In March 2010 President Barack Obama and the Democratic-led Congress passed the single largest change in the American health care industry since the introduction of Medicare and Medicaid in 1965. The Patient Protection and Affordable Care Act (PPACA) aims to drastically change the way that health care is delivered and financed. It partially draws upon the idea of personal responsibility and its role in promoting individual health. Some states, notably Tennessee and Florida, had already tried similar approaches. Expanding upon these models, West Virginia created a new Medicaid plan in 2006 that not only rewards healthy behaviors, but also punishes unhealthy ones.
This invocation of personal responsibility is not a product of recent advent. As the threat of communicable diseases waned throughout the twentieth century, the public health community shifted its focus from contagions to lifestyle choices—smoking, excessive alcohol use, poor diet—that now proved to be larger health hazards. By the 1970s this new paradigm had taken hold in the highest levels of government. In 1979 US Surgeon General Julius Richmond released a groundbreaking report that would define the future course of public health. In this paper he explicitly promulgated this belief on the role that personal responsibility could play in preventing disease and maintaining one’s health. He warned us that “we [were] killing ourselves by our own careless actions.” He went on to say that “the individual can do more for [his] own health and well-being than any doctor, any hospital, any drug, any exotic medical device.” His prescient words have found a welcome home in the current health care reform debate.
The underlying premise of this idea holds that if people have a vested interest in their health, they will do more to maintain it. But can one truly mandate and regulate personal responsibility regarding one’s health? Should this be the new focus of public health legislation? Can this idea play a role in improving health outcomes and lower long-term costs?
Consider this. How should a doctor encourage a patient to stop smoking, lose weight, or adhere to a hypertension regimen? After numerous office visits and little progress using motivational counseling and education, should the doctor use more concrete rewards, like financial incentives? These incentives designed to encourage people to be more concerned about their health have been growing in popularity in the past decade. Employers, looking for ways to lower medical costs of their employees, have been trying to make their workers live healthier lives. Strategies to do this include rewarding workers for good behavior (like exercising and smoking cessation) and punishing them for bad ones (continuing to smoke, gaining excess weight). Some companies have instituted no-tobacco policies (both on- and off-the-job) and offered gym membership reimbursements, insurance premium discounts, and cash bonuses to entice workers to take better care of themselves. For example, IBM is offering its workers up to two $150 rebates if they can reach targets regarding weight loss and increased physical activity.
Public insurance programs are also pursuing these strategies used in the private sector. In 2006 the US Department of Health and Human Services allowed West Virginia to amend its state Medicaid plan to allow such an experiment. The approved new plan, Mountain Health Choices, permits West Virginia to offer two types of Medicaid plans, a Basic Plan and an Enhanced one. Any person eligible for Medicaid is automatically enrolled in the Basic Plan. For children, the Basic Plan includes both inpatient and outpatient services, limited home health, limited non-emergency medical travel, four prescription drugs per month, and limited vision and dental coverage. For adults, the Basic Plan covers inpatient and outpatient services, limited home health, nursing home services, four prescriptions per month, and limited non-emergency medical travel.
As expected, the Enhanced Plan offers many more services. For children, these include skilled nursing care, prosthetics/orthotics, diabetes care, nutrition counseling, and mental health services. Under the Enhanced Plan, adults are eligible for cardiac rehab, diabetes care, nutrition counseling, tobacco cessation programs, and most importantly mental health services.
In order to qualify for the Enhanced Plan, beneficiaries must sign the Medicaid Member Agreement which, among other stipulations, obliges patients to “do [their] best to stay healthy”, “go to [their] medical home for check-ups”, “take the medications [their] health care provider prescribes”, “show up on time” for appointments, and to “use the hospital emergency room only for emergencies.” During the first year of enrollment in the Enhanced Plan, the Medicaid office will monitor four criteria for adherence: engaging in health screenings; involvement in health improvement programs; missed appointments; and medication compliance. If a member is found to be in default of one of these criteria, then the member will be relegated to the Basic Plan with notification. Members have the right to appeal any administrative decision resulting in a diminution of services. After twelve months of remediation in the Basic Plan, the member can be re-evaluated for return to the Enhanced Plan.
