Friday, August 28, 2009
Many health reform advocates blame the drop in public support on the "lies" being spread about health care reform by "special interests" and on the endless reporting of angry voters at town hall meetings. It is true, as I wrote on Tuesday, that the public seems to be buying into many of the untruths being spread by reform opponents, despite the efforts of the mainstream media, and organizations like ACP, to set the record straight. It would be a mistake, though, for health reformers to ascribe their problems to uninformed voters being misled; calling voters "stupid" is not exactly a recipe to win popular support.
A new public opinion tracking poll by the Kaiser Family Foundation provides a more nuanced view. It shows that "a slim majority of Americans continues to favor moving forward on health care reform now despite an intensifying ad war and a political climate of contentious town hall meetings that coincide with rising concerns about the reform effort." But voters increasingly doubt that health reform will be good for them: 51% of voters are more worried "that Congress and the president will pass a reform bill that won't be good for [them] and [their] family" compared to the 39% who are more worried "that Congress and the president won't be able to pass health care reform this year."
Almost half (48%) are more worried that "under a new health reform bill, government agencies would play too big a role in deciding what medical procedures people can or can't get" compared to 38% are more worried that "currently, insurance companies play too big a role in deciding what medical procedures people can or can't get." A solid plurality of voters are concerned that health reform will reduce their choices of doctors and hospitals and increase wait times for non-emergency treatments.
The critics of health reform, though, should think again before concluding that they have won the public opinion battle. 63% of the respondents described themselves as "hopeful" about the health reform plans being discussed in Washington; only 41% described themselves as "afraid" of the plans.
Moreover, voters generally favor many of the specific ideas in the pending bills, with majorities favoring or strongly favoring expanding state programs for the poor, offering tax credits to help people buy coverage, requiring that all persons have coverage; requiring employers to offer coverage or pay into a health insurance pool; and creating a government-administered option similar to Medicare to compete with private insurers.
These data suggest several things to me. One is that a "hopeful" public still wants health reform and are inclined to support most of the key elements of the pending bills, but they are anxious that the result will be to limit their choice of doctor and give the government too much authority over patient care decisions. To put it differently, it seems to me that the public's opposition really isn't to expanding coverage, but to effect of cost controls on their own access to care.
Writing in the Washington Post conservative columnist (and physician) Charles Krauthammer sees a way out for the Democrats: drop the cost controls, the public plan, end of life counseling, and the idea of the government funding research on "best practices" and instead "promise nothing but pleasure - for now. Make health insurance universal and permanently protected. Tear up the existing bills and write a clean one - Obamacare 2.0 - promulgating draconian health-insurance regulation that prohibits (a) denying coverage for preexisting conditions, (b) dropping coverage if the client gets sick and (c) capping insurance company reimbursement. What's not to like? If you have insurance, you'll never lose it. Nor will your children ever be denied coverage for preexisting conditions."
Krauthammer predicts cost control and rationing will come later on.
President Obama has been insistent that health care reform must deal directly with costs, and putting aside tough cost controls - instead focusing on guaranteeing insurance coverage that can't be taken away - would be a huge shift for him and likely make the nation's long-term fiscal outlook worse. But the polls suggest that this might be the best way for him to salvage support for health care reform from voters who want better health insurance coverage, but not if it limits their health care choices.
Today's question: Do you think Obama and the Democrats should shift the debate from controlling costs to expanding coverage?
Wednesday, August 26, 2009
Many of the accounts of Senator Kennedy's death last night at the age of 77 have rightly focused on his astounding record of accomplishment in the U.S. Senate. Most also noted that he passed away without realizing his life-long dream of universal health insurance coverage.
How likely is it that Congress will honor Senator Kennedy's legacy by giving all Americans access to affordable coverage?
It may be unseemly to look at the immediate impact of his death in terms of votes for health care reform, yet until his seat is filled (presumably by a Democrat) by a special election, Democrats will be one vote short of the 60 needed in the Senate to pass health reform on a party-line basis. The special election likely would not take place until January of next year. In one of his last public acts, Senator Kennedy asked the Massachusetts legislature to amend state law to allow for the governor to appoint a replacement on an interim basis until the election is held. Governor Deval Patrick, a Democrat, supports the change, but is unclear if the legislature (which is not in session) will go along.
