An important question to ask at this point in what positive behaviors might a patient engage to stay healthier and reduce costs (as opposed to avoiding negative behaviors such as smoking, excess drinking, etc.) Allow me the following story after which I will develop some concrete thoughts.
In the late 1980’s as a young intern, I was assigned a patient who was in the 1st few hours of his 2nd myocardial infarction (“heart attack”). He was in his early 60s, corpulent, and surprisingly articulate. He was in the cardiac care unit (CCU) which was run by a staff cardiologist. His chest pain and other symptoms were addressed in the emergency room before he entered the CCU. Immediately after he came in, his symptoms lifted and, apparently, he regressed. He had gone into his room’s bathroom which was itself separate from the bed area. After closing the door behind him, I noticed thick cigarette smoke billowing underneath the bathroom door into his room. This man, whose heart muscle was critically injured from a prolonged lack of oxygen, decided to starve that muscle of oxygen further. As the reader may well know, supplemental oxygen is given freely in MI’s (especially if one is hypoxemic) and the combination of oxygen, combustible bed linens, and lit cigarettes is frowned upon. He was quickly convinced to extinguish his cigarette. His behavior left me gobsmacked.
As the chaos of the day ebbed, I came back to him and asked a very earnest, guileless internish question-why would he risk his life in the middle of a heart attack to smoke. My thought was that he would say something along the lines of he smoked when he was very anxious. However, what he actually said with an unexpected smile on his face was “Well, I like to smoke and what’s more, you still have to take care of me”. Gobsmacked had been replaced by floored. Clearly, he was no slave to impulse control. The second part of his statement was, however, quite true, i.e. we still had to take care of him. In our subsequent time together, he turned out to be, well, unique (although I would hear similar analyses from other patients occasionally). He was extremely proud of the fact that his union insurance was “free” to him. He had no understanding of insurance as a risk pool. More specifically, he had no concept that as everybody in his risk pool had their medical reversals, what had been “free” to him one year would shortly have co-pays, deductibles, and withholds attached to his policy. He had no grasp of and felt no sense of obligation to a shared resource. He felt that was somebody else’s problem.
In the United States, many of us can get our driver’s license by age 16 or thereabouts. In order to obtain this license, we must learn that our road system is a shared resource. Even though we all pay road taxes, we may not drive in the oncoming traffic lane even if we feel like it. We may not make right hand turns from the left lane. We may not use the emergency lane as our own private expressway when traffic is backed up. Even though all of us pay road taxes, it does not allow us to use resources dangerously (if we do, there may be both criminal, monetary, and physical repercussions). We have accepted as a culture that a shared resource, such as roadways, must indeed be just that-shared.
Interestingly enough, in the same country, our culture pays less heed of the need to promote one’s health. Like my memorable patient above, many of us have uncoupled our thoughts about behaviors from consequences. Further, few of us acknowledge that health resources are pooled and finite.
One positive action, I believe, that we can do as a society is to educate. Physical education classes from 6 grade through high school should teach students about both negative and positive behaviors and their consequences. As early as grade school, students are exposed to cigarette, alcohol, and even controlled substance use. Unfortunately, in this age group, abstract thinking is not fully developed leading to minimizing consequences. Discussions using objective data should be held regarding consequences of negative behaviors in terms of cost, morbidity, and mortality. Likewise, discussion should be held regarding the benefit of positive behaviors, e.g. consistent exercise, better dietary choices, stress management, and so on regarding cost, morbidity, and mortality. This needs to be emphasized early and repeatedly to change our culture (I believe).
Another important positive action, I believe, is to reward each individual’s positive behavior financially. The patient above, at some level, seemed to believe that he was getting more value out of his “free” health insurance by misbehaving and taking no responsibility for his behavior. There was little downside to this, from his point of view. So how might one design a system in which the patient was rewarded for good behavior and dissuaded from bad behavior? Further, how do we measure a patient’s current state of health enabling us to predict cost to care for the patient?
Certainly, there are actuarial variables which can be extracted from statistical models to predict one’s health. It should come as no surprise that these include age, gender, educational attainment, race, blood pressure, BMI, and many others. They are all sorts of papers of various stripe which can correlate these variables with health and cost of care. However, this might not be considered a good metric since a number of these variables are invariant. Also, re-tabulating the projected cost of care at intervals by using a statistical model might not give the average patient a sense of control over these figures. It might feel like a computer is arbitrarily deciding a person’s health status and cost of care. So, is there something which is highly predictive of health/cost of care which gives the patient some direct control of his/her health?
The best test for fitness and future cost of patient care may be assessing how much oxygen/minute a patient uses when exercising maximally. This is “normalized” according to a patient’s lean weight. If one can burn a large amount of oxygen while exercising, one is fit. The less oxygen the body can process, the less fit one is. High-end athletes seek out exercise physiologists who can take these measurements. However, the special equipment needed for oxygen measurement is quite expensive and not an easily applicable approach for population screening. A reasonable surrogate test would be an exercise treadmill test. As the test becomes more challenging, one has to burn more oxygen to meet demand. Olympic athletes can sometimes get their oxygen use up to 10-20 times their baseline at rest. As one improves one’s exercise tolerance, glycemic control, blood pressure, cholesterol, sense of well-being and mood, etc. all improve. The longer and more intensively one can exercise, the less he or she will draw from the healthcare system. As one’s fitness improves, some reimbursement should be allowed. In other words, there should be some reward built-in to caring for oneself. Equitably implemented, those who follow basic guidelines will no longer be in the same risk pool as someone like my patient above. Again, as one improves one’s fitness, the insurance costs will drop and possibly a direct reimbursement/rebate will be furnished to the patient. In this model, those who “do the right thing” will be rewarded.
(This will be picked up in part II)