The NEJM takes a soft view of the personal responsibility contract

I like the concept of a “personal responsibility contract”, but the NEJM takes exception:

There are well-understood reasons why Medicaid beneficiaries have poorer health indicators and higher rates of noncompliance than many other patients. Poverty results in reduced access to child care, transportation, healthful foods, and exercise facilities, as well as lower literacy, more life crises, and higher rates of untreated psychiatric illnesses. People with fewer experiences of success are less likely than others to believe that they can change their health status. This plan asks the most vulnerable population to do more with less ability to accomplish what we ask of them.

Comments

Anonymous
Unless mentally ill or minors, such patients DO need to earn the taxpayer dollars spent by being personally responsible. End of story. Any other argument is liberal patronization of the less fortunate. While were at it, why don’t we ban sales of fast food, cigarettes, lottery tickets, and alcohol to these recipients? Oh, I forgot, that’s how we fund a lot of state coffers!
Greg P
I question a “contract” as a vehicle for this. It suggests an impersonal approach, with some kind of threat if you don’t follow the terms.
On the other hand, the NEJM comment seems condescending to a whole category of people as if we should just lump them all together into some kind of pitiful blob.
maggie mahar
Yes, there is a threat implicit in this contract. The NEJM article explains how the contract will work in West Virginia:
“West Virginia is planning to ask residents who are eligible for Medicaid because of low income to sign documents outlining ‘member responsibilities and rights.’ By signing these documents, they agree, among other things, to take their medications, keep their appointments, and avoid unnecessary emergency room visits. Patients who don’t uphold their end of the bargain will have some benefits reduced or eliminated.”
As the article points out, this Medicaid contract demands that Medicaid patients do what the majority of patients don’t do: comply perfectly with doctor’s orders whether that means losing weight, never forgetting an appointment, always remembering to take medication, always take medication with unpleasant side effects, exercising regularly–etc., etc. etc.
Moreover it is true that the poorer you are, the more complicated your life is likely to be–making compliance that much more difficult. If you’re poor, you can’t afford to hire someone to care for your children while you go to a clinic and wait two hours to see a doctor; you have one family car, your spouse needs it to go to work, and public transportation where you live is sketchy; you can’t easily afford the groceries you would need to buy to stay on a low-carb, high-protein diet; you can’t afford membership in a gym . . .
Finally, a large percentage of the patients on Medicaid are children, dependent on parents to take them to appointments, buy the prescribed medication, etc. If their parents fail to uphold the contract, should the children be punished?
This is a very interesting article. Before rushing to judgment that Medicaid patients should “earn their taxpayer dollars”, I’d suggest clicking on the link and reading it.
Anonymous
“Moreover it is true that the poorer you are, the more complicated your life is likely to be–making compliance that much more difficult. If you’re poor, you can’t afford to hire someone to care for your children while you go to a clinic and wait two hours to see a doctor; you have one family car, your spouse needs it to go to work, and public transportation where you live is sketchy; you can’t easily afford the groceries you would need to buy to stay on a low-carb, high-protein diet; you can’t afford membership in a gym . . .”
Balderdash. How many of these folks have cell phones/cable tv, buy cigarettes/lottery tickets/alcohol, have children they cannot afford, and are morbidly obese by a diet of junk food and lack of exercise. It is largely a matter of culture and poor personal decision making. Those who try find ways to improve their lot in life. Other than minors, the mentally ill, or those with true disability, society cannot coddle those who do not exercise personal responsibility at the expense of the working taxpayer.
Anonymous
I agree. Some of us who went on to become health professionals were raised in these exact circumstances, some of us in West Virginia. There is no greater motivator than fear and a fire under your fanny. How about tying welfare payments to NOT having children. Otherwise, get a job and be responsible. Charity is fine, education is paramount, taxpayer givaways with nothing expected in return is theft. What separates man and beast anyway? One thing is the ability to reason. Stop treating the able-bodied of sound mind like pets.
Anonymous
Personal responsibility is great, but the devil is in the details.
Would such a contract include all recommended preventive measures or only treatment? Will it only include items that have been proven to be cost-effective (or affect public health like vaccinations or TB treatment) or will it include items that are not even cost effective from purely $$$ point of view?
Also, the ability to refuse treatment is part of our rights. So is telling people: you have to follow this course of treatment or you will not get any treatment at all even constitutional? It sounds more like blackmail. What do lawyers think of this contract? Any ACLU lawuits coming?
The cost to society argument really only applies to very few things that are cost effective. If someone who refuses to take medication dies sooner, does this someone saves medicare money or uses more money? If some recommended test or treatment requires treating or testing a hundred or a thousand people to save money for less treatment on one (and the insurance companies who know it only agreed to pay for it after the government forced them), is saving money argument even applicable? Also, people who loose medicaid may go to ERs. Will that result in savings?
What about public health? What if someone looses medicaid and then cannot get treatment for TB? If I sit next to this person and get infected can I sue West Virginia?
Anonymous
Answer: Give ‘em a BCG at the time their Medicaid is revoked.
Anonymous
How protective is BCG? Even if it is, what makes you think everyone will comply?
Besides, uninsured would just go to the ER when they get really sick. This will be like taking money from one pocket instead of the other.
The most cost effective measure is making everyone stop smoking (hopefully including my employed and insured neighbors whom I really like when they don’t smoke under my window). Maybe loosing weight but it doesn’t come close. Everything else pales in comparison. Any guesses on how many will stop smoking because of this?
Before you count your savings from this program, you also need to subtract all the money spent on bureacracy to watch over everyone. Oh wait, this may mean more people employed. Maybe that’s the idea. Full employment. There is an advantage to this program after all.
Anonymous
Responsibility ? Tell teenagers that if they have kids, they have to take care of them. The state should not be their missing husband.

The NEJM takes a soft view of the personal responsibility contract

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