The Death of Personal Responsibility

Fitting in nicely with my prior post about the Tragedy of the Commons, I was riled into a severe state of Bajungi Tilt this evening when I read the NYTimes article "For Forgetful, Cash Helps the Medicine Go Down."  Before I even clicked on the article, I closed my eyes and prayed that it wouldn't be about a program that pays people to take medicine.  My prayers were not answered.

"It has long been one of the most vexing causes of America’s skyrocketing health costs: people not taking their medicine.

One-third to one-half of all patients do not take medication as prescribed, and up to one-quarter never fill prescriptions at all, experts say. Such lapses fuel more than $100 billion dollars in health costs annually because those patients often get sicker. "

Ok - so they're appealing to my inner capitalist.  See, the point is that by paying people to do something, we'll avoid higher costs later as a result of their failures to do what they were supposed to do in the first place.   I have the phrase DARWINISM, DARWINISM, DARWINISM blaring in my mind, repeatedly, but alas, we can't just tell people that if they don't take the medicines we prescribe them that we will deny them emergency treatment and let them die.

Now, a controversial, and seemingly counter-intuitive, effort to tackle the problem is gaining ground: paying people money to take medicine or to comply with prescribed treatment. The idea, which is being embraced by doctors, pharmacy companies, insurers and researchers, is that paying modest financial incentives up front can save much larger costs of hospitalization.

“It’s better to spend money on medication adherence for patients, rather than having them boomerang in and out of the hospital,” said Valerie Fleishman, executive director of the New England Healthcare Institute, a research organization, who said that about one-tenth of hospital admissions and one-quarter of nursing home admissions result from incorrect adherence to medication. “Financial incentives are a critical piece of the solution.”

In a Philadelphia program people prescribed warfarin, an anti-blood-clot medication, can win $10 or $100 each day they take the drug — a kind of lottery using a computerized pillbox to record if they took the medicine and whether they won that day."


Before the program, Chiquita Parker, a 25-year-old single mother with lupus, too ill to continue her job with special needs children, repeatedly made medication mistakes, although she knows she depends on warfarin to prevent clots than can cause strokes, paralysis, or death.

“I would forget to take it,” and feel “like I couldn’t breathe,” she said. Or she would “take two in a day,” and develop bruises from uncontrolled internal bleeding.

But in the six-month lottery program, she pocketed about $300. “You got something for taking it,” Ms. Parker said. Suddenly, she said, “I was taking it regularly, I was doing so good.”

I'm Speechless... let's keep reading:

"“We’ve made our best efforts to say, ‘If you didn’t take your beta blocker or asthma medicine, you have a greater chance of ending up with a heart attack or dead or hospitalized,’ ” said Dr. Lonny Reisman, Aetna’s chief medical officer. “It’s going to take more. It’s going to take incentives.”"

Well, that's one way to look at it, and anyone looking at it like this should not be surprised at exactly why our health care costs are spinning out of control.  Oh - some people will point out that this is the private companies that are paying these funds - yes - they are paying them with YOUR premiums.  You're supposed to feel good because if Aetna didn't pay forgetful people to take their medicine, then you'd have to pay even HIGHER premiums to pay for the subsequent emergency treatments of these people.

Enough with INCENTIVES.  There is another way - disincentives.  I'm not going to be so radical as to suggest that they use the same computerized pillbox to invalidate your health insurance if you forget to take your pills, and mandate that you die a painful death outside the hospital door as you are refused treatment.  However:  I will absolutely advocate going the opposite direction as this program, and suggest that if you fail to take your pills, you are subject to a fine. Or to some other loss of privilege.  I'm all in favor of benefits - like health care - to help people out.  But if people abuse those benefits, I think at some point it's quite reasonable and not at all heartless to ask for some accountability.   I'd be in favor of more "socialist" benefits, if they came with restrictions. *** {see tangent below}

Sounds harsh, right? I know - and I don't care. At some point we have to draw the line, and this is it.  We shouldn't have to pay kids to get good grades (oh - that program failed, by the way), and we shouldn't have to pay people to take their medicine.   Furthermore, if you are going to pay people to take medicine (it sounds dumber every time I type it) - shouldn't you keep it CIA level hush hush?  

There's a reason the Credit Card companies don't tell you that at some point they'll settle your outstanding debt at pennies on the dollar after you stop paying - if they did, no one would pay their bills.  There's a reason banks aren't screaming out that they have all the economic incentive in the world to reduce your principal balance outstanding on your underwater mortgage instead of foreclosing on you - if they did, everyone who is underwater would stop paying (this is starting to happen, as I discussed previously).  There's a reason we shouldn't bail out states who fail to, as required by law, balance their budgets - because it makes it so that no state has any incentive to exercise fiscal prudence.

And there is a reason why if Aetna is going to pay people to take the drugs they are supposed to be taking if they want to live a healthy life then they should STFU about it.  As the NY Times article puts it:

"Skeptics question if payments can be coercive or harm doctor-patient relationships. “Why should people who don’t want to take medication be paid, when prudent people who take medication are not?” said Dr. George Szmukler, a >psychiatry professor at King’s College London. 

