Friday, February 27, 2009

Should we pay patients to stay healthy - and punish them if they don't?

Writing in the Wall Street Journal blog, Sarah Rubenstein reports that a new study finds that paying smokers to quit is effective and "succeeds far more often than those who got no cash reward."

There is a catch: "Most study participants were relatively well-educated whites with higher incomes, and it's possible the incentives might not work as well with other groups," Rubenstein notes, citing comments by Kevin Volpp, the study's lead researcher.

(The same research team found that paying obese people to lose weight also is effective, but that the results were not fully sustained over time.)

Some people advocate more punitive measures. The Happy Hospitalist, a regular commenter on the ACP Advocate Blog, says in his blog that smokers should get lower wages than non-smokers because "by decreasing a smoker's wage, you are making up for their increased consumption of benefits compared to non smokers. . . If you don't you are discriminating against non- smokers."

I understand the appeal of creating positive incentives for people to lose weight or stop smoking. But I am concerned about the consequences of reducing wages or cutting benefits to people who can't or won't stay healthy.

The West Virginia Medicaid program is being sued by a public interest law firm over a policy that cuts children's benefits when their parents don't sign a pledge to take steps to improve their kids' health, according to the Kaiser Daily Health Policy Report. The report observes that "ninety percent of West Virginia children enrolled in Medicaid have had their benefits reduced because their parents have not signed the pledge."

Is it right for children to get fewer health care benefits because their parents don't sign an agreement that promises to take them to the doctor for regular check ups and not use emergency rooms for routine visits?

The premise behind programs that reward people for healthful choices and punish them for bad ones is that their health is largely a product of choices, made freely by adults who should know better.

But is smoking really a choice, when we know that most smokers start as adolescents and nicotine is a highly addictive drug? Is being overweight just a bad choice, when we know that culture and upbringing, genes, lack of availability of healthful food in some lower-income communities, the super-sizing of portions, and marketing of fast food and soft drinks all play a role?

"Reward or punishment" programs may have the effect of widening health care disparities, because some cultural and ethnic groups and underserved populations - as in West Virginia - have much higher rates of smoking and obesity.

It is one thing for a well-off person to run down to the neighborhood gym, meet with their personal trainer, and pick up nutritious groceries at Whole Foods. They might like getting some extra cash in their pockets to reward them for their healthy "choices."

But what about people in the inner city or Appalachia, who don't have the same resources, education, literacy, and choices available to them?

Today's questions: Should patients be paid to quit smoking, lose weight, or other healthful behaviors? Should they be punished - higher premiums, lower wages, reduced benefits - if they don't?


Steve Lucas said...

There was a Dutch study last year, that found life long health cost were lower for smokers than nonsmokers due to shorter life spans. PLoS medicine: At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers.

In my very first economics course the point was made income drives choices. A common example the instructor used was food. Starches, and now fast food, are relatively cheap, readily available, and offer a great satisfaction level. Inner city grocery stores do not stock produce due to spoilage so the shoppers are left with a limited selection of high sugar, high starch foods.

From the same PLoS study we find this conclusion: Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.

PloS Med 5(2): e29

Insurance is not a per person item but designed to pool risk. Prudence dictates that certain proven high risk behaviors carry with them a higher premium, but the risk needs to be real, and not a marketing tool designed to help the bottom line of an insurance company.

Today we as a society seem to be all about punishing those we perceive to be in some way inferior, including making decisions that we do not agree with, or we perceive to be costing us money. This has lead to some behaviors that are in themselves of questionable value. 60 Minutes showed a group a few weeks ago of people who believed in a starvation diet. I make no claim of medical expertise, but this group had all the earmarks of anorexia.

We thus need to be very careful in deciding which behaviors we support, which we wish to discourage, and which a person has any control over. A person on a limited income, or limited transportation options, may not be in a position to make the healthiest of choices.

Insurance is about pooled risk and as part of that pool some will consume more assets than others, and that is the reason for the pool.

Economic incentives, or punishments, are a slippery slope in behavior modification. Where do we stop and who makes the decisions?

Steve Lucas

Brad F said...

Bob and Steve, I am with you. This is a complicated subject, and as much as I want to assign blame, there are many inputs that contribute to tobacco use and obesity. Additionally, the savings or cost drag of these habits are unclear, as Steve rightly points out. Additionally, see this NEJM abstract. Sobering.