Friday, April 17, 2009

Helping Patients Take Charge of Their Health (Part I)

Making Money a Motivating Factor

Americans spend hundreds of billions of dollars a year treating preventable illnesses. The sums of money spent on these illnesses are even more breathtaking when we realize that it is money that does not have to be spent. For example, in 2007 Americans spent $116 billion on medical expenses related to diabetes, according to the American Diabetes Association. The average diabetic spends $6649 a year just on diabetes. The numbers force us to ask: what must we do to prevent this preventable disease?

In this post, I'll use diabetes as a case study for all other preventable diseases. When speaking of preventable diabetes, I am referring to most Type II diabetes mellitus. Although it has genetic components, the onset of this type of diabetes is generally brought on by an unhealthy lifestyle. The landmark Diabetes Prevention Program study showed that type II diabetes could be prevented or delayed by diet and exercise in 58% of cases (compared to placebo). This effect was seen in all individuals regardless of race, sex and class. In short, type II diabetes can be prevented in most patients by diet and exercise.

The American physician struggles to help patients prevent and treat diabetes. The first-line treatment for diabetes is exercise and diet. Doctors tell this to their patients. Yet deep in his or her heart, the doctor knows that the patient probably will not change their lifestyle. They will return to the next visit with the same blood glucose level and without having exercised or dieted. The doctor will be left with only pharmacological and surgical means for treating a disease that the patient should be able to treat on his or her own. So instead of pounds being dropped, medications are prescribed and gastric bypasses are performed.

One reason that patients may be unmotivated is that we have attempted to remove money as a motivating factor in our health care system. We want everyone to get the care they need, regardless of their ability to pay. We try to create a health care system where money is not the object, but in so doing we may be harming our patients.

Consider the Medicaid patient who knows that diabetes is shortening their life and ruining their lifestyle, but is unmotivated to personally address their diabetes. Free visits to the clinic and daily insulin shots are much easier than a massive overhaul of diet and daily exercise. Instead of getting healthy, the disease progresses and the taxpayer shoulders the bills. Patients with comprehensive health insurance may likewise put off taking care of their health. If they stay on their current policy, their premiums will not radically change and the disease may not hit their pocketbooks too hard.

But imagine the patient that is directly confronted with the cost of their poor health in every visit and with every prescription. In every medical bill these patients have a concrete, immediate reason to take diabetes into their own hands. As stated above, diabetes will cost the average patient $6649 a year on top of their other medical expenses. These self-paying patients are immediately aware of this cost and will look for ways to reduce it.

The thoughtful doctor could talk finances with a self-paying patient and encourage health lifestyle with a conversation something like this:

"Bob, you know that I'm concerned about your weight, your blood pressure, and your glucose levels. Unless we get these under control, it's not a question of if you'll get diabetes, but when you'll get diabetes. But if we can get your weight and these other things under control, you're going to be healthy for years.

Now I know that work and family keep you busy and you don't feel you have time to take care of yourself. But think of it this way. If you get diabetes, it is going to cost you about $7000 a year to treat. Now that's a lot of money. If we can start preventing the disease now, that's money in your pocket. If we work out the numbers, taking a 30-minute daily walk may save you $20 a day. Earning forty bucks an hour to take care of yourself- that's not bad."

I don't know about you, but if I were Bob, I might start jogging. I could think of a lot better uses for $7000 a year than insulin shots. Seven thousand dollars a year- now that's motivation.

Some might say that having patients to pay for their own care is cruel or unfair. But look at the scenario above- paying his own bill just made Bob healthier. We must pay for our own care. Any other system cannot last- such socialism truly is only a contrivance. When the reality of our personal responsibility for our health is realized (perhaps accompanied with some lessons from the school of hard knocks), we will see the epidemic of preventable disease disappear along with its accompanying epidemic of apathy.

Preventable diseases are prevented when patients are made responsible for their own health. As doctors, we're really missing out on one of our best tools to help patients truly be healthy if we don't make money a motivating factor. As Americans and as children of God, we're not meant to be coddled. When given the responsibility, we take care of ourselves. When entrusted to the system, we all get gastric bypasses.

Rusty Scalpel


Kristy Lynne said...

I come up with the problem of students continual unwillingness to prevent problems. This is a very clever way to motivate them to start to take health seriously. Thanks.

Bart Worthington said...

While I generally agree with what has been posted, I do not think that the apathy and failure to take responsibility for one's health begins and ends in the pocketbook. If money does in fact motivate and bring about the long-lasting change of which you speak, then why does it NOT motivate more people to stop smoking or any of the other social ills that vex our society (e.g., the billion dollar sex industry)? Similar to these examples, I would suggest that treating preventable illnesses, such as diabetes, is much more complex than dollar signs. There is a psychological and emotional component that may undermine any monetary motivation that the physician may generate.

Rusty Scalpel said...


I definitely agree with you that not all people are going to be motivated to improve health by the dollar signs. For the same reasons, the cash-only practice is going to appeal to a limited demographic of patients. It is going to attract the patients who want to manage their own health care and control the financing of that health care instead of hiring someone else to do it for them (insurance companies). To these people, who have already taken personal responsibility for their own health, the dollar signs will probably make be pretty important.

It concerns me that as a nation we are taking such a collectivist approach to the problem of health care expenditures. It seems to me a personal responsibility for health care and its costs is going to be much more effective in cutting waste and focusing on true needs. Personal responsibility is the key. There is no substitute for it.

You are definitely right that there is a whole bundle of issues involved with preventable illnesses. Using money as a motivating factor is just a tool and not the final solution. Each patient, with the help of their physician needs to work out their issues and overcome them. The reality of payment may provide the impetus to take responsibility to face those issues instead of putting them off.