Monday, August 18, 2014

You're Supposed To!

There's been much going on that I wanted to comment on, but one Linkedin reader of Paying for Health Care with House Money suggested that I write about patient responsibility, so I want to start there.

I regularly bring up examples where the various parties involved in the business of our health care system are not performing as well as they should, and how we're paying for that with higher costs and lower quality.  Most of the time I also point out that we, as patients and as consumers, bear ultimate responsibility for allowing these parties to act as they do (e.g., waits for physician appointments).

Complaining about our health care system is a lot like complaining about Congress.   In both cases, the people and institutions we complain about work for us -- or, at least, we end up paying their salaries -- and they're only doing what we allow.  We allow it for lots of reasons -- for example, the difficulty in picturing how to change the status quo, and the big money spent lobbying to keep that status quo -- but it's hard to argue that we're powerless to make things change.

We have to take more responsibility for our own health, and our health care system.

Consider this: what if your doctor told you there was something you could do that would lead you to living three years longer, on average, if you did it as little as five minutes a day?  That's all: five minutes a day. That's like popping a pill or applying the kind of miracle cream you see advertised on late night TV.  Sounds like a no-brainer, doesn't it?

Well, it turns out that researchers have identified that something: running.  Amazing as it seems, their research suggests that running even as little as five minutes a day has that kind of effect.

Sounds almost too good to be true.

Or take an example with breast cancer.  Breast cancer is a source of much anxiety for many women; indeed, a recent study found that many women fear it so much that they actually get unnecessary prophylactic mastectomies.  Yet, according to another new study, as little as four hours a week of moderate exercise could cut the risk of breast cancer for post-menopausal women by ten percent.  Other estimates put the potential reduction from exercise as high as thirty to forty percent.  Hmm, mastectomy or walking -- again, it seems like a no-brainer.

I guess neither is actually a no-brainer: the CDC says 80% of Americans don't get enough exercise.

Obesity has become a huge issue, especially over the past twenty years.  New research by Ladabaum, et. alia puts most of the blame for the obesity epidemic on reduced exercise rather than overeating.  Of course, we don't think we're overweight.  A new Gallop poll found that 55% of Americans don't think they are overweight, even though actual data finds two-thirds of Americans actually are.  Then, again, two-thirds of Americans think they're doing pretty good with their health, although they don't think other people are doing so well with their health -- sort of like how we think more highly of our own Congressman than Congress in general.

Obesity is closely linked to a similar increase in Type 2 diabetes.  The CDC now estimates that 40% of Americans will develop diabetes over their lifetime, double the rate from thirty years ago.  Diabetes is not the only health issue blamed on increased obesity; another new study claims that obesity increases the odds of getting ten common cancers, including cancers of the uterus, gall bladder, and kidney.  Add heart disease and other conditions often associated with obesity and it's a grim picture.

We can blame the problem on lots of things.  The food industry, and how it has managed to pack more high-calorie food into our diets (see Salt Sugar Fat by Michael Moss), or not having enough time (although, according to BLS, most of us have plenty of spare time; we just tend to use it watching TV).  Some probably blame the pharmaceutical industry for not coming up with better prescription drugs to melt off the fat for us.

I think we should start closer to home.

The point of  Paying for Health Care with House Money was that we should think more clearly about what kinds of health care expenses we want to subsidize for what kind of situations for which people.  E.g., I'm in for helping low-income people get the care they need and for helping most people with catastrophic expenses, but I'm less eager to pay for predictable expenses that most people should be able to budget and pay for themselves.

The most difficult situation is in the area of chronic illnesses, where the expenses are not only recurring but also often tend to get higher over time.  With the CDC telling us that half of Americans have at least one chronic condition, deciding who should pay for that care becomes a crucial policy issue.

In that post I compared how we finance new cars (ourselves) versus how we finance health care (other people via health coverage).  To extend that comparison, I would not be very happy to find that my auto insurance subsidizes the accidents of someone with a history of reckless driving or DUIs.  I think they should have coverage -- to protect their victims -- but there's only so far I want to go to subsidize their bad behavior.

I don't ever want to go back to the days when people with chronic conditions can't get health insurance, or pay exorbitant premiums simply because they have a chronic condition, but I do have a similar issue with my premiums subsidizing the medical expenses of people who aren't at least trying to manage their health.

Addressing that problem is, essentially, the goal of wellness programs.  Buck Consultants just reported that 78% of employers worldwide are trying to create a culture of health, with 52% tying employee health contributions to participation in wellness programs.  ACA increased the financial rewards firms can offer for such participation, and the National Business Group on Health reports that 53% of U.S. large employers will be adding or increasing such incentives.

In an era of wearables, it's certainly easy to see an employer or health plan requiring employees/members to wear a tracking device that will monitor their exercise, eating, etc.  It's already happening.  Proponents compare these efforts to similar programs in auto insurance, such as Progressive's Snapshot program that electronically tracks driving habits.

Just because it's possible to do, though, doesn't make it a good idea.  I'm not keen on my employer, my spouse's employer, or my health plan knowing quite so much about my life.  Wellness programs strike me much the same as disease management and increased cost/quality transparency -- well-intended ideas that but still don't have much clear-cut, objective evidence that they work.

I'm not convinced that wellness programs are the solution.  For one thing, most Americans -- both the general public and those getting coverage from their employer -- don't think it is appropriate to tie their premiums to participation in or outcomes of such programs, according to a Kaiser Family Foundation survey.  For another thing, the actual impact of such programs is unclear, especially on costs, according to Rand and others.

Maybe a potential compromise is voluntary tracking, with reporting limited to some very summary reporting (yes/no?) to health plans for the purposes of determining level of effort.  E.g., I might not want Jawbone giving my health plan all my data, but I might not mind them reporting I've met my goals.

We're already seeing health plans being charged with discriminating against people with chronic conditions, not via the now-outlawed practices of medical underwriting or preexisting conditions exclusions but by limiting which providers or prescription drugs they allow coverage (or full coverage) for.  The line between discrimination and incentives to act responsibility is not as clean as we might like, and we have to be careful not to swing the pendulum too far.  There are tricky questions about the effect of genes, poverty, gender, and race on who gets which chronic conditions and how severely.  We don't want to penalize people simply for having a condition or for costing more, but we should expect them to be trying to manage their health.

We have to take all these factors into account in determining what responsibility people should have for their health -- but we shouldn't let them stop us from trying.

Whenever I get discouraged about our declining health indicators and what they bode for the future, I think of smoking.  Yes, it is dismaying that, despite the widespread and explicit warnings of the health risks, the various public/private prohibitions, and the heavy taxes, we still have about 20% of adult Americans smoking.  However, what is encouraging is that the 20% is half of what it was some 50 years ago.  Progress can be made -- it just may take a long time, require much effort, and still not eradicate the behavior.

The title for the piece comes from a hilarious yet typically insightful comedy bit by Chris Rock (I'd normally link to it, but I thought the language may be too explicit for sensitive readers - check it out on YouTube if interested).  He criticizes people who take credit for things like taking care of their kids or staying out of jail, noting that "you're supposed to!"  Well, when it comes to taking responsibility for our own health -- you're supposed to!

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