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Reexamining the Ethics of Personal Responsibility

 |  By jsimmons@healthleadersmedia.com  
   September 09, 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.

Sounds great—initially. But as it turns out, the program's goals fell short. A preliminary evaluation revealed that two years after implementation, only 10% of eligible adults and 13% of eligible children even were enrolled in the enhanced benefits plan. Other patients reported limited knowledge of the program—before and after enrolling—while clinicians reportedly felt confused about the paperwork and benefit structure.

"Incentive programs should not discriminate against a class or category of people," says Virginia Hood, MBBS, a co-author of the paper. "Age, gender, race, ethnicity, and socioeconomic status should be carefully considered in designing, implementing, and interpreting results of social and behavioral interventions."

To encourage a dialogue, ACP has compiled a list of recommendations on what should be considered when implementing incentive plans, including:

  • Incentives to encourage healthy behaviors should be appropriate for the target population. Specifically, the incentive structure must not penalize individuals by withholding benefits for behaviors or actions that may be beyond their control.
  • Incentives to promote behavior change should be consistent with the elements of patient-centered care. This means the incentive structure should support appropriate patient autonomy and participation in decision making—including the right to refuse treatment—without fear of punishment.
  • Incentives should support "honest, open and fair interactions" among patients, healthcare professionals, healthcare entities and payers. In particular, health plans should not interfere with "the ability of patients to communicate freely with physicians and other health care clinicians," the paper states.

  • Incentives to promote behavior change should be consistent with the elements of patient-centered care. This means that the incentive structure should support "appropriate patient autonomy and participation in decision making—including the right to refuse treatment”—without worrying about punishment, ACP says.

The road to a healthier future is paved with great intentions. Let's just make sure we're not using punishment, confusion, or other disincentives to push us off that course.

Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.

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