Monday, June 14, 2010

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."


*** 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?


Anonymous said...

Free means you get what you pay for.


No free health care.


Mark said...

What could be a bigger incentive than living. Or, conversely, a bigger disincentive than DYING!!!!

Transor Z said...

Free vodka nips for alcoholic homeless to take their TB meds? Sure! Free clean needles to IV drug users? HMO premium discounts for gym memberships or weight watchers? Free smoking cessation programs -- free means payment.

Natural selection happens at the species level also. What happens to a species that can't get its collective shit together?

PRS said...

KD- interesting article and great subsequent commentary.

While the "disincentives" approach would ultimately, IMHO, be the smartest approach and most effective method, the people in charge of making these decisions don't have the stones (or woman-stones) to sound like the bad guy/girl for suggesting these ideas (ideas that increase national welfare via a negative feedback). Not being able to show "tough love" in this country will be a major factor in the demise of it (when the crutches break, people fall). It is too expensive to accommodate mass ignorance - whether it is in the realm of personal finance, medicine, etc. The only way to teach people to be responsible in the LONG-RUN is to have negative consequences for ignorant actions rather than a piece of cheese for completing a one-path, linear maze which could get boring after a while (e.g. let's say someone doesn't win the "med lottery" in a few months - the will probably lose interest which defeats the purpose of the exercise; the incentives, over time, don't become "enough").

Steve said...

Shut off their cable TV for a day for each pill they skip. Works across all income levels and avoids fining people in poverty (yes, they have cable too).

TraderRob said...

Kid, your stuff is truly gritty. Can't say I've seen a style this fresh in a bit, and it's def a breath of freshness...

Let 'em die... If they can't remember the medicine they deserve a painful farewell.

Thanks for bringing something to the stage that a guy who scours the net for substance can tolerate.

Check out my stuff too if you'd like.


Anonymous said...

Death of personal responsibility has been occurring for a long time. See: Law, Tort. Somebody else is always responsible for whatever it is that is bad that has happened to me. An attorney is ready and waiting to help.

Yangabanga said...

Great post. You know I'm there.

schtoonkmeyer said...

I believe that these are the same folks that took out loans (mortgages) they could not afford! Unbelievable.

Anonymous said...

i saw a bumper sticker once that said:

"too bad stupidity isn't painful."

enough said.

Anonymous said...

Enjoyed your column, but I've had this argument (in various and sundry forms) with my father, and I think you are missing the point.

The point is that a certain segment of population can't be incentivized or disincentivized. So the question for society is what to do with them? We have chosen (for many years now) to pay them off. That's what the social safety net is all about and that's why people can manipulate the system. And really - it is a pay-off, because we are basically paying these people to stay (as much as possible) out of our consciousness and lifestyle.

Okay - let's stop the payoffs. In addition to stopping paying people to take pills, we'd have to stop welfare and unemployment insurance and social security and stop making nice prisons and what-not. Then what? What does society do with these people who have nothing to eat and nowhere to sleep and nothing to lose in case they do see something they want?

Yes, in a perfect world, people would act best for themselves and for society. I for one would enjoy moving there.

Daniel said...

Following on to anon of the last post, the people who can will always pay for the people who can't. This is sort of, on a very basic level, what the republican party USED to try and change. Because they had the wealth and the power and didn't want to share with people that couldn't or wouldn't "pull themselves up by their own bootstraps." I just channeled my father there for a second, he of the Republican ideals, never gave a dime in charity to anyone except the Catholic Church and was baffled his entire life as to why people weren't and didn't behave like he did. But I digress. In San Francisco, public health officials, in cases of Tuberculosis, have to pay visits to certain folks and watch them take the antibiotics to make sure that they didn't spread the disease. TB being particularly contagious. One would think having TB would be all that it would take to incent one to take the medicine to kill it. One would be wrong.

Kid Dynamite said...

anon@1:42pm - i was with you in your first paragraph, but i don't think the second paragraph is the logical conclusion. paying people to take pills is not at all the same as providing welfare and social security.

most people are in favor of some sort of safety net, and guess what - healthcare to provide the pills for the people who need them is that safety net. if they don't want to take them, at some point we have to turn to a more darwinistic solution. since we know that's not practical, disincentives can absolutely work - and there's nothing wrong with making them harsh

Anonymous said...


Right on. Public health is a "whatever works" area, up to and including quarantine and involuntary hospitalization.If incentives produce a net savings and control contagious disease, I say yee-ha.


EconomicDisconnect said...

Great rant!

It's a tough one indeed. This area is always a mix of things.

Consider the avtivities of running/jogging and rock climbing. Clearly both hold long term benefits health wise, yet both are leading causes of orthopedic surgery repairs. Knees, ankles, wrists, you get the idea. Do we incentivize for the activity to cut down on health care costs or do we disincentivize the activity due to the enormous costs os surgery and recovery therapy? A mix? How is that figured out?

See, it's a mess.