Senator Kennedy's record of reaching out to Republicans to make progress on his priorities, without compromising on his core principals, also seems sadly out-of-touch with the partisanship and stridency of the current debate. Dan Balz writes in the Washington Post that, "as much as he was the liberal's liberal, he was the legislator's legislator, a man willing and able to work across party lines, a politician of deep conviction who knew how and when to cut a deal, who believed in the end that the role of a politician was to make progress, if not all at once then step by step."
There don't seem to be many others who have the same ability to reach across the aisle to strike a deal.
Still, we can hope that Congress will do more than eulogize Senator Kennedy with words. It is not too late to seize the opportunity to deliver on his dream of enacting legislation that leads to affordable coverage for all. This will require a willingness among Democrats and Republicans alike to make difficult compromises, to tone down the anger, to speak to each other and the American people honestly about the issues and choices available to them, and to make their arguments respectfully in the spirit of seeking common ground rather than trying to destroy their political opponents.
The Washington Post editorial page writers may have said it best:
"As with most of us, [Senator Kennedy's] final days were another object lesson in the necessity of good health care. He thought it should be available to everyone, and he worked to make that a reality until the end. Moving toward that goal would be the greatest tribute his fellow legislators could pay him."
Today's question: Do you think Congress, Democrats and Republicans alike, will be able to honor Ted Kennedy's legacy by making good health care available to all?
Tuesday, August 25, 2009
During the weeks while I was gone, the debate in the U.S. took a serious turn away from consensus. Instead of moving toward common ground, we have seen warring ideological camps go into attack mode. Instead of all sides listening to each other, we have seen town hall meetings devolve into shouting matches and invective. Instead of arguing on the basis of a common understanding of the facts and evidence - and from there, debating our legitimate policy differences - we have seen misinformation designed to stop health care reform spread like wildfire.
Howard Kurtz writes in the Washington Post that an effort by the mainstream media to debunk even the most inaccurate and outrageous claims - such as that the House bill will create "death panels" to cut off care to the elderly - are not believed by much of the public:
"The crackling, often angry debate over health-care reform has severely tested the media's ability to untangle a story of immense complexity. In many ways, news organizations have risen to the occasion; in others they have become agents of distortion. But even when they report the facts, they have had trouble influencing public opinion."
(Kurtz's online discussion about his column makes for interesting reading.)
Now, I believe that critics of how health care reform, as it is being pursued by President Obama and Congress, have a right and responsibility to make their best case for a different approach and to cite the facts and evidence to support their views, just as proponents must do the same. But I also believe that the public is not well-served when people cross the line from making a principled argument to spreading outright untruths to score political points. Nor is a free and open debate served when people shout down those who disagree with them. Two independent and well-respected fact-checking websites (Politifact and FactCheck) have shown that both sides are guilty of stretching the truth, but some of the biggest whoppers are coming from critics of health care reform.
I also believe that physicians have a special responsibility to get the facts about health care reform. Doctors are trained to analyze evidence to reach the best possible treatment decisions for their patients. No patient would trust a physician who ignores the facts of their case or falsifies the presenting information to make it fit a diagnosis. The public should have the same expectation that physicians will strive for accuracy in weighing conflicting information about the implications of proposed health reforms. As an evidence-based scientific organization, ACP has made resources available to ACP members to help them make their own informed judgments, based on the facts and evidence.
To be sure, "facts" about public policy aren't always clear cut, may be contradicted by other facts, can be cited or ignored selectively to make a point, or may be viewed differently depending on one's own views. As Mark Twain famously wrote, "there are three kinds of lies: lies, damned lies and statistics." By the same token, though, some things about health care reform are either true or false. Saying, for instance, that the House health care reform bill would allow the government to set up "death panels" simply is untrue, while arguing that the government should stay out of discussions of living wills is a legitimate point of view, and worthy of debate.
Today's questions: Do you agree that the health care reform debate is being poisoned by mischaracterizations and untruths? What responsibility do physicians have to get the facts straight?
Thursday, August 20, 2009
Reporter Shankar Vendantum reports on a urology practice that had a whopping 700 percent increase in CT scans after it bought its own machine:
"In August 2005, doctors at Urological Associates, a medical practice on the Iowa-Illinois border, ordered nine CT scans for patients covered by Wellmark Blue Cross and Blue Shield insurance. In September that year, they ordered eight. But then the numbers rose steeply. The urologists ordered 35 scans in October, 41 in November and 55 in December. Within seven months, they were ordering scans at a rate that had climbed more than 700 percent.
