As I read health management and health policy articles and listen to politicians do what they do best (talk out of both sides of their mouths), it amazes me that no one includes the patient in solving the health care crisis. I keep saying that this is the one part of the equation that must be included before we can solve the cost problems. However, since it is politically unpopular, it doesn’t get done.
I have a noncompliant, overweight, diabetic, hypertensive female patient who works in the cafeteria of a local school. For three years, I have been working with her, trying to get her to understand her predicament. Along comes this new plan by her insurance company. She has to undergo “education” and evaluation by the “educators” and staff of a nearby hospital. They will do all the tests I have already done, will force her to go to all the education seminars I have already sent her to, and say they will copy me on everything (they haven’t yet). In exchange they would give her all her supplies and medications.
Here is the result: Her HbA1c is worse, her BP is worse, and she is still giving me the same excuses. She is a prime example of a patient who will not take responsibility for her health — period. How much did the insurance company spend? What made it not work is simply her apathy coupled with the lack of emotional attachment between her and the company plan. She at least had a connection with me, but I was taken out of the equation.
I am no longer shocked by the patient who can’t afford medical insurance, medications, or office visit fees but has ample funds for beautiful fingernails and expensive hair care, gold and diamond-studded teeth, expensive cars, and tobacco and alcohol habits.
Patients with diabetes and/or hyperlipidemia regularly tell me that they “cheat” on their diet, or it was a holiday, or they were traveling, or didn’t take their medicine (for a variety of reasons) and so why can’t I just give them another pill, and “oh, by the way, make it a generic that I can get at Wal-Mart for $4.” I’m left wondering if they want the money for cigarettes, beer, or whatever.
I find myself trying to convince a patient with three weeks of back pain and no neurological deficit that he doesn’t need a lumbar MRI. Patients don’t want to hear that they can’t have or don’t need the latest, most expensive test.
When I ask about quitting, smokers tell me, “I don’t want to quit,” “I like it,” “I’ll quit when I die,” “It doesn’t cause the problems you say it does.” What are the costs to our employers, our public health, our insurance system?
So while it is not a popular idea, or one insurers want to tackle, it is time to include the patient in the equation. The fat has mostly been cut from the provider end. Hospitals are cutting costs at the wrong end by always cutting nursing staff by way of the “acuity level” system, which ultimately adversely affects care.
Employers have suffered economically by providing health care to employees at an ever-increasing cost. While it is true that insurers have recently begun to step into the area of patient responsibility with programs designed to include them in their care, such as the diabetes program I mentioned above, it’s not enough and it’s done incorrectly.
Under our insurance system today, the patient has become financially separate from his health care. That’s good and bad. The good is obvious. What’s bad is that this has created a country of patients who want top-shelf care without having any responsibility for adopting good health habits. The insurers must make patients feel that sense of responsibility.