Incentivizing Good Health Habits

Some of the most expensive contributors to the cost of healthcare are chronic medical conditions and health behaviors, such as diabetes, obesity, and smoking. For example, the estimated costs of obesity and smoking in the US are $254 billion and $96 billion, respectively. These estimates obviously do not encompass the opportunity cost in lost productivity, as it is quite difficult to calculate with accuracy. 

Given these immense costs, many policy experts and physicians have advocated incentivizing good health habits, such as weight loss and smoking cessation. If research shows increased risk of adverse health outcomes that cost individuals and the system more, should individuals who "choose" less healthy lifestyles not pay more in terms of premiums, copays, and deductibles? Or conversely, should people who are or become "healthier" over time be rewarded by lower payments? (Sort of like the "Vanishing Deductible" concept popularized by Nationwide) 

Given nondiscrimination laws enshrined in the Health Insurance Portability and Accountability Act (HIPAA), employers and insurance companies opt for the latter, by offering individuals discounts if the engage in healthy habits, such as maintaining a healthy BMI or abstaining from smoking. However, as this great article in the New England Journal of Medicine illustrates, this approach is fraught with potential ethical hurdles. The authors argue that the approach may end up being unintentionally discriminatory to individuals on the lower end of the socioeconomic spectrum who may not have the means to exercise or eat healthy or individuals who try, but fail, to lose weight. 

This is an extremely important point. Exercise and healthy eating are often challenging for individuals living from paycheck to paycheck, or those who live in neighborhoods where healthy food options are limited or gym memberships are prohibitively expensive. After struggling to lose weight myself, I appreciate the numerous barriers to developing healthy habits. Insurance schemes that reward weight loss should absolutely take into account socioeconomic background and a patient's ability to exercise and eat healthy, or we may effectively be punishing people for failing to achieve something they may not have the ability to accomplish. As physicians, our job is to consider these limiting factors before simply advising patients that they "really should lose some weight". We need to work with patients to come up with strategies to live healthier lives, even within the limits of socioeconomic status. 

The potential for punitive incentivization is especially true for weight loss - most diets do not work and people often gain back much of what they have lost. True, lasting weight loss comes not from fad diets, but from revamped habits of exercise, portion control, and limiting culinary indulgences. 

I disagree with the authors on the application of incentives to quit smoking. Irrespective of socioeconomic status, quitting smoking does not require a gym or access to healthy foods. Smoking essentially amounts to a life-shortening and unnecessary expense for all those who partake. While it is imperative to have access to smoking cessation aids, quitting must start with education about the harmful effects of tobacco smoke, from coronary artery disease and strokes to several types of cancer. For the lower end of the socioeconomic spectrum, it even makes economic sense to drop a habit that costs greater than $7 a day. As long as patients are provided with the appropriate education, counseling and resources, and yet fail to reduce tobacco use in a given time frame, shouldn't their premiums be higher? 

Several companies already do this in some form. From an actuarial perspective, this model is based on risk calculation and makes complete sense, incentivizing the patient to lower their risk or face direct penalties, similar to how getting a ticket for reckless driving results in higher insurance premiums. Importantly, this tactic has the potential to wield significant influence in health insurance, where currently people have no financial incentive to stay healthy because their premiums are based on pooled risk of many people. Directly aligning how much a patient pays for insurance with their dedication to keeping themselves healthy could reduce costs for the individual as well as for society. However, this approach will need to be refined to avoid discrimination as well. For example, insurance companies will have to be more liberal in covering medications and patches that help people quit. If not, we will run into the same problem with people at the lower end of the socioeconomic spectrum being less successful with smoking cessation given the relative higher out of pocket costs they would face as part of a smoking cessation program. 

Incentive programs are easy to talk about, but will likely face some difficulty with implementation. In addition to the aforementioned potential for discrimination, there will always be individuals who try to game the systems. This is no different than athletes who game the anti-doping rules in professional sports or professionals who abstain from drug abuse prior to pre-employment drug tests. However, this is a small price to pay if we end up with a more healthy population that costs less to care for. 

Interesting thought: instead of all these incentive programs affecting premiums/deductibles/copays, what if insurance companies (or employers) just paid people in cash for meeting certain health targets? This concept is similar to several anti-poverty programs (such as Brazil's Bolsa Familia) that provide financial support to poor families only if they vaccinate or send their children to school, for example. This benefits the family as well as society as a whole, which now has healthier and potentially more productive members of society joining the ranks. Why not pay people to maintain a low BMI or quit smoking? Given the thousands it costs to care for a patient after they have a heart attack fueled by smoking and obesity, it may make more economic sense to pay patients to reduce their risk factors. If insurance companies do this, it would not cost the taxpayers anything either, avoiding any fiscal congressional acrimony. This has been tried in a limited scale before, with little success: John Cawley reports a study of wellness programs that included 2,635 individuals across the country that failed to result in meaningful weight loss and struggled with commitment to the program. As he explains, this may have resulted from the parameter that was being measured (e.g. weight loss that may not have accounted for weight gain in the form of muscle) or inadequate incentives (the financial reward was not high enough to change behavior). It is possible that if applied more broadly by insurance companies or perhaps in specific populations (e.g. lower end of the socioeconomic spectrum), this program can result in meaningful changes to health outcomes and cost, but more studies are clearly needed. 