The increase came in the months after the urologists bought their own CT scanner, according to documents obtained by The Washington Post. Instead of referring patients to radiologists, the doctors started conducting their own imaging -- and drawing insurance reimbursements for each of those patients."
A lawyer representing the practice responded that the increase was unrelated to buying a scanner and that all tests ordered were within the "standard of care."
This is not a new issue. As far back as 1993, the GAO found that physicians in Florida who owned diagnostic imaging facilities had higher referral rates for all types of imaging services than non-owners.
The reason the issue is now getting a fresh look is that physician ownership of diagnostic testing facilities has steadily increased, and related or not, so has utilization of high cost imaging procedures. As Congress looks for ways to trim costs, self-referral will be under scrutiny.
ACP policy "opposes any financial arrangement that links income generation explicitly or implicitly to the volume or revenues generated by the investor-physicians; referrals if there is no valid medical need for the referral; any arrangement that involves an explicit or implicit inducement or encouragement of physicians by the management of the entity to increase the volume of referrals to the facility; and referrals to any entity (except those specifically exempted by law) unless disclosure has been made to patients of the physician's financial interest in the facility and, to the extent practicable, a list of alternative facilities from which the goods or services can be obtained." At the same time, ACP supports the current "in office" ancillary services exemption, which allows physicians to refer patients for testing done in their own offices. This policy was originally written in 1998 but reaffirmed in 2004 by the Board of Regents. The intent when the policy was written was to allow physicians to keep X-ray machines and minor diagnostic procedures in their offices. Technological innovation, though, has since led to much more advanced diagnostic procedures falling under the exemption.
Today's question: Do you think that physician ownership of the diagnostic tests they own benefits or hurts patient care? Why or why not?
Tuesday, August 18, 2009
With the passage of the health IT incentive program (also referred to as the HITECH Act) as part of the American Recovery and Reinvestment Act of 2009 (also known as ARRA), structured payments were put in place to stimulate the adoption of Electronic Health Records (EHRs) with the caveat that these EHRs would need to be "certified" and used to demonstrate "meaningful use." If a practice documents meaningful use of a certified EHR at the start of 2011, over the subsequent 5 years (2011 - 2015) that physician would receive payments equaling $44,000. You can start in 2012 and still receive the maximum amount. However, start later and you get less (i.e., starting in 2014 would result in incentives totaling only $24,000 at the end of 2016). Note, these dollar values are specific for the Medicare incentives. If you qualify under the Medicaid program, the incentives are a bit higher (click here for more details).
But what does "meaningful use" mean and how will it be demonstrated? The legislation defines it as follows:
"A meaningful user of EHR is defined as one who: (1) demonstrates to the satisfaction of the Secretary that the professional is using certified EHR technology in a meaningful manner, which includes the use of electronic prescribing; (2) demonstrates that the technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care; and (3) uses the EHR to submit certain performance measures to the Secretary (but only if the Secretary has the capacity to receive the information electronically)." The Secretary has some flexibility to define additional criteria or to change the criteria over time.
So far, so good - but what does this really mean you might ask? The Health IT Policy Committee released a "Meaningful Use Matrix" on July 16, 2009. There are plenty of well-intentioned measures of clinical parameters included in the set of metrics for 2011 but a quick review raises some important questions. Here are a few to consider:
- Can EHR vendors develop the data collection and reporting capabilities of EHRs to incorporate such measures into EHRs by 2011 (or even 2012) - especially since many of the clinical measures identified were originally designed to be based on claims data and/or chart review and not developed with enough specificity for computer programmers?
- Many of the proposed measures still rely on paper-based activities which could add administrative burdens and costs to practices. Should proof of meaningful use include dependence on paper processes?
- One of the measures is the "percentage of orders entered directly by physicians through CPOE" (CPOE = computerized physician order entry). However a footnote explains that, "CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referrals) but electronic interfaces to receiving entities are not required by 2011." This seems odd and, frankly, backwards. Physicians will be required to generate orders through their EHR for which there is no guarantee - and in fact no requirement - for receipt of these orders by the "accepting" entity. Shouldn't the capability of receiving electronic orders be built and tested prior to the requirement for those orders to be initiated?
