Skin in the Game

In the healthcare reform debate, one strategy potential cost containment strategy rests on the idea that patients should have a greater financial stake in their care. They reason that patients that are financially penalized for unhealthy behaviors will quickly change them and thus bring down costs (or at least pay more for their greater need for care). The idea has some merit, after all a lot of modifiable behaviors, such as smoking and diet, lead to higher health care costs.

A recent study in the NEJM analyzes this by comparing two groups of medicare enrollees: those with copayments that stayed the same and those that had their copayments doubled (to both PCP and Specialty docs). If we buy into the argument above, one expects that the higher monetary cost would provide a disincentive to overuse healthcare services.

Interestingly, the results showed the higher copay plan resulted in fewer outpatient visits but increased overall hospitilizations as well as days in the hospital. Apparently, increasing copayments created a perverse incentive: instead of making a cheap doc visit when they had a preventable or more cheaply treated condition, people waited until it got worse (hoping it would go away, which some issues probably did) and then ended up requiring more expensive care.

Caveats: this was among medicare patients, who are elderly (read:expensive) patients, but the results are compelling. If we are going to incentivize patients to take control over their healthcare costs, this doesn't seem to be the way to do it.

Perhaps as an editorial pun, the NYTimes Health section also ran an article about Henrietta Lacks, the women whose cervical cancer gave rise to the HeLa cells that revolutionized the development of numerous vaccines and medicines. A boon to research...and profits! Oddly, in this case a patient's skin was literally in the game, yet while society benefited the patient (or family) didn't see any kind of reward (the book looks really fascinating!). Another case arose later that went to court in the 80's and found that the patient in question didn't have the right to the billions of dollars made from their cells removed in a surgical procedure. The issue has not gone away though, as noted by NEJM. Perhaps some kind of mechanism to recognize the patients (and at least respect autonomy by asking!) or drive some of the profit back into controlling health care costs is in order?

It simply goes to highlight that our collective, and individual, bodies and paychecks are tied to healthcare in such intimate ways. Of course, I write this as a MS1, I wonder what I'll think of these words in a few years...