Perspective

Imposing Personal Responsibility for Health

Robert Steinbrook, M.D.

N Engl J Med 2006; 355:753-756August 24, 2006

Article

The concept of personal responsibility in health care is that if we follow healthy lifestyles (exercising, maintaining a healthy weight, and not smoking) and are good patients (keeping our appointments, heeding our physicians' advice, and using a hospital emergency department only for emergencies), we will be rewarded by feeling better and spending less money. The details of programs that emphasize personal responsibility, however, are often sketchy, and many difficult questions related to individual freedom and patients' autonomy remain unanswered. For instance, which well-meaning measures to promote responsible behavior actually make a difference, and which are primarily coercive and potentially counterproductive? Which measures may actually improve health or save money, and which may merely shift costs from government, private insurers, or employers to patients?

There are many examples of initiatives that are meant to promote personal responsibility. The World Health Organization will no longer hire persons who smoke, suck, chew, or snuff any tobacco product, although it will still recruit people “who do not have a healthy lifestyle.” In the United States, some employers target smokers, some even going so far as to fire workers who smoke when they are not at work. At some companies, health insurance may cost less for nonsmokers or for people who complete weight-loss programs, and employees may receive financial incentives to participate in health screenings, fitness programs, or tobacco-cessation programs. Wal-Mart has considered discouraging unhealthy people from applying for work by including some physical activity in all jobs. A national survey conducted in July 2006 estimated that 53 percent of Americans think it is “fair” to ask people with unhealthy lifestyles to pay higher insurance premiums and higher deductibles or copayments for their medical care than people with healthy lifestyles.1 In November 2003, the comparable figure was about 37 percent. A healthy lifestyle was defined as not smoking, frequent exercising, and weight control.

Promoting personal responsibility for health and for obtaining health care is also part of the federal government's “Roadmap to Medicaid Reform.” Under the Deficit Reduction Act of 2005, states have increased flexibility in designing and implementing their Medicaid programs, which are jointly financed with the federal government. For example, they can require cost sharing for certain medical services, such as the use of nonpreferred drugs and nonemergency care furnished in a hospital emergency department, and can participate in a demonstration program to evaluate the potential effectiveness of Medicaid-funded personal health accounts, which are similar to health savings accounts.2

The redesign of the West Virginia Medicaid program has recently become a leading but controversial example of efforts to reward personal responsibility. West Virginia has a population of 1.8 million; as compared with the United States, it has a higher percentage of residents with Medicaid coverage and near-poor or poor incomes (see graphsHealth Insurance Coverage and Income in West Virginia and the United States.). In May 2006, the federal government approved the state's plan to provide reduced basic benefits to most healthy children and adults who are eligible for Medicaid because of low income while allowing them to qualify for enhanced benefits by signing and adhering to a “Medicaid Member Agreement” (see boxWest Virginia Medicaid Member Agreement.).3 The enhanced benefits include all mandatory services as well as additional age-appropriate services that focus on wellness. Examples include diabetes care beyond basic inpatient and outpatient services, cardiac rehabilitation, tobacco-cessation programs, education in nutrition, and chemical-dependency and mental health services. Under the basic plan, prescriptions are limited to four per month; under the enhanced plan, there is no monthly limit. According to Nancy Atkins, the commissioner of the Bureau for Medical Services in the West Virginia Department of Health and Human Resources, the goals of the redesign are to streamline administration; tailor benefits to specific groups; coordinate care, especially for members with chronic conditions; and “provide members with the opportunity and incentive to maintain and improve their health.”