The target population for MHC includes non-disabled adults and children who are eligible for Aid to Families with Dependent Children benefits and other AFDC-like programs. This makes up roughly one third of the 392,000 Medicaid members in the state. Furthermore, any new enrollee into the Medicaid program is automatically placed in the Basic Plan. The other two-thirds of WV Medicaid members excluded from MHC include those persons who, under federal law, are guaranteed comprehensive coverage. These include pregnant women, children in foster care, people with disabilities, those with mental retardation/developmental delay, and those in long-term care facilities.
MHC, at its core, seeks to encourage its beneficiaries to be actively engaged in their own health maintenance and to reduce unnecessary expenditures. Its explicit aim is “to promote health and reward Medicaid members who choose to be personally responsible for their own healthcare and choose to adopt healthier lifestyles.” The hypothesized benefit of having this two-tiered system is that patients in the Basic Plan will strive to obtain the Enhanced Plan by making the necessary behavioral changes. However, forcing patients to sign a contract obliging them to “do [their] best to stay healthy” shifts the burden of health maintenance from the physician to the patient. On the other hand, instituting penalties for a patient’s failure to uphold a promise with the state can provide beneficiaries with another concrete motive to be healthy.
Social science research has shown that people tend to be more conscious of their health care decisions when the costs and benefits are tangible and real. MHC attempts to capitalize on this behavior by creating a Healthy Rewards program whereby members can accrue “points” into a member “account.” These points can be redeemed for goods and services not covered by the Medicaid plan, similar to the flexible spending accounts offered by private insurance.
Florida created a similar rewards program for its state Medicaid plan, the Enhanced Benefits Account. Under this plan, all Medicaid members begin with a zero balance in their EBA accounts. They can then earn dollar credits by engaging in healthy behaviors, like keeping their immunizations up to date, going to their primary care visits, refilling prescribed medications, and undertaking preventive measures like Pap smears. In its analysis of the Florida program, the James Madison Institute, a libertarian think-tank based in Tallahassee, found that after the first year of implementation, Medicaid members had earned over $4.3 million in EBA credits. Most of these funds were used to buy over-the-counter medications and infant supplies like baby wipes. Their analysis shows that when people are provided with the appropriate incentives, they will adjust their behavior to maximize their rewards.
To improve the health of its clients, MHC hopes to shift its focus from “sick” care to well care. Every member is assigned to a primary care medical home where all their health maintenance is to be managed. Also, preventive medicine services, such as mammograms, Pap smears, colonoscopies, and immunizations, are not only encouraged, but required, to qualify for and maintain the Enhanced Plan.
Unfortunately, despite these commendable goals, a plan like this does run into several logistical and ethical roadblocks. Creating a system of surveillance to ensure that patients are keeping their appointments and following their doctors’ orders would require the creation of a whole new level of bureaucracy and its inherent personnel costs. Also, the amount of capital needed to create both a monitoring system and the idealized medical home could overshadow the potential (long-term) savings gained from improving health outcomes.
Also, the MHC requirements could have significant negative effects for its members. The plan targets the least costly of Medicaid members. Non-disabled adults and children make up nearly 60% of West Virginia Medicaid enrollment, but account for only 27% of spending. Furthermore, the stipulations of the Member Agreement can adversely affect children due to the (in)actions of their parents. If a parent fails to sign the Member Agreement or adhere to the requirements of the Enhanced Plan, then the child is automatically downgraded to the Basic Plan. Children have no say in how their health is managed, making it quite feasible for the child to be punished with a diminution of services because of a parent’s behavior. Since 75% of those enrolled in MHC are children, this plan has the potential to affect tens of thousands of the state’s children.
