Health Care Reform and The Elephant in the Room
By Cary Gutbezahl, MD
When an organization has a performance problem, managers seek information to identify and assess the causes of the performance failure. Similarly, an analysis of a social problem should require policy analysts to identify and assess all significant contributors to the social problem. Our public discussion on health care reform has failed to meet this expectation.
The debate about health care reform has focused on several significant issues, such as getting financial coverage for the uninsured’s medical needs, building incentives for hospitals and physicians to provide better care, and removing inefficiencies from the fragmented delivery system.
However, there is an elephant in the room that is not being discussed – personal responsibility for health. For years, studies have shown that up to 70% of disease is influenced by personal (not provider) behaviors. As such an important aspect of health care costs, this issue cannot be ignored.
Why is personal responsibility being ignored? As health care providers know, changing patient behaviors is extremely difficult. The first step is for the patient to want to make the changes and not every patient wants to change their behavior to get better. Patients who struggle with emphysema still smoke. Patients with diabetes eat cakes and candies. They choose to continue the behaviors that got them sick despite the counsel of their physicians and other health care providers. From a psychological perspective, there are many reasons why this happens. Providing better access to care is not going to change this.
Talking about the need for personal behavior change is not politically popular. When he was president, Jimmy Carter advised Americans to reduce energy consumption. This unpopular message contributed to his failed reelection bid. Admonishing people is not an effective way to build a coalition of support. Yet, the failure of individuals to adopt pro-health behaviors will cause accidents and disease that will have to be treated, at great expense, after disease or injury occurs.
The elephant has to be addressed. Can we effectively control health care costs without including individual incentives? Assigning responsibility for patient behaviors to health care providers is easier from a political standpoint. But it fails to address a known driver of health care costs. It also has the unintended potential for creating discrimination against people who struggle to control their behaviors. Providers may terminate care relationships with patients who fail to comply with medical advice. Similarly, physicians may screen patient to determine whether a new patient is likely to fail to comply with medical advice. Ultimately, these patients will wind up in emergency rooms and other venues that cannot turn patients away.
Policy makers have a public obligation to understand the complex dynamics of the health care system before they propose changes that may have adverse effects that are as undesirable as the problems within the current system. “First, do no harm” does not only apply to caring for individuals.
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