To remain in the enhanced plan, members must keep their medical appointments, receive screenings, take their medications, and follow health improvement plans; West Virginia will monitor “successful compliance with these four responsibilities.”3 Members whose benefits are to be reduced because they have not met these criteria will receive advance notice and have the right to appeal. Those who meet their health goals will receive “credits” that will be placed in a “Healthy Rewards Account” to be used for purchasing services that are not covered by the Medicaid plan. Although details about how these accounts will work and what services will be eligible for purchase are forthcoming, the services might include fitness-club memberships for adults or vouchers for healthful foods for children. In July 2006, transition to the new plan began in three West Virginia counties; the program will eventually include about 160,000 people — or about half the state's Medicaid beneficiaries. Beneficiaries who are 65 years of age or older or who have disabilities will retain their current level of coverage, as will some others, such as children in foster care.

There have been no previous efforts to change Medicaid benefits in the way West Virginia intends to do, nor are there comparable examples among private health insurance programs. Thus, it is difficult to predict the effects, including those on costs, beneficiaries' health, and medical practice. Many specifics are uncertain, including the level of acceptance of the member agreement on the part of Medicaid enrollees and the criteria beneficiaries must meet to remain in the enhanced plan, as well as program regulations and implementation details. Although there is no limit on the number of eligible beneficiaries who can receive the enhanced benefits, the percentage who do receive them will not be known for several years. According to the Washington-based Center on Budget and Policy Priorities, which monitors policies and programs affecting low- and moderate-income Americans, West Virginia's assumption that Medicaid beneficiaries will change their behavior in such a way as to improve their health (and maintain their eligibility for enhanced benefits) as a result of signing a member agreement is “unproven and untested.”4

There are many reasons why patients might not comply with medical recommendations. These include poor physician–patient communication; side effects of medication; advice that is impractical to follow for reasons that include job responsibilities and difficulties with transportation or child care, psychiatric illness, cost, the complexity of the recommendations, or the language in which they are communicated; and cultural barriers.5 Patients who may benefit from additional services, such as diabetes care, education in nutrition, or chemical-dependency and mental health services, include many who might have difficulty with compliance, thus increasing the likelihood that they will not be eligible for these services under the West Virginia program. Moreover, as compared with elderly Medicaid beneficiaries and those with disabilities, healthy children and adults are inexpensive to cover. Any savings for these groups could be offset by the costs of administering the changes in Medicaid or by increased costs for mandatory services for patients who remain in the basic plan.4 In their Perspective article in this issue of the Journal, Bishop and Brodkey raise additional questions about the plan (pages 756–758).

Although personal responsibility for health and for obtaining health care may seem intuitively attractive, the design and implementation of specific insurance initiatives may be complicated. Before such plans are implemented, it would be best to evaluate them rigorously in a controlled trial conducted by an independent group. If they do not improve health or save money, or have unanticipated negative effects, they can be discarded or revised.

Source Information

Dr. Steinbrook (rsteinbrook@attglobal.net) is a national correspondent for the Journal.

References

References

1. 1

   Wall Street Journal Online/Harris Interactive Health-Care Poll. Many Americans back higher costs for people with unhealthy lifestyles. July 19, 2006. (Accessed August 2, 2006, at http://online.wsj.com/article_print/SB115324313567509976.html.)
   

2. 2

   Center for Medicare and Medicaid Services. Roadmap to Medicaid reform: new options to improve and expand insurance coverage for acute care needs. March 31, 2006. (Accessed August 2, 2006, at http://www.cms.hhs.gov/smdl/downloads/Rvacutecare.pdf.)
   

3. 3

   West Virginia's Medicaid State Plan Amendment (SPA) 06-02, approved by the Centers for Medicare & Medicaid Services, Department of Health and Human Services, May 3, 2006. (Accessed August 2, 2006, at http://www.wvdhhr.org/bms/.)
   

4. 4

   Solomon J. West Virginia's Medicaid changes unlikely to reduce state costs or improve beneficiaries' health. Washington, D.C.: Center on Budget and Policy Priorities, May 31, 2006 (Accessed August 2, 2006, at http://www.cbpp.org/5-31-06health.htm.)
   

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   Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-497
   Full Text | Web of Science | Medline

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