Tuesday, August 4, 2009

Personal responsibility for health: latest fad or approach with promise?

Advocate Blog Guest Blogger: Lois Snyder,JD, Director, ACP Center for Ethics and Professionalism

Should patients be encouraged to take responsibility for their health? Who should encourage them? How? For what goals? How should we balance the interests and liberties of individuals on the one hand, against the interests of the collective in being fair? What is the physician's role and how does all of this affect the patient-physician relationship?

Most people agree, especially anyone (like me) with a teenager, that incentives work in motivating behavior change. Human beings respond to rewards and penalties. Should something as fundamental as health care, however, be incentivized? Can it be done in an ethically appropriate way?

Health reformers are leaving no stone unturned in the pursuit of access to care for all Americans. Stones uncovered to reveal potential cost savings are particularly attractive. Supporters of personal responsibility programs maintain that individuals should be encouraged to take an active role in promoting their own health and choosing healthier lifestyles; this benefits the individual in improved health outcomes, and may also have a collective benefit in improving health and controlling health care costs. Opponents caution that this approach may have a disproportionately negative effect on the disadvantaged, may discriminate against those with increased risk factors for disease, and may lead to blaming individuals for health status without consideration of other health determinants.

Recent programs on personal responsibility for health have employed both positive and negative incentives. Positive incentives include removal of structural barriers such as eliminating or reducing high co-pays, removal of attitudinal barriers through improved patient and provider education and communication, and direct rewards for desired behaviors such as cash payments or credits. Negative incentives penalize people for failing to meet stated goals. The focus on personal responsibility for health has been adopted globally in countries with universal health care using a variety of strategies and practices. In the United States, projects targeting health behaviors have been launched by state governments and employers offering incentives.

The College is examining the ethical appropriateness of positive incentives for individuals to be prudent health care purchasers and to take responsibility for their own care, and how this approach might be part of a larger comprehensive strategy to improve health outcomes. The College is also concerned, however, that incentive programs not penalize or discriminate against individuals because of poor health that may be associated with socio-economic factors, inadequate access to health care, cultural barriers, or other reasons. Such programs also must not shift costs to sicker individuals or themselves place barriers on care. Or put physicians in the position of becoming accomplices to ethically suspect activities. And such programs need to be studied to determine which incentives are most effective, and their effectiveness compared to other interventions. The goal is finding the right balance: cautiously designed and tested programs that account for these concerns, and are equitable and preserve individual liberties while recognizing that patients should be part of and accept some responsibility for their roles in improving their health and using resources prudently. The challenge is doing so in a way that continues to allow the physician to put his or patient first.

Which is why positive incentives - for fitness, nutrition, smoking cessation or wellness programs, for example - seem more ethically attractive than negative incentives. Can positive incentives help level the playing field for patients? Can they align with medical professionalism, and the duty of the individual physician to his or her individual patient?

Congress is currently considering legislation that would expand the ability of employers to promote healthy behavior among employees, using both financial rewards and penalties.

Today's question: Is that a good idea?


Robert J. Sobel, M.D. said...

My experience to date with disease management programs and wellness initiatives leads me to think this is a bad idea on several levels. First of all, employer based initiatives have a conflict of interest quality to them. The encouragement to enroll (frequently with no co-pay) seems a veiled attempt to substitute for physician visits (though the reports universally disclaim responsibility for interpretation of results). Of late, I have seen patients returning with colorful print outs that reduce their health evaluation to numerical values. If these programs continue, they should be understood as true health care interventions and be subject to all the laws and regulations that apply to practicing physicians.
While you did not address disease management programs, they are most concerning for interjecting themselves into patient care, creating both duplication of services and confusion about lines of communication and accountability. Patients and physicians are ever redefining their roles and relationships. The further decentralization of health care inherent in these initiatives does not further the cause of public health.

Regarding addressing personal responsibility within health care, it is a dangerous step to take. Regarding my type 1 diabetics, they certainly bear no responsibility for their disease but are burdened with a huge management responsibility. The nuances here are quite subtle. It is near impossible for a third party to incentivize sufficiently, though the cost sharing that currently goes on is a very effective dis-incentive to self-care. I would address elimination of this before looking to add any experimental approaches. Regarding type 2 diabetes, no one denies that we could primarily blame lifestyle choices for both causing the disease and intefering with control. Drugs are helping immensely, but at a terrible cost due to our dys-regulated financing system (see my prior Regulated Royalties comments). As there is little disagreement on the public health goals here (dietary modification, exercise, work/leisure balance), it is more important that policies enacted outside of the health care system are conducive to our efforts. Taxing the vices and incessant attention to the relationship of our food industry to schools and society is a more direct approach than further manipulating the patient-physician relationship in service of managed care ideology.

Steve Lucas said...

Continuing on with Dr. Sobel's comments: I also see issues with the concept of penalties being imposed by an employer. As an example: Through the years I have seen senior managers who were runners. They have conveyed the concept that running is good to their employees and made it almost a requirement for promotion. Do we now allow these managers to penalize employees who do not run?

Many people cannot run. Bad knees, weight, heart conditions, and any number of other issues may make it impossible to participate in this particular activity.

While this example is very simplistic, we do have companies who not only will not hire smokers, but who have fired existing employees who smoke. This was done through testing which raises the question of: Does an employer have the right to test an employee for nonlegal issues and if so where do we stop? After smoking does an employer have the right to require a set LDL number? The list becomes almost impossible to manage.

The financial incentives, and convoluted conflicts of interest, make this an issue fraught with unintended consequences,

Steve Lucas