that their programs will save employers between 1.5 and 3.0 dollars for each dollar spent on DM. My own employer, which has approximately 20,000 employees in the U.S. has long paid for physicals at various intervals depending on age (annual after age 55). While I don’t know whether DM saves money on a lifetime cost basis or not, employers (and shareholders) do benefit if improved employee health results in less absenteeism, higher energy levels and a better overall job in making the product or providing the service and satisfying customers even if overall healthcare costs are somewhat higher.

BC, I’d imagine some preventive programs save money, others use more than they save. On the average, it is probably neutral, but there is no evidence as to the total. Have you read the Dinasaur rant on the subject (linked above). It is clearly illustrates many uncertainties with such measures.

My employer has a bunch of programs too. I’d imagine smoking cessations programs and incentives may save company money; I doubt anything else does as far as primary prevention is concerned (not sure about desease management programs as I don’t know much about them) I wouldn’t trust company policy-makers to make evidence-based decisions any more than I would the government. Doctors and epidemiologists don’t always agree on the evidence, but policy-makers often just go on what beliefs rather than scientific evidence.

Many measures that are cost-effective in terms of QALY are not cost-saving. Some are expensive. I’d be skeptical about claims about money-saving from companies unless there is real evidence. Cigna wants companies to use its services, so it is hardly an objective source. For example, there is also no evidence that complete annual physical examination of healthy individuals does any good. There is evidence that such examinations often include non-recommended tests at a great total cost. So how can they save money?

As far as the absentism is concerned, my company’s solution works great: it doesn’t limit the number of sick days (I think if you are out for a long stretch of time, at some point you need to go on temporary disability – I think after a month, but I am not sure), but it evaluates you at the end of the year based on what you accomplished during the year. If you are out for 3 months, you have 9 months to accomplish sufficiently not to end up in the bottom 5%. If you are in the bottom 5% two years in a row – you have to show great performance immediately, find another department that wants you or you are out. If there are layoffs, people at the bottom based on previous year evaluations are most vulnerable. There is also huge variation in bonuses and raises depending on evaluation. Even before evaluations and rankings became this critical, hardly anybody took advantage of sick days. When people have 10 sick days they often want to take them all. But when there is no fixed number, people only take days when they are really sick. This also keeps people with flu away from work, so less people catch it. It wouldn’t work for every job, obviously. We are not paid by the hour, our schedules have always been flexible, we can always take a few hours for “personal business” and many meetings have lately been replaced with teleconferences. The flipside is that we don’t get paid overtime either. The main thing about absentism though – a lot of times it has nothing to do with health.


Thanks again for your most recent link on the routine physicals. Also, I did read Dinosaur’s comments which were very enlightening. At the same time, I know enough people who had potentially serious conditions picked up at an early, treatable stage during a routine examination to make me at least somewhat biased in favor of preventive medicine. However, based on comments from you and a number of the docs, I think we should be extremely careful in using coercive approaches to force people to undergo preventive treatment. At the very least, the evidence that such an approach would, in fact, save money needs to be clear and convincing. I completely agree with you on your QALY point. Cost-effectiveness is not the same as cost saving, and treatment can be expensive.

With respect to companies opting to purchase disease management services, I recognize that the insurer trying to sell these services is not exactly an objective source of information. However, large, self-insured employers have the resources either in house or through the consultant community to evaluate these programs in an objective and sophisticated manner. Besides, insurers are interested in sustaining their business over the long term. If customers felt they were sold a bill of goods that didn’t deliver as promised, they wouldn’t be customers for long, and they would spread the negative word among other prospective customers as well.

I also agree with you on the absenteeism policy. My company uses a similar approach, though I think we are less rigorous in terms of quantifying and ranking individual performance. Our bonus compensation probably varies quite widely as well but does not fluctuate as much from year to year as other firms in our industry. By the way, are you in the healthcare field? If so, in what capacity? I am not.

One thing I’d like to mention about early detection. In some cases it makes enormous difference but often it doesn’t. Sometimes the problem is still easily treatable if detected later, sometimes it is non-treatable and early diagnosis simply prolongs the time one knows that he/she is sick, and sometimes the problem would never have given symptoms if remained undetected. I don’t know if you’d ever seen this book, but it clearly explains the issues involved. It is about screening, but I think some of the issues apply to preventive treatments as well.

No I am not in healthcare. I am in IT R&D. I work for a well-known research center of a large Fortune 500 IT Company (if you guess what it is, keep it to yourself). I do have a strong math background (undergrad – math, grad – CS), and I had probability and statistics in college,which is what most epidemiological papers are about anyway. I actually find some of these papers fun to read – sometimes I see the flaws and sometimes I think of new study designs; if I were in college now I’d probably seriously consider epidemiology.


Thanks for the book reference. I hadn’t heard of it before but will probably add it to my growing healthcare book library.


Thanks for the book reference. I hadn’t heard of it before but will probably add it to my growing healthcare book library.

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