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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 graphs). 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 box).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."
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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{at}attglobal.net) is a national correspondent for the Journal.
References
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