Anonymous said...

@KD - I think paying people to take pills - just like paying women not to have children - is exactly like welfare but on a smaller scale. We think it's a lower cost to pay these people than deal with the consequences of what we consider inappropriate behavior.

My other point is that people can talk about disincentives and darwinistic solutions all they want, but until we as a society are ready to deal with people who have nothing to lose, it's probably going to be a lot less costly to society just to pay them off.

Kid Dynamite said...

anon, i absolutely understand what you are saying.. but there's a big difference between having to incentivize someone to do something they are already incentivized to do, and other welfare examples. Some people don't have the means to earn money for food - so welfare programs take care of them. But not having the means to remember your pills is not a cost that should be borne by society.

the point about people who have nothing left to lose is spot on - but most people are not in the "nothing left to lose" camp. an earlier commenter said "take away their cable tv"... simple things like that - that seem Orwellian and intrusive... practical? maybe not. but philosophically reasonable? absolutely.

the "it's a lot less costly to pay them off" argument collapses when everyone decides that they want to be paid off too.. Moral hazard (or what i referred to as Tragedy of the Commons, even though it's not really TotC)

Anonymous said...

KD -
You have to check out psychological motivation research:
The biggest problem with this program is not paying idiots to take their meds - the problem is when the program stops. Once the motivation ($) is removed, we know the dummies that needed the external motivation will stop taking their meds. The bigger problem is a new group of dummies will emerge that will no longer be motivated to take meds because the external motivator ($) is removed. This program creates a group of “new dummies” who will no longer be intrinsically motivated…the program will destroy the motivation of taking meds for the sake of health. So once this program ends, we can all pay for even more idiots that don’t take their prescribed medication.
While we are at it…can we motivate young urban minority girls to not take birth control and have more babies?
-Mrs Big Show

miles said...

Let's not forget personal responsibility for mortgage brokers who push loans on people who clearly cannot afford them. Or pharmaceutical reps who push ailments for pills they have for sale to people who are not sick. Personal responsibility only works if everyone is willing to do it.

And..not than I am a fan of the paid pill pushing thing. But consider it from their perspective for a second. If you are very poor, a bit of money makes things a better. Better than being well just so you can go on living poor.

fasteddie said...

your "morality" argument is getting in the way of simple economics. If these folks don't take their medicine, the cost of treatment GOES UP. If these folks are among the 45% insured by the government ( medicare/medicaid/Veterans/Gov. Employees and their dependents ) then these folks not taking their meds is COSTING YOU MONEY.

Look at the situation without assigning "blame" or being judgemental.

1) If people don't take their meds, COSTS GO UP.
2) Finding a way to get them to take their meds will make costs go DOWN.
3) Adding "prizes" gets folks to take their meds for a very small extra cost with no extra regulation.

If you quit trying to be indignant about it, you would see that the problem has been solved very cheaply. At a cost of a few raffle prizes, lots of folks took their meds better and made costs go DOWN. How is this not a "win"?

Quit trying to force your moral values on people. Step back and see it for what it is - a problem with a cheap and effective solution.

Kid Dynamite said...

fasteddie - really? you're gonna fire me up on friday morning? ok - i'll bite:

of course i understand the economics of it - i explained that in the third paragraph of the article.

what the economics don't take into account is the effect of the moral hazard of this nonsense.

See, when you pay one idiot to do something they should do anyway, then all the other idiots want to get paid for it also... and the downward spiral exacerbates.

and where do you draw the line? as the NY Times commenter noted:

""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?"

sometimes people need to do the right thing without being coddled or rewarded for it. and if they aren't they should be punished. DISincentive, not incentive.

Anonymous said...

Absolutely loved your post - it sure hit home for me! I'm diabetic, and if I don't take my insulin, not only will I die, but it will be a long, slow, painful death, leaving behind my two-year old. I do see plenty of diabetics die, however. And most of those have bitched about being diabetic the whole way out. I believe that people inherently NEED something to whine about. They have to whine about their disease, the cost, how unfair it is... blah blah blah. Get over it. Take care of your business. Simple, take care of it. No one else can manage your finances, your health, your education but YOU - and if you're too stupid to do it, you're a darwin award.

Anonymous said...

An alternative to creating incentives or disincentives is to simply identify non-compliant patients and allow insurance companies to take life insurance policies on them.

Anonymous said...

Sorry Kid, dumb rant.

The study just tried to see if incentives would have an affect. It wasn't proposing a policy.

The lottery aspect was meant to solve the moral hazard. It probably does, too.

Good to know you value ideology over pragmatism and evidence -- Do you invest that way too or is that sort of behaviour only good for running a country?

Kid Dynamite said...

huh anon? the lottery aspect WAS the moral hazard. and it WAS proposing a policy - not just proposing it, but enacting it.

you are more than welcome to favor crap like this - and i can only promise you that you'll disagree with my views if you think that paying people to do shit they are supposed to do anyway is a good idea.