Integrated care cannot change how we behave

I am a patient. Yes, and a physician; a brother, father, husband, grandfather, uncle, friend, neighbor, taxpayer and concerned citizen. What healthcare reform means to you means the same to me, or more. Maybe because as a physician I focus on it a little more than the average person, I have an additional responsibility to share my perspectives? Maybe a little knowledge is a dangerous thing, as the saying goes.

I am surrounded by very bright people every day: doctors, businesspeople, administrators. All have good hearts; all want to do the right thing for patients, but all can’t be correct.

The struggle today is how do we provide healthcare to all in a value-focused manner? It is easy to agree that quality must be the primary driver. Physicians and healthcare institutions are accountable for this and oversight is written into the regulations. Got it; check.

What I wanted to opine on, need to opine on, is the third leg of the stool, which, if missing, will lead to failure. Yes, you guessed it—that would be me and you—the patient.

When my father came to this country from Mussolini’s Italy, he was fascinated that Americans were free to choose, even if they chose poorly. Not so in Italy of his time; if you were unfortunate enough to choose poorly in Italy of the 1930, you generally never got another chance—fini! He would famously joke that “In American you have the right to be stupid, and most people exercise that right!”

I agree, and so do you—admit it. What you did as a teenager you would never do when you were a young parent or later as a grandparent; see where I am going?

I rounded this weekend and easily 50% of the patients we saw made choices, poor ones, that impacted their lives as well as the healthcare system. Most were not focused on healthcare change (if you know what I mean). They had, let’s say, shorter-term goals.

So where am I going? My conflict is that as a physician I want us all to make the right choices. Yes, education, information access will help. But as a patient I want choice, the freedom to choose, even if I am incorrect. Why? Because that is the essence of this country, why my father came here.

The “quick fix” is getting the doctors and health institutions on board; that’s the easy part. Changing patient behavior will take generations. But we are told that change has to happen more quickly; political solution? Legislate behavior? It is starting. Legislation as to the size of sugared drinks recently floated as an idea in New York is surely the tip of the iceberg; there are many hungry bureaucrats that are sure they know what is best for you, for us. Is “free” healthcare the way to change patient behavior, to make us accountable for our own actions? History has clearly shown us the answer is a resounding no.

What will be done if we, patients, do not adhere to the regulations? There are already proposed fines if you choose to not be insured; it wouldn’t be a stretch to extend that penalty to behaviors deemed to be unhealthy.

So here we are. What do I believe? I believe that integrated care is the right thing to do—hospitals and doctors will work out the details. But when it comes to us, the patient, I am concerned. Only personal responsibility and accountability can save us from ourselves. This cannot be legislated; it is what we should have learned as children. Let commercial insurance products be priced based on patient risk, just like home, car and life insurance. Let’s get back to “insurance” protection against catastrophic care needs, not for Band-Aids and everyday needs.

Does your auto insurance pay for oil changes? Medicare could, to some extent, mimic this and yes, incrementally increase participation age commensurate to life expectance indexed to when the legislation was effected. Safety-net programs, State Children’s Health Insurance Program and Medicaid need to be seriously cleaned up and funded for those individuals who may not change behavior no matter what payment system is in place. And we need to be accountable in a society that rarely holds anyone accountable anymore.

Robert Provenzano is a nephrologist and Vice President of Medical Affairs, DaVita Inc. He blogs at the ACO Blog.

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  • Steven Reznick

    It needs to start with improved education of children starting in elementary school. Basics like nutritious shopping and food preparation, the importance of going for benchmark growth checkups, the benefits of an active and fit lifestyle and the dangers of tobacco, drug abuse and alcohol abuse need to be taught in the schools again. Its only through education and reinforcement of positive lifestyle behavior that we will get individuals to take responsibility for the important things they can control

  • Margalit Gur-Arie

    So we should preserve the right to be stupid for the wealthy, while the
    poor should learn to live in Mussolini’s system, which is by and large
    what we’re doing anyway.

  • Laura Billingsley

    Thank you for a common sense message. I agree the missing piece is patient responsibility and accountability – the very things that cannot be legislated. Free will is our inalienable right so we cannot dictate that people refrain from activities and lifestyles that damage their health. Nor should our government dictate that our healthcare system be penalized for recurring acute care readmissions for people who, by their life choices, damage their health.

