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Reexamining the Ethics of Personal Responsibility

Janice Simmons, for HealthLeaders Media, September 9, 2010

Tucked into the healthcare reform legislation passed this year is a provision that calls for state grants to create initiatives to encourage Medicaid beneficiaries to adopt healthy ways of living to prevent chronic disease. But before any state—and while we're at it, any employer, insurer, or health system—moves ahead with an incentive plan, they may want to look at the West Virginia example cited by the American College of Physicians (ACP) in a paper on the use of patient incentives to promote personal responsibility for health.

ACP uses the West Virginia Medicaid program--one of the earlier controversial programs to use incentives—to highlight some of the problems that can befall incentive programs, even when they're started with the best of intentions.

As ACP notes in its recommendations, programs should support a patient's role in achieving positive health outcomes. Moving down the path of penalizing individuals who fail to meet goals (such as smoking or weight loss) by withholding or reducing benefits or increasing health insurance premiums won't work in the long run, it said.

In 2007, the West Virginia Medicaid program implemented a new benefit plan that was designed to improve health by promoting personal responsibility. The Medicaid would be divided into a behavior-based two-tiered benefit structure: the basic plan and the enhanced plan.

The basic plan offered fewer services than the enhanced plan, which provided unlimited prescriptions and transportation, and programs such as weight management, smoking cessation, diabetes education, nutritional counseling, and substance abuse treatment.

To get into the enhanced plan, patients and their physicians would develop a "health improvement plan" in which patient would be required to agree to a number of conditions such as: medication adherence, attendance at recommended educational programs, keeping scheduled appointments or notifying the office to cancel, timeliness for appointments to their medical home, visiting the medical home when sick, and using the hospital emergency room only for true emergencies.

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