Academic journal article The Hastings Center Report

Lifestyles of the Risky and and Infamous: From Managed Care to Managed Lives

Academic journal article The Hastings Center Report

Lifestyles of the Risky and and Infamous: From Managed Care to Managed Lives

Article excerpt

The house officer groans inwardly as the alcoholic reappears in the emergency room with his eighteenth--or is that nineteenth?--bout of acute pancreatitis. The internist sighs as she examines the obese, diabetic, hypertensive man who doesn't take his medication but still manages to take in plenty of greasy, salty foods. The surgeon is shocked as his patient, now on the mend after Medicare paid $275,000 for intensive care of his ruptured abdominal aortic aneurism, refuses to spend $75 of his own money for the new dentures that will enable him to eat solid food and regain his strength.[1] Why can't people take a little responsibility for their health, these physicians wonder.

The nation is beginning to wonder, as well. Many commentators have proposed that citizens should help tame costs by trying to stay healthy and helping to pay for their care. That move is likely to intensify and accelerate in the next few years, as managed care organizations provide an increasing proportion of citizens' health care.

According to senior analysts, managed care evolves through three stages.[2] In stage one, intensive utilization review controls expenditures via rules that limit physicians' decisions. Stage two replaces this costly, intrusive monitoring with economic incentives. Physicians regain clinical autonomy by assuming financial risk. The third stage is dubbed "true managed care": health plans "actually reduce the health risks of their enrollees. `Plans' competitive advantages will not come from premiums, which are already nearly the same, but from proving that . . . they actually did something about health care risks.'"[3] Health plans' main vehicle for reducing health care risks is, of course, to reduce health risks. And that, inevitably, means addressing patients' lifestyles. When managed care organization are integrated delivery systems,[4] they provide all the health care that patients need. Reducing need is thus crucial to containing costs.

The move has already begun. Like the man who finally realized what actually causes cancer in laboratory animals--scientists cause the cancer!!--managed care organizations recognize that the real cause of health care costs is patients' illnesses and injuries. They are undertaking or considering a variety of lifestyle initiatives via economic, medical, and even legal means.

Economic responses to lifestyle-induced costs are becoming more common. Some employers and insurers charge higher premiums for people with unhealthy habits,[5] or deny benefits if injuries were caused by reckless behavior like drunk driving.[6] One analyst predicts that managed care organizations "will eventually require enrollees to pay a portion of their medical bills if they neglect their health. A motorcycle-accident victim, for example, will have to pony up part of his medical bill if he wasn't wearing a helmet."[7]

Medical approaches begin with preventive care, which consists of three kinds of interventions: preventing illness and injury, early detection of illness, and preventing or reducing recurrences and exacerbations of a chronic illness. Each can involve lifestyle issues. Preventing illness and injury, for instance, almost always concerns patients' conduct outside the physician's office, since smoking, overeating, and hazardous sports all have predictable morbidities. Early detection of illness requires that patients undergo screening tests that in turn require them to spend their time, undergo some measure of discomfort if not risk, and perhaps pay for extra childcare or experience other inconveniences. Preventing recurrence or exacerbation of chronic illnesses usually requires rigorous adherence to therapy.

Such adherence can be tracked. Because the care provided by managed care organizations usually includes medications, they can (and some now do) use their computer databases to determine which patients receive immunizations and mammograms, and who fills and refills their prescriptions. …

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