  • Dorothygreen

    We don’t have generations to wait to “fix” what is wrong with our health and health care. The costs are already killing our budget, and setting up for a shorter life of the next generation.
    ACA is a start and could, with cooperation from the medical community (stop the over utilization, fraud and abuse, embrace a National or a Statewide EMS and all other aspects of the ACA), Big Pharma (stop putting the burden of drug development used for chronic diseases on the taxpayers – our drug bill is double the next country just like our overall health care) Big insurance, (must stop market driven health insurance for basic care- people are not analogous to cars). No health care system in the world is “perfect” but of all the rich countries the US is no where near the top in outcome indicators except for breast and prostate cancer and then by only a little (2011 OECD report).
    You say “Only personal responsibility and accountability can save us from ourselves”. This is true, but what about those who will not take responsibiltity? What about those who snub those how try to stay fit and say things like “you gotta die of something”. I will not stop eating my 3 cheap burgers and fries” a day? We have millions of people in Medicare and Medicaid, and some who will remain uninsured so addressing this issue in insurance is only for some. So how does a country “get to” the entire population?
    The US has done very well with decreasing the “smoking” epidemic. To decrease the “E.A.T.” (excess adipose tissue) phenomenon, will take much, much more. It is our eating culture that must be changed – from farm to fork. The only way to make this happen is to take action similar to the tobacco model because it has worked). It must impact where farm subsidies are used, to decrease TV ads of unhealthy eating, a strong message of RISK on processed food packages and of course a tax. I would call it a RISK tax. Why must we always go to income tax to cover health care costs? A RISK tax would be on processed sugars, processed fats and sodium as they have been proven to be the addictive substances that cause us to overeat and are the leading RISK factors of chronic preventable diseases. This revenue would go back into pubic health education on nutrition and help to those who are addicted to these substances (it is not the physician’s responsibility to educate patients in nutrition – everyone needs this information from birth. It MUST become part of our culture.

  • Valarie Murphy

    This is not rocket science. It would reduce prices and increase
    quality. Free markets tend to do that.

    1) Allow health insurance
    purchase from any state-approved company in the U.S. Equal tax treatment for all.

    2) Require transparent and
    nondiscriminatory pricing. Why
    shouldn’t everyone pay the same price for the same service from the same
    provider? Transparent and
    nondiscriminatory pricing puts insurers out of expensive first-dollar claims
    processing. If the deductible is not
    met, insurance (and government) stays totally out of your business.

    3) End secret insurance
    company/provider contracts that serve only to corner the market and obfuscate
    pricing. Where are antitrust laws when
    we need them?

    4) Provide for coverage for all
    through a reinsurance system that spreads risk.

    5) Options, not mandates.

    6) 12-month waiting period
    before insurance kicks in or before new options are available.

    7) Everyone has a
    high-deductible policy and an HSA, including those on Medicare. Medicaid can be handled in much the same

    8) People begin building an HSA
    by at least age 30 and Medicare is slowly phased out.

    9) Health insurance becomes 10%
    higher per year for every year after age 30 that it isn’t purchased. Seniors know they have to buy into Medicare
    by age 65 or it is 10% higher for each year thereafter. Thirty-year-olds can learn the same.

    10) Provide an incentive for
    careful spending from an HSA.

  • Inspire Chiropractic

    I don’t disagree with the intention of the article, but to lay this on the patient without taking a hard look at the permissiveness of the government in allowing the mixed messages they do is disingenuous. Eat better? Ok, how about changing the regulations behind advertising of fast food and other products that we know are affecting health in a negative way. Stop marketing sugar and unhealthy food to kids. Force schools and fast food restaurants to provide healthier food. Take away the corn and soy subsidies that make it cheaper for companies to produce low quality cheap food. Make stricter standards for advertising so that companies can’t falsely proclaim that their product is part of a well balanced diet when in reality its not. It just seems like for all of the effort being put into telling people to change their behaviors, not enough is being done to protect them from themselves in the way we have done with tobacco. There’s a lot of mixed messages and its a big reason why the public is confused and misinformed about what they should be doing.

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