Unintended Consequences

Joe is a guy that never really cared about his health. He is overweight, according to any objective standard, and always attributes this to “bigger muscles” (it isn’t). He dutifully comes in once a year, but admittedly only because of his wife’s insistence. She worries about his lack of exercise, his growing abdominal midsection (“muscle”) and the fact that all he does on weekends is sleep. There is a strong history of heart disease in his family—his father was only a few years older than Joe, when he collapsed at the dinner table and died. Joe always turns down repeated offers for the flu vaccine with the response, “I never get sick,” and shows little interest in his lab results, even though his blood sugar and office blood pressure are always high (“I get nervous at the doctor’s office”) and his “bad” cholesterol has never been even close to normal.

At his last appointment, Joe forcefully slapped a stack of papers on the exam table and seemed agitated. “We had a health screening at work last week,” he explained, “My numbers are out of whack and I need your help.” I wasn’t surprised at the numbers, but his seemingly new interest in his own health had me intrigued until he explained. “I get $50.00 off my health premiums, if my blood pressures are normal and $150.00 for having a physical,” he said. Mystery solved—money supplied by his employer was motivating Joe to get healthy.

Not that I’m complaining. Anything that motivates patients to make a positive change and take charge of their health is always welcome. I’m always hoping it’s not a health scare that brings that change. What worries me is the future of healthcare for guys like Joe. Outside business forces now pressure primary care physicians to show quality outcomes. A movement has been afoot to ‘certify’ those physicians that demonstrate quality care: Making sure the patient’s average blood sugar, blood pressure and cholesterol levels are normal and that he receives all the preventive care recommended by health experts. This certification may ultimately affect the physician’s reimbursement and potentially even future employment. But what happens when the patient is simply not interested? Or when the patient shows interest, but can’t afford the many medications required for his many health issues?

Joe becomes a liability. Physicians may feel that guys like Joe need to find a different “medical home.” Joe becomes high risk and physicians will be unwilling to negatively affect their personal certification profiles by having him in their practice. And since all health data is now available electronically, other physicians will turn down his requests to join their practice. Clearly, this is not what the health system intended, as it tries to radically engineer how the provision of care to patients. It becomes an unintended consequence.

Even patients who try their best, but unfortunately stay in poor health, can get caught in this quagmire. Before we embark on “treatment by numbers,” we need to understand that providing adequate health care has always been a partnership between the physician, patient and insurers. We all need to do our best to address what is under our control, while recognizing that optimal health care will never be perfect. We should never let practice by numbers affect access to heath care to those that need it most. After all, that access is the result that physicians intended when they took their sacred oath and that’s the only certification we should depend on.

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9 replies »

  1. rbar – I think your idea / suggestion is on the right track. However, benefits experts tell me that HIPPA severely limits how much self-funded plans can do in this area. For individuals and small groups with full risk insurance plans, the underwriting mechanism already effectively charges higher risk patients higher premiums. Community rated plans, which currently exist in five states, do not.

    My employer, which self-funds its health insurance, recently introduced an incentive that offers our non-union employees and their spouses a $250 payment if we certify that, by a certain date, we (1) got a physical, (2) had blood work done that includes a complete cholesterol analysis, and (3) certify that we don’t smoke, are enrolled in a smoking cessation program, or complete a health risk assessment questionnaire.

  2. The logical solution is to do exactly what is done in the beginning of the little anecdote – have the patients have skin in the game, with short term motivation (money) helping long term outcome (health).

    Increase premiums for unhealthy lifestyles by an approximation of the incurring HC costs. The biggest factor would be obesity, followed by HTN (if the PCP doesn’t get to normotension, he/she may involve an internist/nephrologist) and smoking. Unmodifiable risk factors are not taken into account. This is logical (it’s akin to charging drivers who get tickets more for insurance) and will safe years of healthy lifes.

  3. So…nothing should be measured, there should be no consequences, and we should continue to pay doctors based on number of visits rather than (1) adhering to practice standards they themselves set or (2) moving the needle on outcomes. (not perfection, mind you, just improvement)

    We should rely on your adherence to the Hippocratic Oath, which, if taken in strict construction would pretty much preclude prescribing any modern prescription medication, because everyone of them has side effects that DO harm.

    And that helps reduce our nation’s medical bill how? Improves quality how?
    What about the IOM’s one million lives program to reduce medical errors – are you in favor of that? Do medical professionals bear any burden whatsoever in your scenario?

    The patient who doesn’t comply pays with his life. And the doctor who overtreats still gets paid. Sorry, not buying it.

  4. I think this is the American solution, blame your provider, and now the government is doing it. It couldn’t possibly be that the patients do not want to take charge of their lives. They want a pill that will solve all their problems. If money is the source of motivation then why not charge higher premiums for those that are not taking care of themselves. Now don’t get me wrong, some things are genetic like HTN and DM, but most can be controlled or prevented by a healthy diet and exercise. I think that PCPs are going to be pushed out of practice because of this new reimbursement plan and then our ERs will be filled with people that could have seen a PCP for their problem. And then there goes our health care costs sky-rocketing again!

  5. I give one solution, the implementation of “free health care” system is expected to make people easily get health care. health funds taken from the expense of the state.

  6. Not to worry, there are always more patients and not enough PCPs. The system will quickly be overwhelmed with lots of data and less and less information.
    Or you can always default to the tried and true excuse from hospitals, “our patients are sicker.”

  7. I can suggest two strategies that might be helpful. First, higher payments to physicians who treat patients with higher risk scores should, hopefully, adequately compensate doctors for the higher cost of treating sicker patients. Second, if doctors can provide reasonable documentation that the patient is non-compliant with respect to diet, exercise, smoking, and / or taking prescribed medication, then that patient should be excluded from the physician’s panel for the purpose of assessing care quality. Exclusions for various reasons, including non-compliance, are allowed in the UK system.