Personal responsibility: Penalties non-compliant patients

NY Times on West Virginia’s personal responsibility approach to Medicaid. This approach should be universal:

Ignoring doctors’ orders may now start exacting a new price among West Virginia’s Medicaid recipients. Under a reorganized schedule of aid, the state, hoping for savings over time, plans to reward “responsible” patients with significant extra benefits or “” as critics describe it “” punish those who do not join weight-loss or antismoking programs, or who miss too many appointments, by denying important services.

This guy doesn’t look too happy about it:

“I told them I eat what I want to eat and the hell with them.”
“I’ve been smoking for 50 years “” why should I stop now?” he added for good measure. “This is supposed to be a free world.”

Comments

carl
I agree that it is a free world. So they should step up and accept responsibility and not expect the rest of the world to pay for their continued poor choices in life style. One more example in my mind of the “I deserve……” mentality that too many people seem to have now days.
Anonymous
Free World.
“Free” as in: gimme anything I want for nothing.
or
“Free” as in: I want to do as I please AND I will accept the consequences of my actions?
Diora
Carl, you have proof that every single measure they describe is cost-saving? Because the devil is always in the details, if you don’t mind my using a cliche.
Look at some of plan’s details from the article:
In a pilot phase starting in three rural counties over the next few months, many West Virginia Medicaid patients will be asked to sign a pledge “to do my best to stay healthy,” to attend “health improvement programs as directed,” to have routine checkups and screenings …
Cost of “health improvement program ” vs money saved would depend on how many people need to attend these programs and how effective these programs are, also how many people need to attend for one person to benefit. Are they also going to provide babysitters to single mothers to attend such a programs, by the way?
What about “routine checkups”? As many doctors here, including Kevin posted zillion times, these are pretty useless. Yet when you come in for a routine checkup, doctors feel obliged to order a bunch of defensive tests. Kevin recently posted a surway that showed how many physicals included tests that are not recommended. Each and every one of these tests can lead to false positives that can lead to more expensive tests. So how can a measure that is not shown to be useful save money? And why we are at it, is it evidence-based?
As far as screenings are concerned, as I posted German plan discussion their cost-saving potential is far from clear given the high number of people that need to be screened for one person to benefit, large number of false positives, overdiagnosis and longer periods of treatment for cases that are not helped by screening. Also, the tests are not harmless. So according to you people have to submit to potentially invasive tests that can actually harm them or be penalized? “You have the right to refuse medical intervention, but if ou exercise your right you’ll be penalized”. What next? Penalizing every single person with high cholesterol who doesn’t take statins or every woman with osteopenia who doesn’t take Fosamax even if it is to reduce risk by a couple of percentage points? Penalize every person who doesn’t follow doctors’ advice for a test or a medicine even if a test is clearly defensive and a medicine is overprescribed?
Now, some things liked missed appointments make sense, but there should be some provisions for good reasons. An old woman with dementia who forgot her appointment is hardly at fault. Doctor is not at fault easer, so why not simply have the medicaid fine the patient for the cost of missed appointments and reimburse the doctors?
By the way, here is an interesting article from the mythbusters about whether these prevention measures are really so cost saving. While it is hardly a scientific article, it shows that calculating cost-savings is more complex than one would think.
Diora
To anon at 11:06. No, the free world is when people can be forced to submit their bodies to potentially harmful interventions or be penalized.
Anonymous
Thanks for the witty rejoinder Diora
Gasman
This sounds like one social experiment that docs ought to stay out of.
We do have a checkered past for reccomendations. For a century pediatricians advised that children be place prone for sleep. Now real evidence shows this to be quite wrong; and there are conservatively a hundred thousand dead babies (quite likely several times more) that resulted from this bad advise.
The social experiments can try to save people from smoking which is indisputedly bad, but needs to drop the individual patient attacks here.
Social measures should focus on things that make the society stronger through better health in ways that the individual is little empowered to accomplish on their own. This is through the provision of safe drinking water (last century stuff that we take for granted now) protection of the food supply from harmful contaminants or ingredients (synthetic trans fats vs naturally occuring fats) and making available vaccinations and basic public health measures.
Beyond the basics, let people figure it out (and suffer the consequences) on their own. In the end, even the smoker will regret smoking more than I regret having paid taxes to treat smokers.
Rich, MD
Hmmm….
1. There is a move from government and non-government payors to incentivize doctors to provide “quality” care by applying broadly defined guidelines that may or may not apply to any given patient, (no matter how the physician actually feels about it, either, they don’t measure that or exclude patients for whom there is a contraindication or who has had an adverse reaction in the past, etc.)
2. The doctor will be penalized if the patients don’t agree to or comply with the guidelines
3. Patients should not be penalized if they fail to follow the guidelines
It seems to me that this will lead to widespread cherry-picking of favorable patients
Anonymous
Rich,
just because penalizing doctors for patient’s choice is a bad idea, doesn’t mean removing the choice from a patient would be a solution.
My main problem with P4P is that it completely ignores the principle of informed consent: the doctors are expected to convince patients to follow the guidelines by any means necessary – framing the information to make benefit appear larger, downplaying the risks, etc. -in order to get bonuses. When patients are penalized, the whole process of informing can be expressed in four words “do it or else”.
Diora
Rich, this is my main problem with both P4P and plans such as this one in Virginia — they are really two sides of the same coin: the change of “prevention” and “screening” from science into religion. Except for imposing one’s religion on other people is not exactly legal, is it? The main problem with Virginia’s plan is that it equates missed appointments and overuse of the ER with checkups, screenings and “following doctor’s advice”. It makes no distinction between serious cases of non-compliance with a healthy 30-year old’s deciding not to do annual checkups or a middle age healthy woman refusing to take a statin to reduce her risk of heart attack by a couple of percentage points.
Doctors are no longer supposed to educate patients on benefits and risks, but should just convince as many people as they can to blindly follow guidelines; patients are no longer supposed to make informed choice, but are supposed to just do what is recommended ignoring whatever reservations they may have. This is morally and ethically wrong; not being a lawyer I cannot coment on the legality of such practices’ interferance with every person’s right to refuse a medical intervention.
Just because some people want to penalize doctors for not blindly following the guidelines doesn’t mean penalizing patients is the solution. If I may use a cliche again, two wrongs don’t make a right. As gasman’s example, HRT experience and may I add neuroblastoma screening in Japan, these types of experiments have a serious potential to harm.

Personal responsibility: Penalties non-compliant patients

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