Personal Accountability

This has always been an interesting topic to me. Some of the events of the last few weeks ranging from athletes punching one another out to kids returning to school seems to make it particularly relevant.

A colleague and I were discussing this topic the other day especially as it pertains to health care. Isn't it interesting for all the debate about whether there should be single payer, a public option, how much it will cost, etc. there is little discussion about the individuals role in the whole health care discussion other than as a beneficiary.

I have some pretty strong opinions on this topic. Among them I believe that all Americans should have access to a basic level of health care much like public education and that until we provide that the costs will never really be managed.

I also believe that individuals have a right and responsibility to participate in the management of their own well being and health. We don't talk about that very much. I would venture to say that the majority of Americans who have health insurance are also covered by a group plan- employer, government agency, association, etc. so they have little understanding of how much their health care actually costs and care less until it impacts them in the way of increased co- insurance, higher deductibles, denied claims, or related activities.

I have mentioned a couple of other related concepts regarding health care like our inefficient delivery and focus on the costs of processes rather than paying for outcome based management, but this is a different issue.

I remember years ago when a new employer arrived in town and declared a tobacco free workplace. People were outraged. How interesting? An employer who took the position that if you knowingly contributed to the detriment of your own health they didn't care to subsidize your real or potential higher expenses so they wouldn't hire you.

We tried to pass a law recently requiring all restaurants to post calorie counts for everything on their menu, luckily it failed. Would we want to extend that to homes like the dram shop laws?

Dram shop laws extend liability to private individuals for serving intoxicated people or allowing them to depart your home intoxicated without at least attempting to intervene. Can you see requiring a menu with calorie counts at dinner parties?

I think a big part of the issue is that of personal competency. Personal competency is that "other" right that constitution provides us with in addition to the concept of personal property.

When we began to industrialize and people left the "farm" many went to work for large employers. Large employers responding to both collective bargaining and offering competitive compensation began offering "fringe benefits" including paid time off, retirement and pension plans, and group health insurance benefits. A few years ago it was not atypical for employers to pay all the costs for health insurance for employees and their dependents. Employees had no idea and didn't care what they cost. Add these third party payer systems to advance health care techniques, technology, and a few other things and we created a trillion dollar health insurance industry, and very high expectations.

Very few employers to my knowledge even today talk extensively with their employees about ways they can contribute to lowering health care costs. The idea of "mandated" health screening, enforced wellness, and sliding employer contribution rates based on lifestyle health care costs would probably be seen as some type of corporate fascism. Your employer shouldn't be able to tell you how to manage you lifestyle, right? Even if they pick up the majority of the cost....

I believe until we address the personal accountability issue and employers
actively engage and educate their employees about the root causes of many of the costs we will only be addressing part of the problem. What do you think?

A "Healthy" Debate

I have been following the discussion and debate around our health care crisis and alternative solutions with particular interest. As a human resources practitioner and consultant I have probably been involved with health care in one fashion or another for thirty years.

The discussion of whether or not we should have a national plan is particularly interesting, as is the general debate on where the "fault" is for where we are at today.

I used the word crisis because I believe we really do have a crisis. Although I think we have some of the most sophisticated systems and processes in the world we have huge issues with our delivery system. It is also interesting to me how little the average person understands or aspires to understand the health care system.

I had a chance to listen to a HBR (Harvard Business Review) Idea Cast with Dr. Richard Bohmer the other day. It was probably one of the most succinct discussions of the issues with health care that I have heard in years. Dr. Bohmer points out that there are really are three major issues with our health care system in his mind: how we define a service, how we finance health care, and how we deliver health care. I found his discussion really valuable. He also gives a great explanation of the difference between managing health care which deals with defining and delivering services as opposed to "managed care" which he refers to as an insurance or financing model. I won't bore you with all the details, but I will tell you it is a value added 13 minutes to listen to his interview.

Health care is delivered and defined in his opinion currently as a series of separate events beginning with diagnosis and then proceeding through treatment and "follow up". He argues that health care delivery and costing should be based on outcomes rather than the way we currently track and price it. It is kind of like lean manufacturing or total quality; success is determined by outcome not process.

What I found interesting is most of the debate I hear is about providing access to care and financing, I hear very little about outcomes.

The other thing I find I hear very little about is the individuals responsibility in their health care. I don't mean just paying for it, I mean accountability for lifestyle choices and related activities that directly and indirectly affect health care costs.

Most of us have historically had our health care provided through our employer, our spouses employer, or in some cases the government. We pay a fraction of the real cost and understand the way it works like we understand Cantonese. The insurance industry doesn't make it much easier. For years health care was considered like paid time off a "fringe benefit". Then we noticed that the cost of that particular fringe benefit continued to go up at double digit rates long after wage inflation receded. By that time we had created an entitlement.

When this becomes particularly interesting is when we start to track connections. Jeffrey Pfeffer of Stanford believes (and I agree) that much of our health care related costs connect directly or indirectly to our work environment. If you are stressed about your job it effects your health. If you are stressed about your home life it effects your work. Some studies say it costs us $200 billion annually! In a shaky economy when you are concerned about losing your job and your health care benefits the problem accelerates.

I also believe at least at this stage there is little about personal accountability in health care delivery. We are suing Big Tobacco successfully for misleading advertising and withholding information about the addictive and health risks of smoking, but we are reluctant to reduce or deny care to smokers.

We want to label the calorie content in food, but do we want to deny or reduce coverage to those who have bad eating or exercise habits? Are we ready for employers to require wellness programs and screening as a function of company provided health care insurance?

Do companies educate their employees about things they can do to affect their health and the companies costs? Not many in my experience. Should we allow "tiered" coverage for people who deliberately practice behaviors that could or actually affect their health?

I don't mean to imply that as Dr. Bohmer points out "fixing" health care is a complicated issue, but should we be addressing personal accountability along with delivery, definition, and financing?r

To me this speaks of respect, engagement, and personal competency. What do you think?