- One measure is a requirement to report on the percentage of patient encounters for which insurance eligibility was confirmed. Meaningful use of an EHR? I thought this is a practice management system function.
- Another metric simply states, "Full compliance with HIPAA Privacy & Security Rules." How will that be measured through the use of an EHR? Does this imply that EHRs will now have to include security and privacy applications that monitor and report on all access/clicks/views/prints/emails of protected health information?
To be fair, there are good clinical measures on the meaningful use matrix relating to diabetes care, cholesterol management, blood pressure control, cancer screening, vaccinations and others. But as noted above, there are going to be challenges with specifying the denominators and numerators in order to accurately provide meaningful information from "meaningful use."
Imagine you are a practicing physician and leader in a group of fewer than 10 physicians (where the vast majority of ambulatory care visits take place). You have been contemplating the purchase of an EHR off and on for a couple of years but now have decided to get serious given all of the attention being paid to health IT. After reading about the ARRA incentive program, are you more or less likely to purchase an electronic health record? Has the business case been made? Are you feeling pressure to do so? If you are not ready, what would help you make the leap? In short - is it time to purchase an EHR?
Thursday, August 13, 2009
Responding to legislation on behalf of ACP can be a daunting task. How does an organization of 129,000 members address legislative proposals for health care reform that are moving rapidly through Congress, whose provisions are complex and are being revised frequently, and on which ACP members may have differing or opposing views?
All five congressional committees with jurisdiction on health considered (and four passed) legislation in just a few months this year. Differences in legislation between the House and Senate will now need to be reconciled when Congress returns in September from its recess and then each chamber will consider passage of a final bill that could also include consideration of amendments. ACP has been involved at each stage in the process, seeking to assure that legislation is consistent with ACP policies and priorities.
ACP's involvement, however, began long before Congress considered any specific bill and will not end with a presidential signing ceremony. ACP also will need to respond to proposed rules and regulations that will be forthcoming to implement any provisions that are enacted. The process could be repeated again next year as further legislation is considered. Fortunately, ACP has a process for developing factual, evidence-based public policy positions that are representative of its members' views. These policy positions then serve as the basis for our legislative advocacy efforts. The process involves ACP membership, leadership, committee members, chapters, councils, and staff.
All of the health reform bills considered by Congress are comprehensive and complex, addressing a broad range of issues: health insurance reforms, access to care, physician payment, workforce, health care delivery, health professions loans and scholarships, prescription drug coverage - to name a few. ACP had extensive policy on most issues, but of course there were some new issues for which we did not have existing policy. For these, a fast-track process was employed to develop new policy. I'll explain how ACP responded to all of these health care reform proposals, but first let's quickly review how the College develops policy.
The process begins with the College's Strategic Plan. It sets forth ACP's high-level priorities, such as improving access to care and eliminating disparities. The objectives are developed by ACP's content-focused committees and its councils, which represent key member groups, with oversight by the Strategic Planning Committee and ultimate approval by the Board of Regents. Staff then develop programs to achieve these objectives. Governance and staff annually follow developments in the health care arena to adapt the College's positions.
The Health and Public Policy Committee (HPPC) develops ACP's positions on issues affecting the health care of the American public and the practice of internal medicine. Policy on payment and regulatory issues are developed by the Medical Services Committee (MSC), and ethics policies are developed by the Ethics, Professionalism and Human Rights Committee (EP&HRC). Membership on the committees includes a diverse mix of generalists and specialists, academics and private practitioners, ACP Regents and Governors, and representatives of ACP councils. Special attention is paid to assuring representation of all ACP members.
Development of public policy papers generally commence with ACP staff conducting a literature search and preparing background materials for the policy committee. Draft policy papers are then prepared for committee review and discussion. Following initial committee approval, a draft policy paper is circulated for comments to Governors, Regents, ACP chapters and/or their health policy committees, and the ACP councils representing subspecialists, students, residents and young physicians. Occasionally outside experts also are invited to review the confidential drafts. Comments and proposed revisions are then shared with the policy committee prior to submission of a final draft to the Board of Regents for final review and approval.
