Thursday, April 1, 2010

Should You Pay for My Bad Habits?

Funny thing. If I ask whether you should pay for my bad habits you might answer one way. But if I ask whether I should pay for your bad habits you might very well answer differently. Thus, I phrased the title in the way that felt the most engaging.

Admittedly, we all belong to one community, but does that mean that you are responsible for my bad habits and vice versa? It's one thing to be your brother's keeper, but quite another to be everyone's brother's keeper.

Of course, bad habits are not the same thing as being sick. Encouraging people to rid themselves of bad habits is not the same thing as saying that we should not insure those who are ill.

These questions took center stage during the recent health care reform debate. They involve moral philosophy and the psychology of motivation and incentive. Since they also lead to questions of how we can go about incentivizing good behavior, they also involve coaching. They are not, strictly speaking, questions that you would learn about in med school.

Nevertheless, cardiologist Sandeep Jauhar attempts to tackle the issues in the New York Times. Link here.

Dr. Jauhar begins by noting what we all know, only too well. Bad personal habits contribute significantly to rising health care costs. If we were all to exercise daily, eat healthy, stop smoking, and take our medicine... then the cost of health care and health insurance would decrease significantly. But how do we encourage people to replace their bad habits with good ones.

Given that Dr. Jauhar is not a moral philosopher and has no background in motivational coaching, we should not expect him to offer the best answers to this question. He has written a polemic, involving a certain amount of faulty reasoning, due largely, I assume, to inexperience.

To address the question of whether or not we should all be paying for someone's bad habit, Dr. Jauhar notes that once in Australia a group of physicians decided that they would no longer operate on smokers, even if the surgeries were necessary to keep the patients alive.

Clearly, they were out of line. As an example, this is a red herring. We may sympathize with the impulse that drove the Australian doctors to their desperate conclusion, but withholding medical treatment-- effectively pronouncing a death sentence-- as the penalty for bad habits is absurd. The physicians might be committing a criminal act-- as in, criminally negligent homicide.

Unless you believe that the death penalty is an appropriate punishment for a two pack-a-day smoking habit, and that you should be the one administering it, the example is a chilling anecdote of little practical value.

Dr. Jauhar continues by offering evidence that punishing people for bad behavior, even rewarding them for good behavior has little effect on their habits. He asserts that punitive measures do not work, or, to be more precise, they do not work on Medicaid patients.

As we know, Medicaid patients are not paying for their health insurance or their health care. You cannot discourage bad habits by telling them that they can eventually pay less for their insurance.

What incentives were West Virginia Medicaid patients offered? If they agreed to sign up for a special wellness program they were rewarded with better prescription drug coverage, a stop smoking program, and a free consultation with a nutritionist. They would also have to make far more visits to the Doctor's office.

In short, they were offered the chance to become better consumers of medical care. Little wonder that it did not work.

The truth is, sometimes punitive programs do work. Witness the following results from work on heroin addicts.

If you make addicts pay a sufficiently high price for their addiction, they will, as Dr. Sally Satel points out, mostly stop it on their own. Link here. They will, under threat of punitive sanctions, change their bad habits.

If an addict is given a free choice between his addiction and his job, most addicts will opt for the latter. And we would all agree that addiction is a very bad habit, indeed. At the least, we can say that it is wrong to say that punitive measures never work. And it is even more wrong to conclude from false premises that we cannot do anything to change bad habits into good ones, short of public service announcements and a massive advertising campaign. I mention these latter possibilities because they end up being Dr. Jauhar's recommendations.

We also know that there are other ways to incentivize good personal habits. Dr. Jauhar should know about the much discussed program at Safeway Stores. He could have read about it on this blog. Link here.

Safeway Stores did not use punitive measures to encourage good behavior. It measured the effects of good habits-- lower blood pressure, lower weight, and so on-- and rewarded employees who achieved better results. Their reward was: lower insurance premiums. Apparently, this motivating factor... more money in your pocket-- was a better incentive than the opportunity to make more visits to your doctor and your nutritional consultant.

The Safeway program did offer access to an onsite gym, but it did not try to force anyone to do anything. You might consider it punitive, but it is no more punitive than charging a bad driver more for his auto insurance. Even then, it does not seem to be a question of punishment as a question of recognizing the reality of higher risk.

We all know that good habits will improve our health. We are all looking for ways to promote good health. And yet, we now have a new health care reform law that extends Medicaid benefits to more and more people, and that makes it more difficult for insurance companies to tailor premiums to the health risk of individual citizens.

Perhaps if we were spending less on avoidable medical conditions we would be able to spend more on those that are unavoidable. Just a thought.


Anonymous said...

I dunno.... Maybe promoting "healthy habits" won't save as much as we think: Vigorous exercise, weight lifting, running and sports can lead to a lot of debilitating injuries and nagging chronic injuries requiring therapy, MRIs and occasionally surgery.

In my military experience, even in triaining, I saw many, many young healthy guys injured and debilitated by chronic "over-use" maladies. Heck, I've had a few injuries that required all kinds of medical care....

"The Vigorous Life" can cause one to be an unlucky consumer of medical care of all kinds.

Some people smoke, others race bikes, jump out of airplanes or run long distances. Moral judgements aside, they will all cost money for a society if we have socialized healthcare.

I just want to pay my own way to indulge in high-risk behavior, healthy or otherwise....


Anonymous said...

To put it in less abstract terms: take up distance running; get great blood pressure and heart rate; get a blister and staph infection (very common) and you are looking at days in hospital on antibiotics followed by months of therapy and wound care. Maybe even grafting if enough skin is lost.

Now you've cost as much money as any smoking sinner, but at least the smoker drops dead and saves money overall....


Stuart Schneiderman said...

Surely, it is true that some athletes overdo it and contract injuries.

It is also true that the Safeway policy did lead to much lower expenses for health care.

So, perhaps for every athlete who gets injured by running too much in bad shoes, there are a few dozen who improve their health so much that they become less avid consumers of medical care.

I have seen an awful lot of people profit immeasurably from improved personal habits, both physically and mentally, so I remain committed to them.

I would suggest, however, that the culture does not pay more than lip service to the need for an exercise regimen because there is not enough money in it... especially when compared to the costs of inactivity and couch potato-ness.

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