There is consensus that the delivery and financing of care cannot be optimized without a more meaningful focus on personal accountability. The choices individuals make about where they live, the habits they form, relationships they build, providers they use and dollars they spend drive the costs of care in their households, our communities and society.
The rationale is clear: 90% of the $3.6 trillion spent for U.S. healthcare is result of chronic conditions: lifestyle choices made by individuals contribute to the growing incidence and intensity of problems like heart disease, diabetes, obesity, and others. “Preventing chronic diseases, or managing symptoms when prevention is not possible, can reduce these costs” per the CDC.
In response, the Affordable Care Act put its emphasis on incentives for providers to engage patient behaviors more directly by eliminating co-pays for routine preventive health and enhancing access to primary care services. But, by design, it did little to advance personal accountability as a key to better care and lower spending: the only unhealthy behavior penalized in the ACA is smoking. That’s it.
PERSONAL ACCOUNTABILITY IS A CONUNDRUM IN HEALTHCARE. HERE’S WHY:
The potential for increased personal accountability is complicated by factors outside the control of most individuals.
Social determinants of health (SDOH) account for as much as 60% of patient outcome compared to individual genetics (30%) and medical care (10%). In recognition, CMS identified 5 social determinants as priorities: food Insecurity, housing Instability, utility needs, transportation needs, and interpersonal violence. In a study published last week in JAMA (1), the level of screening activity for these factors in hospitals and medical practices was assessed. The Dartmouth researchers found the levels modest:
Screening for all 5 social needs was reported by 24.4% of hospitals and 15.6% of practices, whereas 33.3% %of practices and 8.0% of hospitals reported no screening.
Screening for Food insecurity: practices 29.6%, hospitals 39.8%
Screening for Housing instability: practices 27.8%, hospitals 35.5%
Screening for Utility needs: practices 23.1%, hospitals 35.5%
Screening for Transportation needs: practices 35.4%, hospitals 74.0%
Screening for Interpersonal violence: practices 56.4%, hospitals 75.0%
Personal circumstances matter.
The disadvantaged in most communities face unique barriers to access: fewer physicians, fewer hospitals, fewer retail clinics, fewer wellness programs, less insurance, poorer health and high costs. Healthy food is more expensive than healthier foods and out-of-pocket costs a major barrier. They depend on a patchwork of state and federal social services programs starved for funding and often stigmatized as “welfare.”
For the advantaged, personal accountability is also problematic.
Unhealthy lifestyle choices, poor eating habits, lack of exercise et al are pandemic issues in every socioeconomic group. According to HHS, only one in three U.S. adults gets the recommended amount of exercise daily (and even fewer who are older) and one in four is physically inactive altogether. More than two-thirds of all adults and nearly one-third of all children and youth in the United States are either overweight or obese. And so on. The fact is that in the U.S., healthy living is the exception, not the rule. And hospitals, doctors and drug companies depend in large measure on the likelihood it will continue.
Many think personal accountability in healthcare is fool’s gold. It’s certainly easier to operate on the presumption individuals are incapable, illiterate and disinclined to be accountable than to address it head-on.
Engaging individuals effectively regardless of their socioeconomic status is necessary to health system transformation. It’s achievable but not without a major shift in public policies that encourage its role and reduce barriers to its implementation. Some thoughts:
State and federal lawmakers, in tandem with community leaders, should pilot programs to fully integrate health and social services programs in communities so that care is seamless, coordinated and personalized for every individual. There’s no excuse for social services programs to operate in parallel but distant relationships to local hospitals and physicians. It’s not a matter of tools: there are impressive software platforms for mapping the availability of social services programs, assessing the effectiveness of their performance and matching them to at-risk populations. It’s a matter of will.
Primary and preventive health should be prioritized by community leaders, employers and policymakers to strengthen the “front door” to the health system. The clinical model should include physical and mental health, dentistry, eye care, nutrition, exercise and more. And gains in personal accountability, calibrated to individual SDOH factors, included in compensation formulae.
CMS in tandem with private insurers should double down on personal accountability by adding valid and reliable measures to its alternative payment models and allowing savings to be shared with individuals themselves. Sharing savings with individuals based on their personal accountability in accountable care organizations, bundled payment programs, et al should be a key design feature in every value-based purchasing model.
Personal accountability in healthcare is foundational to its future. It is more than net promoter scores, patient experience measures and member satisfaction. It’s a fundamental shift in how the health system operates.
But the reality is this: personal accountability makes sense in theory, but in practice, it’s a tough sell. That’s the conundrum.
P.S. THIS WEEK, WATCH FOR NEWS ABOUT….
House Speaker Pelosi’s Drug Pricing Plan: Friday, the Speaker released her plan which includes structural changes to Medicare Part D prescription drug coverage, a cap in drug prices tied to inflation rates for Medicare Parts B and D, allowing Medicare negotiate prices for high cost drugs including the use of international comparisons and more. Next: to House Ways & Means and Energy & Commerce for mark-up amidst continuing political pressure on drug makers: brand-name companies increased their wholesale prices by 3.1% in this year’s 2Q, a smaller boost than the 4.6% hike in 2Q 2018.
Purdue Pharma Bankruptcy: Purdue Pharma declared bankruptcy last week. The proposed $10-12 billion settlement would resolve more than 2,000 lawsuits and dissolve the company. But the New York attorney general’s office disclosed that the Sackler family participated in 137 wire transfers totaling about $1 billion in recent months in an apparent effort to protect its wealth via overseas bank accounts.
Surprise Medical Bills from Hospital Emergency Use: When a patient uses an in-network hospital emergency room, there’s a high likelihood they’ll get a surprise medical bill for ambulance charges or physicians’ services that are out of network. Among those with privately insurance, out of network bills increased 39% from 2010 to 2016 (+42.8% in ’16 alone). But revenues from out-of-network use are important to private equity investors who have funded many prominent emergency room management services, so these companies are fighting against policies being considered by the Senate to disallow/limit out-of-network billings for emergency services.
Site Neutral Payment Policy Clarity: Last week, a D.C. District Court Judge found that the Centers for Medicare & Medicaid Services (CMS) exceeded its authority on-site neutral payment policy when it finalized a hospital outpatient rule last year which went into effect on January 1, 2019. The Judge has asked CMS and industry groups for additional information this week. Stay tuned.
1-Fraze et al “Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals”
JAMA Network Open. September 18, 2019 2019;2(9): e1911514. doi:10.1001/jamanetworkopen.2019.11514
Castrucci B, Auerbach J. Meeting individual social needs falls short of addressing social determinants of health. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20190115.234942/full/. January 16, 2019
Solomon LS, Kanter MH. Health care steps up to social determinants of health: current context. Perm J. 2018; 22:18-139. doi:10.7812/TPP/18-139
Artiga S, Hinton E. Beyond health care: the role of social determinants in promoting health and health equity. 2018; https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-socialdeterminants-in-promoting-health-and-health-equity/
Thomas-Henkel C, Schulam M. Screening for social determinants of health in populations with complex needs: implementation considerations. Center for Health Care Strategies. https://www.chcs.org/media/SDOH-ComplexCare-Screening-Brief-102617.pdf.
Chronic conditions are not "lifestyle choices", and blaming patients for their health problems (fat shaming, etc.) is a cheap way to let the rest of us off the hook. Better would be a positivist approach: Make the system more consumer-friendly, and empower patients to engage more easily and effectively with the system. We also need a stronger social safety net and better access to mental health care. You can’t force people to take care of themselves, but given the right support structures, most people will take on more personal accountability.