Another area of contention is the burden placed upon the health care provider, who now occupies the awkward role of enforcer of state policy. Although MHC reports that it will only use administrative data and chart review to assess member compliance rather than direct reporting from the providers, this plan still interferes with the doctor-patient relationship. The provider may be more understanding than a chart auditor about a patient’s inability to keep an appointment because of lack of transportation or child care. Also, any treatment plan is a collaboration between the provider and the patient where both parties negotiate options and come to an agreement. This exchange is often not recorded in the chart. The criticism of the West Virginia plan is that it “is a blunt instrument that takes the therapeutic contract outside the medical encounter.” This outside assessment of compliance will be difficult to accurately measure.
One also has to consider those members who may be hurt by this drastic change in health care delivery. MHC incentivizes patients to stay healthy. If they do so and follow the tenets of the Member Agreement, they will be rewarded with more services and cash bonuses. But what about the converse? What about those patients who fail to reach target goals, for whatever reason? Should a physician or insurance provider really deny access to intensive diabetes and nutrition programs to a diabetic who only intermittently takes his medication and maintains a hemoglobin A1C of 8.5? Or what about the woman who suffers from a myocardial infarction and would benefit from cardiac rehabilitation, but is denied because she missed several doctor’s appointments in the preceding year?
MHC handles non-compliant patients by decreasing services for them. Under current law, West Virginia has no alternative to this punitive approach. Every enrollee is entitled to a minimum level of acceptable care, but only motivated and accomplished members receive exceptional care. A real concern is that those people who would gain the most from the enhanced benefits are the very ones denied access to them. One way around this is to identify those people most at risk for adverse health outcomes and provide them with the expanded services on a trial basis. Of course, if the patient does not comply with treatment, then those benefits could be revoked. At the very least, though, these patients would have had a chance to improve their health and succeed rather than never having had a chance at all.
Physicians should have more say into a patient’s treatment plan, not a third-party insurance carrier, even if that insurance is paid for by the state. Trying to make patients more responsible for their individual health can be achieved and is a goal that we all should strive for. We should find ways to increase the health literacy of our patients and increase the ease of providing primary care, like through video- and phone-conferencing with patients who cannot come into the office, more home visits, and more flexible evening and weekend hours for working adults.
Withholding beneficial services under the pretense that the patient does not deserve them is both ethically challenging and, ultimately, counterproductive. Denying enhanced benefits hardly seems like an ideal way to encourage non-compliant patents to become actively engaged in their health care. On the other hand, using more carrots than sticks has been proven to produce good outcomes. As in economics, people respond to incentives. The trick will be making sure that the incentives are both enticing enough to change behaviors and persist over time. West Virginia’s bold step should be appreciated for its attempt to address these issues, but it should also be re-evaluated to determine who is benefiting (and who is not) from this system. This new Medicaid plan may indeed be the next leap forward for American health care, but we need to ensure that we are not doing more harm than good by asking patients to take matters into their own hands.
Commentary by Dr. Surbone:
The piece by Dr. Bradley is highly informative and it will be of great interest to all readers of Clinical Correlations. The piece speaks for itself and it stimulates many reflections on the social and ethical implications of increasing personal responsibility toward one’s health status. The final remarks on the meaning and essence of the patient-doctor relationship are especially poignant. Aside from any policy making consideration, a patient-doctor relationship based on reciprocal communication and trust is likely the most determinant factor in people’s taking responsibility toward their health.
In oncology, for example, it has demonstrated that minority patients are less likely to adhere to screening programs. This is due to many socio-cultural reasons, but also to the fact that physicians do not provide the same amount and quality of information to minority or underprivileged patients as they normally do with other patients. Studies have shown that, when communication and trust are established and maintained, patients fare better and are more compliant with recommendations for screening, treatment or follow-up.
The foundation of medical ethics, as Dr. Edmund Pellegrino taught us several decades ago, lies in the patient-doctor relationship. It is our own personal responsibility as physicians to build a therapeutic connection with our patients and help them achieving the highets degree of well-being that is possible for each one of them. Not because it is mandated by law, or regulated through incentives and penalties, but because it is the right thing to do for the fellow human being who happens to be our patient.
Dr. Ishmael Bradley is a Section Editor, Clinical Correlations
Commentary by Anotnella Surbone, MD, Adjunct Professor, Medicine, NYU Langone Medical Center, Ethics Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
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