My first reaction to a picture of a Medicaid recipient with one leg lost to diabetes smoking was outrage. After reflecting, I’m still outraged.
Behavior drives a significant chunk of health care costs. People with multiple modifiable risk factors are more than twice as costly to insure than folks without those factors.
So what do we do about it?
West Virginia is adopting a new policy for Medicaid beneficiaries, enriching benefits for those who commit to healthy behaviors, and providing the bare minimum for those who won’t. The plan will protect children of beneficiaries who won’t commit to the contract, but provide clear incentives for all to participate. And that’s long overdue.
Critics complain that this providing different benefits for individuals based on their behaviors is somehow unfair, or unethical, or not likely to reduce costs over the short term.
I don’t see it that way.
Medicaid recipients have a responsibility to taxpayers to ensure their funds are spent wisely. As long as we are considering “fairness”, I believe it is unfair to ask taxpayers to pony up tens of thousands of dollars to pay for an overweight smoker’s cardiac care.
Especially when those dollars could have gone to provide more pre-natal care, preventive care, immunizations, cancer screenings, and lower cost drugs.
Critics miss the essence of the problem – we have a limited pool of dollars to spend, and a limited amount of patience for those who want to spend dollars inappropriately. Personal responsibility for health behaviors should be a pre-requisite for Medicaid coverage.
And no, this does not mean I’m suddenly a big fan of consumer-directed health plans.
See the two most recent threads at http://www.medrants.com for an interesting discussion on this subject. While the site owner and most of the contributors are docs, some (including me) are not.
Another relevant thread is the one discussing German plan of penalizing cancer patients who failed to screen in bioethics discussion forum:
http://bioethicsdiscussion.blogspot.com/2006/11/you-failed-to-screen-for-cancer-you.html#comments
Given your support of West Virginia plan, I am sure you’d support the German plan as well. After all West Virginia plan includes routine checkups (I seem to be unable to find the USPSTF recommendation for those, I am sure you can provide it, all I can find is an article about how many non-recommended tests are done during these visits), screenings, and just plain “following doctor’s advice”. I fail to see “informed consent” anywhere in West Virginia plan, NY Times must’ve omitted it accidentally.
Joe,
I’d agree with you but…
The but part is a wide array of what some might consider excuses for behavior. I’d consider them part of the problem that the medicaid dollars may need to be spent on…
I’ll quote from the article: “If you think about the people least able to do simple things like keep appointments and take all their medications,” she said, “people with mental health and substance abuse problems are right up there.”
Now I don’t have any statistics. What I do have is experience working in both urban city and sub-urban hospital emergency rooms and the quote above – appears to be accurate to me.
Perhaps all schizophrenics ought to be excluded from the medicaid plan? Maybe every person who has borderline personality disorder, every alcoholic, every major depressive – etc…
After all – they’re all “not responsible” aren’t they?
One thing that I mentioned in other discussion on this subject is that there is a clearly irresponsible behavior (e.g. overuse of the ER) and there is a legitimate right of an individual to make informed choices about screening, tests or treatment. Any intervention, including screenings has risks – false positive evaluations that can involve invasive tests with their own risks, overdiagnosis are the obvious examples. They are also not cost-saving — just do math on mammograms, for example.
As far as “routine checkups” – not only there is no evidence of their usefulness, but in the current climate doctors often order a lot of unnecessary and non-recommended tests. There was a study about it. Each of these tests has a potential of harm, not to mention increased cost. West Virginia authority has no business asking people to do them.
It is morally and maybe even legally wrong to blackmail people into signing away their right to refuse a medical intervention (unless there are clear public health issues like in infectious deseases). This is what West Virginia plan seems to do, at least based on the information in the article.
It’s Wondered
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Abdrew William
West Virginia Alcohol Addiction Treatment