Joanne Shaw, who runs a department of Britain’s National Health Service, asked: “Will others think, ‘If I behave like a potential noncomplier, I’ll get money for taking medication?’ And once you start paying people to take medication, when do you stop paying them?” 

I want to bring personal responsibility back, like Justin Timberlake is Bringin' Sexy Back.  This concept applies to other areas I've written about as well:  there should be very clear requirements regarding stock trading that make sure that people ACKNOWLEDGE that they understand that when they send a market sell order, they can get filled at $.01 when their stock is trading at $40.   Then, we wouldn't have to cancel trades after the fact because "hey - I didn't know that could happen."

Mortgage borrowers should be required to pass a test that shows that, in no uncertain terms, they understand the product they are using.   Mortgages and other financial products, including credit cards, should be made simpler - so that there is nothing to misunderstand - no fine print.  I have only seen one adjustable rate negative amortizing mortgage in my life.  My friend has this mortgage, and I read her contract, expecting it to be a jumble of incomprehension.  Guess what - it's not. It tells you that at first you're paying only the interest, and not even all the interest, and none of the principal. It tells you what the rate is, how long the rate is good for, and when the rate resets. It tells you what the new rate will be based on, what your payments might be depending on different reset rates at the time,  how often the rate resets, and by how much.  It's impossible to not understand.  If they aren't all like that, they should be.

See - once we remove "blame" from the equation the rest gets easier.  Now, when Johnny Speculator says "I was tricked into this mortgage, I had no idea that my payments would skyrocket," we say "Well Johnny, you demonstrated that you understood the product by passing the Mortgage License test that was required before hand.  You can't blame anyone else - you are accountable.

"Hey Kid Dynamite," you are wondering, "since when do you want all this Big Government?  Why do you want MORE regulations, certifications and restrictions - what happened to small government free market Capitalism?"

Well let me tell you - we (we, as a country) have clearly demonstrated that we don't like the effects of the free market, which allows people to fail.  We want to place the blame for failure on all sorts of different parties, some of whom are certainly actually guilty, and many of whom are not.  But we've gone way too far off the deep end of abandoning and ignoring that in the end, everything comes down to PERSONAL RESPONSIBILITY.  If more government, or more market intrusion is required to make sure that people lose the "hey - I didn't know - it's not my fault" excuse, then I'm all for it.  THEN we don't have to have philosophical debates about how Johnny was tricked into being given more money than he could afford to pay back - the blame will be removed from the equation, we will know that Johnny is responsible for his situation, and we can objectively figure out how to address it.

Trying to get back on topic:  how do we bring personal responsibility back to medicine?  Since we're not willing to let people who fail in their personal responsibility die as a result of their failure, the answer isn't quite as simple as it seems!  I'll say it again though - forget "incentives"  - if life isn't incentive enough, we need to go to "disincentives."

Now, a few of the reader comments on the NY Times article which I found enlightening or interesting:

-"The life-saving effects of her medication are not a good enough incentive? If she can remember that if she takes her medication, she might win some money, she should be able to remember that if she takes her medication she might continue to be around to watch her little boy grow up. Maybe it's just the computerized pill box that helps keep track. What if patients were FINED each month for not taking their medication? Certainly the incentive would still be in place."

-"Why don't we pay people not to be criminals requiring incarceration? Why don't we pay people to not do drugs? Why don't we pay people not to have more than one child? Why don't we pay people to stay in their own country instead of coming here illegally? Why don't we pay people to work instead of not to work? The list goes on. The real questions to ask are: Why don't we expect some personal responsibility for a change? Why don't we stop taking from those who are responsible to reward those who are not?"

and finally, from a reader who takes her meds:

-"I understand the rationale of paying people to comply with their pharmaceutical treatments; I really do. But, I know that if I don't take my meds, I will suffer considerable pain and, ultimately, death. So, I take my meds -- at a considerable cost to me. I often have to forgo eating three meals a day in order to afford those meds, despite the promises made when Medicare Part D was passed to relieve seniors from having to choose between food and medicine (and, not incidentally, to pad the pockets of pharmaceutical companies and insurance companies). I go without the little extras that make life more pleasant in order to have life -- period. And I'm not complaining, because I choose to live rather than to die.

So, please forgive my for being livid that people who care so little about their own personal health are being paid to do what they should be doing because they forget to take theirs meds. Every action has a consequence, and the consequence for their action is suffering and death. If they don't know that, they will learn very quickly.

And please forgive me for not really giving a damn if they do suffer and die. That, ultimately, is their choice."

-KD

*** tangent from above:  see, here's the kind of "socialist" benefit I could get behind.  You want free health care for everyone?  Noble goal. I do too.  So, my rule is this: if you're on the free government health care, you are not allowed to eat at McDonald's.  You're not allowed to smoke cigarettes. etcetera - get the point?