Regardless of how we end up incentivizing good health habits, we must remember to avoid making our patients feel ashamed. At the end of the day, all behaviors are habits that are immensely difficult to change in a short time span. We must acknowledge this difficulty and provide positive feedback and instructive guidance, working with our patients to come up with personalized solutions to lose weight and quit smoking. I like to tell my patients of my own experience with weight loss and emphasize the positivity in small victories: even one pound lost in a week or one less cigarette smoked a day are steps in the right direction. I certainly hope that in addition to constructive counseling and guidance, financial incentives leave us with a healthier population that is less expensive to care for. 

Reflections on Healthcare Economics: Inadequate Insurance Coverage and the Emergency Medical Treatment and Active Labor Act (EMTALA)

Everyone should know by now that over 47 million Americans were uninsured in 2012. As a medical student, I knew that this well-known statistic contributes to healthcare costs, but my experiences during residency has opened my eyes to exactly how.

First off, insurance companies generally work with hospital systems and standalone practices (which are becoming less common over time), to predetermine rates for the provision of medical care. For being included in a insurance company's list of "in-network" providers, these hospitals provide discounted rates for a given healthcare commodity. This benefits both parties, as hospitals get preferred access to the patients on the insurer's books, while insurer's pay discounted rates for their customers' care. Patients would also obviously benefit from lower costs, as this may mean lower deductibles and copays. 

Therefore, when an uninsured individuals goes to an Emergency Room and gets admitted to the hospital, they receive bills that are significantly higher than they would if they had been insured. This is especially more difficult at the lower end of the socioeconomic spectrum: about 38% of the uninsured include people under the Federal poverty line. The average cost of a hospitalization in 2010 was almost $10,000. The average night spent in the hospital in the United States is over $1,500, but this number varies widely from state to state and in different types of hospitals. Imagine the impact of such a bill for a family making less than $23,050 who do not have health insurance! This highlights the potential cost-saving benefits to individuals and the system as a whole of expanding coverage, whether it is with an individual mandate or not.

Working in the ER early in my first year of residency revealed some of the implications of the Emergency Medical Treatment & Labor Act (EMTALA). EMTALA was passed in 1986 by Congress with good intentions: any person that requires emergency medical treatment can receive it at any ER without any questions asked about their ability to pay for care. First of all, physicians should ideally never consider a patient's socioeconomic status and ability to pay for care. However, from a cost perspective, the impact of this law has been atrocious - millions of people who do not have insurance have utilized the ER for all of their healthcare needs. The practice of defensive medicine in the ER alone has served to amplify the effects of millions of people using the ER as their primary care physician for even trivial chief complaints and medical conditions (more on this later). Hospitals often have to front these costs; about 55% of the costs of caring for the uninsured are not reimbursed. 

How can we overcome this challenge? First of all, more people need to be covered with some type of insurance plan. This is the goal of the individual mandate that has caused so much political controversy. However, from a cost modeling standpoint, if more healthy, young, otherwise uninsured individuals join the market, it should spread the risks undertaken by insurance companies now obligated to cover people with pre-existing illnesses. Unfortunately, at this point in time, enrollment of these healthy individuals is far below what is needed to make this feasible. It is believed that the penalty of failure to enroll is too low to incentivize enough individuals to sign up.

Certain populations, especially those in less wealthy parts of the country and in big cities, will still have plenty of uninsured patients even after broader implementation of the individual mandate. Therefore, whenever an uninsured patient has an interaction with the healthcare system, whether it be in the ER, the clinic, or the inpatient setting, every effort should be made to encourage and assist patients in seeking out an insurance plans; this is where case managers can potentially make a huge impact. Hospitals benefit from this too - the reimbursement for a future hospitalization for a patient at high-risk for readmission (such as one with CHF or COPD, for example) will be higher if that patient presents with insurance. 

There have been been instances during my training where I have seen patients have longer hospital stays because they have no health insurance. For example, if a patient presents with something as life threatening as a blood clot in the lung, known as a pulmonary embolism, and this patient cannot afford an outpatient anticoagulation regimen that could hasten discharge (bridging with Lovenox), then as physicians, we are obligated to keep the patient in the hospital to bridge with heparin. Situations like this still happen frequently, but I hope the incidence drops over the next few years. 

The ACA applies to US citizens as well as naturalized citizens, but does not apply to undocumented immigrants. Almost 20% of the 47 million uninsured are undocumented. This is a travesty, as many of these patients also utilize the ER, and are essentially left out of the healthcare overhaul. Furthermore, these individuals often suffer from the same chronic illnesses (heart disease, diabetes, obesity) that cost our healthcare system billions of dollars. When they present to the emergency room for care, it is often because of the catastrophic consequences of these illnesses (myocardial infarctions, strokes, etc.) that add significantly to cost and negatively affect the balance sheets of hospitals. I have taken care of plenty of such patients. Ideally, we should allow undocumented immigrants to purchase health insurance from exchanges - but that would be politically tricky, as people against immigration reform would consider this legitimization of what they consider their "illegal" status. I hope that the immigration reforms currently being consider in Congress considers the provision of health care to undocumented immigrants, since addressing this issue is something both sides of the aisle can agree on - cutting the cost of healthcare overall.