As Congress began consideration of health reform legislation in 2009, ACP was well prepared to provide its input to influence the legislation.
For the new issues for which we did not have existing policy, ACP's Health and Public Policy Committee responded by developing policy monographs on a public plan option, taxing employer-paid health insurance premiums, and mandating that all individuals obtain health insurance. The monographs were reviewed and approved by the committee within a very short timeframe and were then recommended for approval by the Executive Committee of the Board of Regents in June 2009, following review and discussion. The full Board of Regents reviewed and approved the three papers in July 2009.
In 2008, ACP prepared a proposal for legislation to improve the attractiveness of careers in primary care. Working with Congresswoman Allyson Schwartz (D-13th PA) and her staff, this proposal was introduced last fall and was eventually re-introduced in the new 111th Congress as the Preserving Patient Access to Primary Care Act (H.R. 2350) in May. Obtaining support for this legislation was a major objective of ACP's Leadership Day advocacy effort this year, and much of its provisions are now reflected in the proposed health care reform legislation. A companion bill was introduced in the Senate by Maria Cantwell (D-WA), S. 1174.
In March, then ACP President Jeffrey P. Harris, MD, MACP, presented testimony to the House Energy and Commerce Health Subcommittee.
Also in the spring, Senator Max Baucus (D-MT), chairman of the Senate Finance Committee, began issuing proposals for regarding health care reform. These proposals came in three waves. First, were proposals for delivery system reform, then options to improve quality, and finally financing options. ACP staff promptly reviewed each proposal and prepared side-by-side analyses with comparisons to ACP policies. The ACP policy committees then reviewed the proposals and the staff analyses. ACP's leadership was then briefed and approved the stances to be taken by ACP. Meanwhile, ACP lobbyists worked closely with staff of the key health committees to convey ACP priorities for health care reform legislation. In May, new ACP President Joseph Stubbs, MD, FACP, submitted ACP recommendations for reform to the Senate Finance Committee.
When the three House committees reported-out their 1,080-page bill, ACP staff thoroughly reviewed it and prepared another side-by-side analysis with comparisons to ACP policy. Similar to the process with Senate Finance, ACP comments on this bill were also approved by ACP leadership and conveyed to the appropriate congressional committees.
Similar review, analysis, and comments were prepared in July for the bill reported by the Senate Health, Education, Labor and Pensions Committee and will be prepared when the Senate Finance Committee issues its actual bill.
In each case, proposed health care reform legislation was thoroughly reviewed and compared to evidence-based ACP public policy positions that had been widely vetted prior to ACP supporting any piece of legislation. All letters of support were first reviewed by the respective ACP committees and approved by ACP leadership.
For each piece of legislation, ACP has only supported those provisions that are consistent with ACP policy and has clearly stated its concerns about those that are not. Some issues, such as Malpractice Liability Reform, which ACP strongly advocates, were not addressed by Congress, and have been raised by ACP and other medical organizations. Throughout the legislative session, ACP's lobbyists and its leadership have also worked directly with congressional staff, members of Congress, and the White House to improve proposals for health care reform and achieve affordable health insurance coverage for all Americans.
For more information on legislation and health care reform please view our set of frequently asked questions.
Tuesday, August 11, 2009
CMS has recently proposed that Medicare no longer recognize the Current Procedural Terminology (CPT) codes describing office/outpatient and inpatient consultations. If the CMS plan takes effect in 2010 as the agency proposes, a physician will bill Medicare for an office consult using a new or established patient office visit code (99201-99205; 99211-99215) and bill an inpatient consult using an initial hospital care service code (99221-99223).
CMS would take the money that it currently spends to pay for the consult codes (99241-99245; 99251-99255) and distribute it to increase payment for the codes that "replace" them. While other CMS-proposed changes impact the 2010 Medicare payment rate for office visits and initial hospital (and initial nursing facility) care, this results in a slight increase in payments for these services. Assuming, for the sake of simplicity, that the 2010 payment cut from the flawed SGR is averted and that the 2009 conversion factor remains the same for next year:
* Medicare 2010 payments for initial hospital care services will generally be lower than the 2009 inpatient consult payment rates.
