My colleague Tom Morrison, Founder of Navinet, shared an interesting analysis with me the other day pertaining to physician compliance to demonstrate meaningful use. In essence, he noted that about 41% of phase I criteria will have heavy reliance on patient behaviors, including medication adherence, adherence to care plan, trips to testing facilities and others. I think it is fascinating that we are about to embark on an unprecented effort to accelerate the adoption of electronic health records by health care professionals in hopes of improving the quality of health care for our citizens, but there has been no attention paid to motivating the citizen or holding him or her accountable. Stated succinctly by another physician friend of mine, ‘When are we going to have a pay-for-performance program for our patients?’
This opens up any number of intersting avenues to mull and debate. One more time, lets run through the high level view of how health care works. Unfortunately, at some point you are bound to get sick. Once you get sick you need care. Two things are important to note here: once you get sick you are a victim – sickness is a random, bad-luck occurance. This is the reason we insure ourselves against sickness. The second is that sickness is far to complex for you to manage on your own. You need a relationship with an expert, an oracle – we call these people doctors (from the latin doctus– a teacher or learned one). We expect them to almost magically have access to millions of facts about our particular situation, make flawless decisions on our behalf, and most importantly carry the burden of getting us well again. After all, when you are a sick victim, you want someone to care for you and do the heavy lifting required to bring you back to health.
Of course, the medical profession has done its share of things to perpetuate this stereotype. As you read this tongue-in-cheek description of what a doctor is supposed to do, wouldn’t you want that job? And as a recipient of such magic, wouldn’t you value the doctor’s input highly (i.e. make sure the doctor is well compensated)?
This model of thinking, while arguably over simplified and outdated, works reasonably well for those health issues that are truly accidents or the result of bad luck (e.g. the wrong genetics). Think about the victim of a random shooting or the child born with a congenital heart defect.
So far, so good.
But what about chronic illness? Varying estimates of the burden of chronic illness all describe a Pareto principle ‘on steroids’. I like the one that says 7% of individuals consume 70% of our health care costs as a result of caring for 6 chronic illnesses (coronary disease, CHF, asthma, COPD, kidney failure, and diabetes). For the most part, these are illnesses that occur because of sustained unhealthy behaviors over time. Another way to think of it; 50% of health care costs link back to unhealthy behaviors. The model of patient as victim, abdicating all decision making to the oracle does not work well for dealing with illness that is the result of unhealthy behavior.
However, our libertarian roots, combined with our mechanism for electing our government representatives make it almost impossible for us as a society to hold individuals accountable for their unhealthy behaviors. Accountability can be viewed as reining in freedom and no politician wants to remind their constituents that individuals are in control of unhealthy behaviors. Its much easier to be in favor of programs that guarantee care to victims.
I’m curious if you have ideas on how to deal with this conundrum. I have some and will detail them more in my next post.