State Bailouts: The Tragedy of the Commons

Readers may be familiar with Garret Harden's Tragedy of the Commons.  As Wikipedia describes it:

"Central to Hardin's article is an example (first sketched in an 1833 pamphlet by William Forster Lloyd), of a hypothetical and simplified situation based on medieval land tenure in Europe, of herders sharing a common parcel of land, on which they are each entitled to let their cows graze. In Hardin's example, it is in each herder's interest to put the next (and succeeding) cows he acquires onto the land, even if the carrying capacity of the common is exceeded and it is temporarily or permanently damaged for all as a result. The herder receives all of the benefits from an additional cow, while the damage to the common is shared by the entire group. If all herders make this individually rational economic decision, the common will be depleted or even destroyed to the detriment of all."

Simply: each individual has incentive to do the exact action which, if everyone does it, will result in a pareto-inferior (aka: worse) result for everyone.  It's not entirely unlike the Prisoner's Dilemma.

I've been using the Tragedy of the Commons to describe the downward spiral which I think will result if the Federal Government starts bailing out cities and states from their failed budgetary decision.  Today, in the NY Times, I read the article "Obama Presses for Aid to Cities and States," and could only think: and so it begins. {tangent:  this post has nothing to do with Obama - this piece would be identical if you changed all the "Obamas" to "Bush," "Palin," "Clinton," or anyone else - so please save your partisan rantings for another blog}

The NYT says: 

"President Obama on Saturday implored Congress to provide more aid to states and cities to blunt “the devastating economic impact of budget cuts” by local governments that imperil the jobs of teachers, the police, firefighters and other public employees."

Now, the House and Senate have thus far resisted this aid, and my home state Senator Judd Gregg even tried to insert a clause into the financial reform bill which would have prevented the Federal Government from bailing out individual states.  His amendment failed.

The NYT article continues, clarifying:

"Unlike the federal government, all but one state and most local governments are required by their laws to balance their annual budgets, and they continue to struggle against the increased costs of relief programs and lost revenues from high unemployment and home foreclosures."

I do take issue with the argument used by the President:

"Making the economic case for helping the states, Mr. Obama said that if teachers and others are laid off — his education secretary, Arne Duncan, has said that without federal aid, up to 300,000 fewer teachers would be in classrooms this fall — “it will mean more costs helping these Americans look for new work, while their lost paychecks will mean less tax revenues and less demand for the products and services provided by other workers.” 

Now, I love teachers.  I think education is immensely important, and it's one of the main problems we have in our country.  My father was a teacher for over 30 years.  My mother was a teacher for over thirty years.  My sister is a teacher.  My brother-in-law is a teacher.  I am certainly in favor of teachers keeping their jobs and getting paid - and I think most people think similarly - which is why I hate the "we have to give the States all this money or the teachers will lose their jobs and your kids will wallow in their own ignorance" manipulative argument.  What next?  Will the next batch of money go to help save starving puppies and kittens?  After all - we all love puppies and kittens.  It's somewhat disingenuous to suggest that merely because people agree that we need something that the Government has to bail out the decisions of those who failed to adequately provide it.

I live in a town with good schools.  I don't have kids, and the majority of the residents in town also don't have school aged children.  Still, each year, we vote for massive property taxes  (mine are nearly 3% of my home's assessed value!) which go largely to support our schools, because the community values it.

Of course, teachers weren't the only emotional appeal.  In the opening paragraph I quoted, firefighters were also thrown in there.  Who doesn't love firefighters?  I love firefighters - I think they're heroes, and I absolutely want them to be there if my house burns down (although I'm told, slightly tongue-in-cheek,  that out here in the woods, in the Land Without Fire Hydrants, if you call the fire department their main job is to come and watch your house burn).  But wait - THERE'S MORE!  If teachers and firefighters isn't enough for you:

"Mr. Obama had supported about $50 billion in aid initially — $25 billion for public employees, $23 billion of which would go for teachers’ salaries, and $25 billion to offset states’ increased costs for their share of Medicaid, the public health program for the poor, people with disabilities and many nursing home residents....Mr. Obama warned that if Republicans blocked a vote, it would “undoubtedly force some doctors to stop seeing Medicare patients altogether.” 

So now we have teachers, firefighters, poor people, disabled people, nursing home residents, and Medicare patients - you'd have to be Satan Incarnate to vote against this money! (this is starting to remind me of the SnL classic: Steve Martin's Christmas Wish)

Look - we all want all this stuff.  No one wants teachers to lose their jobs, or for doctors to stop seeing Medicare patients.  But States are required by law to balance their budgets.  There are other solutions, and I don't just mean "hoping that the stock market comes back,"  which, horrifyingly,  has been suggested on more than one occasion recently.   Debts must be restructured, benefits must be scaled back, belts must be tightened, and, simply, spending must be less than revenues.  

If, instead, we just resort to Federal bailouts for every state who fails to balance their budget, the result can quickly spiral downward into a Tragedy of the Commons nightmare - where each state lacks the incentive to exercise fiscal prudence, knowing that Uncle Sam will be there to pick up the tab.

No - we're not there yet - this article was about, specifically, teachers and medicare - but once you open Pandora's Box of Bailout Bucks, it can be very hard to close.

-KD

p.s.: I wrote, two weeks ago, an analogy: " Greece : European Union :: Troubled States (CA, NJ, MI, NY) : United States.   Greece is a model for the pending budgetary crises in our respective municipalities, who cannot print their own currencies."