* Payments for office visits will be less than for office consults, and significantly less if the beneficiary is an “established patient” known to the consultant. For example, Medicare will pay $103.16 for a mid-level new patient office visit and $68.89 for a mid-level established patient in 2010; it paid $124.80 for a mid-level office consult in 2009.
The highlights of the agency-provided rationale for its proposal are below.
CMS states that physicians have a hard time billing consults correctly because the distinction between a consult and a transfer of care continues to be unclear.
CMS states that the physician work associated with a consult and an office visit/initial hospital care service is "clinically similar." Further, the agency states that the historically higher payment for a consult was primarily because of the requirement that the consultant provide a formal written report back to the requesting physician. It asserts that a significant discrepancy no longer exists now that the consultant's report can take any written form.
The agency notes that the increased payment for office and initial hospital visits would benefit primary care physicians - as they provide relatively few consults, although it stopped short of citing that as an explicit reason for its proposal.
CMS is accepting comments on this proposal (and other changes to the Medicare physician payment schedule for 2010) from the public through August 31. ACP is determining how it will respond to the agency. The College and other physician organizations have feuded with CMS since the agency expanded its definition of what constitutes a transfer of care - which narrowed when it is appropriate to bill a consult - three years ago. While ACP is skeptical of the CMS, especially considering this recent history, it is taking the time to evaluate the surprise proposal
Today's question: Is the physician work involved in furnishing a consult "clinically similar" to an office or initial hospital care visit to the point that no payment differential is warranted?
Thursday, August 6, 2009
From time to time, I get an email from an ACP member decrying for-profit health care. One member wrote: "It seems that the other parts of the medical system will do fine under the new plan - for profit insurance companies will make even more money while exerting a strangle hold on how we practice and how we are paid. Pharma, medical device manufacturers, hospitals will all do fine. I don't understand how internists will be better off under this new system then we were before."
Another internist wrote: "We pay enough taxes that health care can be given to all Americans only if the greed and abuse by powerful businesses were excluded. Millions of people file for bankruptcy and millions of businesses die every year due to unaffordable healthcare cost. My HMO agent came to deliver my new Plan and told me that my premium will be up by 8% this year. For what? I hardly use it and my wife uses it 1-2 times per year and so does my kids. How fair is this? For Profit HMOs are not synonymous with better and affordable healthcare of Americans."
The Physicians for a National Health Program, which advocates for a single-payer health care system, points the finger at "for-profit" health care as the culprit behind the problems in the U.S. health care system:
"The reason we spend more and get less than the rest of the world is because we have a patchwork system of for-profit payers. Private insurers necessarily waste health dollars on things that have nothing to do with care: overhead, underwriting, billing, sales and marketing departments as well as huge profits and exorbitant executive pay. Doctors and hospitals must maintain costly administrative staffs to deal with the bureaucracy. Combined, this needless administration consumes one-third (31 percent) of Americans' health dollars."
An opposite perspective is offered by Stephen L. Carter, a law professor at Yale. In a commentary posted on the Washington Post web site, he argues that, "High profits are excellent news. When corporate earnings reach record levels, we should be celebrating. The only way a firm can make money is to sell people what they want at a price they are willing to pay. If a firm makes lots of money, lots of people are getting what they want." When it comes to health care, he says this:
"Indeed, one reason the 'public option' health insurance program under debate may turn out to be more expensive than advocates suggest is that here, unlike in Europe, we are unlikely to put up with government restrictions on what sorts of care will be available, especially for seniors. A board of experts might decide to limit access to hip replacements, for instance, but there is little chance Congress will let them get away with it. Private insurers, by contrast, will cut whatever they can. This puts them at constant war with regulators and patients, but beneath this tension is a certain useful discipline. We want health care to be cheaper, and the for-profit health-care industry has every incentive to make it so."
I can see why many ACP members are troubled by health care profit-making - the idea of making money off sick people just doesn't ring right to people who have dedicated their lives to treating the sick. (Although truth-be-told, most doctors - including I would imagine some members of PNHP - make healthy incomes off the sick.) But I also believe that elimination of profit-making in U.S. health care could stifle innovation that leads to better treatments and efficiencies in health care delivery. Besides, making money in America is ... well ... as American as apple pie - sold by your local baker to make a profit, for course!
Today's question: Do you think profit- making is good or bad for the U.S. health care system
Tuesday, August 4, 2009
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?