In May, I explored the idea of whether health care was a right or a privilege. Turns out lots of people have interest in the subject, and I heard from Vance Kirklin, a great St. Luke’s senior project manager, who wrote in with the following:
“One additional topic (I’m sure there are a multitude of possibilities) relates to the individual’s willingness to participate in their own health quality. For example, if a person receiving subsidized health care is obese, diabetic, and hypertensive, with no untreatable medical reason for the obesity, and continues to make lifestyle choices that contribute to that condition after being counseled as to the consequences, what is our responsibility as a society and a health care provider?”
I told Vance I would write an entire post about the important issues this question raises, touching on a patient’s accountability for his or her own health. This is often referenced as a shortcoming in the health care reform law recently before the Supreme Court.
My parents always taught me that with rights come responsibilities, and Vance's question ties together two related and inextricably intertwined issues:
As for the rest of the population, I have been at various positions on this at different points in my career. I worked in a large, urban, county Level I Trauma Center when I was a resident in training, and I saw many people who came into the emergency room largely because they put themselves in situations that endangered their own health, such as drug overdoses, automobile accidents due to alcohol, the end stages of alcoholism, people shot while committing crime, people with sexually transmitted diseases who knowingly took significant risks, and the like.
When I was tired and overworked, there were times I wondered why the county should have to pay all the costs of people’s poor judgment, and why I should have to be up in the middle of the night taking care of them. I’m ashamed to admit it, but it’s true.
I matured and gained life experiences. I got older and found that I didn’t take care of myself as I should have. I gained weight, and became obese, and have been fortunate not to have medical consequences. I had a family member with a drug addiction and realized it truly was a disease, rather than a character flaw. Visiting my family member in rehab, I met youths who were addicts, many of them with piercings and tattoos.
I am ashamed to say that previously I would have judged those young people negatively without even knowing them. When I really took the time to talk to them, I realized that many of them had gone through life experiences that I could not have imagined. They were incredibly smart, nice, and fun to be with, but damaged by life’s circumstances. They were overcoming incredible challenges just to sober up or get clean and to participate in their own recovery. I realized that my outlook had been poorly informed, naïve, and unfairly prejudicial.
I am not suggesting that there should not be consequences for bad decisions. And I think that there comes a time that, if a person continues to make bad decisions despite help offered, that person does have to bear the brunt of the consequences. But what I also see is all the times the system failed many of these folks.
We can’t save everyone and not everyone wants to be saved. But how many times did I treat one of these patients for the consequences of their behavior, but never took the time or made the effort to get at the root cause of that behavior, to offer help, or even let them know that I cared? How many times were patients in need of behavioral health treatment and support, but either could not afford it or the system simply could not accommodate them?
How many times did I see someone who was obese and think that they ought to just have better self-discipline, until I myself was obese?
The lack of time and incentive to explore the situations that patients find themselves in, and the root causes of their behavior, are emblematic of the fee-for-service world we live in. We are always trying to put out fires and do things to address complications which are rewarded under fee for service, as opposed to getting to the bottom of a problem which is time-consuming and not rewarded under fee for service.
This is why I am so passionate about us fixing what is wrong with health care. We have to do more than treat the complications. We have to take time to try to get at the root of the problem. I believe a pay-for-value model will more appropriately reward the time and effort this will take.
That shift, toward value, will allow us to become more patient-centered. This means taking time to identify the patient’s goals, discuss options, decide which options a patient can embrace and follow, and then coming up with plans that are individualized to maximize the chance for success for that particular person.
I know this will help some of our patients, because it helped me. I have now lost more than 60 pounds and I exercise every day. If anyone previously had suggested to me that I would be regularly exercising, I would have thought they were crazy.
It takes effort to identify motivators, set small, incremental goals that are achievable, get started, create reinforcements, and establish follow-up. It won’t work for everyone. But how many people have we not really done the hard and time-consuming work to help because we were busy, because we were just treating the problem and needed to get on to the next patient, because we had prejudged them?
We do need ways to hold patients accountable, but just as I have written about in how to establish a culture of accountability in an organization (“Organizational Accountability: What’s Your Role?” posted here December 30), we start by making clear what is expected of people and then provide them with the tools necessary to do their job. Then, if despite clear expectations and the necessary tools, the person cannot perform in that role, there must be consequences.
In the case of patients, we have to build a care model that provides them with the education, tools, reinforcements, individualized care, assistance, and follow-up to help ensure success. We have to be clear on what we expect and what patients agree to do, we have to establish mutual goals, and then we need to make sure patients have the education, skills, and the resources that will help them when they have a question or problem.
After that, failure with a treatment plan should not eliminate rights to health care, but there should be consequences. They might be financial , such as higher premiums if a patient does not mitigate his or her risk factors. Conversely, they should get financial rewards if they do.
Or they might be structural, such as a requirement to attend and actively participate in certain programs or classes, such as programs for weight loss, healthy shopping and cooking, smoking cessation, and rehabilitation, to maintain coverage without a significant rate increase.
As we consider changes to the Medicare and Medicaid programs in the future, financial incentives and penalties and/or required classes or programs for those who have health risk factors that can be modified with healthy lifestyles should be explored.
One area of opportunity may be ERISA employer-sponsored health care plans. We have had early success in promoting positive health behaviors through our St. Luke’s Healthy U program, designed with financial incentives or penalties, depending on how you view it. Perhaps it’s a model for deployment to local employers, and perhaps eventually to our communities at large.
It won’t be easy to transition from a culture of entitlement to one of accountability, but just because it is hard doesn’t mean we should shy away from trying!
This is not a wholly satisfying answer, I am sure, but I hope it will spark even more discussion. Thanks for your question, Vance!
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.