How should healthcare costs be determined?

This was sparked by something posted on another blog somewhere, mentioning that the Today Show was talking about charging people for healthcare based on things like smoking and obesity. I find this problematic, though possibly somewhat on the right track.

I'm fine with the idea of having measures of healthy living, much like we do for driving. We would need to make sure though that they're objective. For instance, while obesity is a problem, a lot of studies are showing us that it's actually more healthy for some people to stay their heavyset size than to struggle to lose weight and gain it right back. A person's fitness level, cholesterol level, etc., are much more important in determining whether the person is taking care of him/herself. We also need to be careful to take into account whether a person has another medical condition that prevents what we'd consider optimal diet and exercise. We can't have the same fitness standards for a typical person as we do for someone with severe orthopedic or neurological conditions, or for someone with major mental illness.

The feds have (had? I know it's changed and believe the name might now be different) a program called Medicaid Rehabilitation Option, which employs Performance Based Contracting for programs that provide support to people with mental illness who live in group homes or in apartments where staff visit them to provide support. In this program, in order for the program to be paid, the program had to demonstrate that 75% of people were meeting 75% of their goals. The goals had to be rehabilitation goals rather than quality of life or maintenance, but they were quite individualized. In other words, they weren't measuring "health" for each person based on whether that person had a job, was raising a family, and was driving a car. For some people, the person was making progress by deciding that she wanted to go out and buy a newspaper twice a week so she could get out of the house and be more in touch with what was going on in the world. For another person, it was making his own coffee. For some people, yes, it was getting a full-time job or getting into college. But the goals were individualized by the staff (with client input except when a client was really unable to express preferences) to push each person to be a little more independent and engaged in life. Not to try to get every person up to the same standards.

Something like this would make sense with physical health care. A provider and patient would come up with fitness and lifestyle goals that were appropriate to the person's physiology, other physical health concerns, and mental health. People who were meeting their goals, thus showing an investment in health, could get a discount on their health insurance. It would be similar to how my plan gives me $150 per year toward a gym membership. We'd need to be careful that we're giving bonuses to particularly motivated people, rather than making insurance impossibly expensive for people whose health suffers because they're under tons of stress because of factors in their life they can't control. (There was recently a study showing that Black families have a much higher rate than whites of low-birth-weight and/or premature infant births, even when controlled for by income, education level, family stressors, etc. Leading to the conclusion that daily effects of racism itself cause stress, which we know is linked to intrauterine growth restriction and pre-term labor.)


Jodie said...

A person's fitness level, cholesterol level, etc., are much more important in determining whether the person is taking care of him/herself.

No, it's not.

Aside from limitations some may have with fitness because of various disabilities, cholesterol is not a good indicator of how well people are taking care of themselves. In many people, it is not a modifiable risk factor- as in, there's nothing that some people can do to lower their cholesterol beyond a certain level. For example, I have been vegan for 2.5 years, and was vegetarian with limited dairy & egg intake for several years before that, I exercise and eat whole grains like nobody's business, but my LDL cholesterol is still nearly as high as it was when I ate Big Macs, fries and Ben & Jerry's several times per week. My dietary and exercise habits aren't the problem- it's my liver. It won't quit pumping out the cholesterol. On the other hand, being overweight probably contributes to the raw materials that my liver has on hand to keep manufacturing the cholesterol, but that's still a murky scientific subject and also known to happen in people who aren't overweight, so hopefully the government won't start charging me extra over that. Yet.

[Of course, there are always statins- the cholesterol lowering medications. However, while they do have a significant impact on cholesterol levels, they have not been shown to reduce risk for heart disease. They're also heavy-duty medications with serious side effects. Benefits don't outweigh the risks in younger, otherwise healthy individuals, until cholesterol reaches a certain high point].

It's not an easy subject, determining what people CAN do to take responsibility for their health. We do know that as a population, weight and associated problems don't have to be as serious of a problem as they are, but when it comes to individuals it gets much trickier. There were people who were overweight, had type II diabetes, high cholesterol and all the other problems that have been growing since before the middle of the twentieth century. There are also things that many people are capable of doing that would lower their risk of chronic disease. So how do we separate the extra cost of society-induced chronic disease versus what was always there? Do we try?

I think the government should get involved- but not at the individual discriminatory level. If they would stop subsidizing the factory farming that makes meat cheap and corn syrup flow like a river, we'd probably see a natural decline in chronic illness over time. If the government made growing healthy foods a financial priority, it could be done.

eeka said...

Yeah, good points. I was responding specifically to the idea of measuring health by measures that aren't great measures of health. Of course genetics play a huge role. I definitely don't like the idea of categorizing people based on stuff that we still don't have a definitive answer as to whether they can help (and for which our evidence is leaning toward a lot of it being mostly genetic). I feel like if there's an incentive-based plan, it should be based on rewards for going the extra mile. I'm personally fine with everyone paying based on income. I think maybe one of the benefits could be something like giving someone a break for doing something that increases health in most people, like lowering LDL. Not everyone could lower it, but it would get a lot of people trying, which would be great. There have been studies like paying people to attend presentations in their workplace or kid's head start or wherever on how important it is to eat breakfast, counseling them on how they might fit it into their lifestyle, and following up and seeing how people followed through. It would be nice to see insurance companies doing more of this sort of perk where they pay people to participate in health-increasing things rather than just pulling numbers that may be more genetic than anything. Blue Cross gives me a gym stipend (good) and offers things like car seats and helmets (also good) and weight-loss programs (which don't have to be ones that focus on getting nutrients or making healthy choices in general or anything, so on the right track, and certainly helpful for many people, but could be made better).

And yes, the larger problem is societal, and the government would have plenty of money to put toward health if they weren't subsidizing unhealth, just like you said.