July 10th, 2011

complaining about _The Innovator's Prescription_

There are all kinds of problems with this book, but I'm really getting stuck on one of them.

The authors argue that people are better at sustained efforts to improve their financial health than their physical health. They argue that people could be convinced to work harder on their physical health if it were connected to their financial health. Then they say there are regulations making it so employers cannot differentially charge some employees more because of their health status. Then they say, we should make it so that employers can decide how much/whether to contribute to each employees HSA, based on their compliance on treatment for chronic disease and, in the event of inadequate compliance, to redirect what would have gone to an HSA to insurance against likely higher complications down the line. It is wildly unclear what they mean by chronic disease in this context, because they mean different things in different places. In a footnote, they suggest this is already happening, because the state of Alabama, in September 2008, "announced that it would begin charging additional premiums to employees for health risk factors and, for those found to be at higher risk, failed to see a doctor free of charge to discuss those risk factors". Without getting into whether this is or is not an accurate summation of the state of Alabama's actions, there's a _huge difference_ between requiring an employee to get some form of physical and then sit through a lecture/participate in a discussion of the results of that physical and requiring an employee to comply with a regimen of treatment (which they may or may not agree with) based on a diagnosis (which they may or may not agree with).

How about an example.

Let's say a woman is diagnosed with hyperlipidemia and is prescribed one or more statins to treat it. That's a chronic "disease" (a pretty common one, likely to turn up in a state of Alabama style screening, because you find it with a blood draw) and that's a typical treatment. Let's say she takes the statin for a few days (or weeks or whatever) and decides that the side effects are really awful. Specifically, let's say she's got fairly significant muscle pain that has caused her to miss one or more days of work. Assuming the employer can actually detect that she is not taking the drug, they then ding her on contributions to the HSA. Does this seem reasonable to you? Should she have to, say, go see a doctor and argue about whether the side effect is bad enough to justify ceasing treatment? Should she be required to try each other statin in turn in an effort to find one which doesn't have that or some other side effect? Do we really know that statins actually do any good in women? Do we really know that whatever good they are doing might somehow be better than avoiding the side effect risks, particularly in a woman who has already detected one of the kinda-bad-and-might-get-really-bad side effects?

Do we really want to apply this kind of crude, behaviorist intervention to a medical decision? And if we _do_ apply this kind of crude, behaviorist intervention (and let's say the money that doesn't go into the HSA really is used to buy more longer-term insurance for her, so it's not just an opportunity for the company to save money off her -- altho if they self insure . . .) and over time we learn that we dinged a bunch of employees for failure to comply with a treatment regimen that ultimately turns out to be wildly harmful, can the employees who _did_ comply then sue the company for the damage to their health? Can the employees who were dinged sue the company for lost benefits?

Returning, now, to the enormously sticky question of, how does the company detect non-compliance, I'm pretty _damn_ sure we don't want our managers or even people in HR looking over our medical records, so it's going to be a health care professional reporting some sort of thumbs-up-thumbs-down and it can't be too detailed or it turns into a whole lot of HIPAA violations. So who gets to make this determination? Do we get to appeal it? How does the appeals process work? Can we just _lie_ to the doctor, the way people usually do, and say, yes, doctor, I took my pills, never mind that I've quit filling the prescription, or is someone going to check to make sure we bought the pills. If they check to make sure we bought the pills, and it makes sense (on an HSA basis) to buy the pills and throw them away to get the contribution (that is, the contribution to the HSA exceeds the out-of-pocket for filling the scrip for the statin), is that good enough or are they going to demand blood draws that show we actually _took_ the pills? And will that be once a week, a month, a quarter or what? (And does any of _that_ make sense for a corporation? Does that benefit the bottom line, to fill a bunch of unused prescriptions to guarantee an HSA contribution -- because this is a classic instance of perverse incentives?)

This all sounds a wee bit intrusive to me, but it actually gets worse.

Let's say the employer says you-must-comply-with-prescribed-regimen or I take this money away and it's _really really really obvious_ that the amount you'll by out by complying will be vastly greater than the amount you'd be out by _not_ complying. And that you have _other_ medical expenses. For example, let's say the amount they'd ding your HSA would be $100, complying would cost you $300 (for copays over the course of a year) and you also have to buy eyeglasses or go to the dentist or whatever.

I'm sure, in the authors' heads, this was a very different scenario. They were thinking, okay, someone has high blood pressure but they are too lazy to regularly take their diuretic (super cheap, off patent, no-copay for generic) and they keep landing in the ER when their blood pressure spikes after they take their grandkid to the ball game where they have a couple hot dogs but their wife tells them to lay off the beer because every time they have one they start a fight with someone. Grandpa is enough of a skinflint that if you tell him they're taking $200 out of his HSA if he doesn't take his water pills, Grandpa Will Take His Water Pills (in fact, grandpa might get so reliable about the diuretic that he could generate a low bp event, but never mind that now). It's nice and clear: they can tell he's taking his pills because he doesn't land in the ER on a Sunday afternoon and he's a helluva lot less likely to have a fatal cardiovascular event before he retires (whenever that might be).

But I'm betting there are more women who have quit taking statins for hyperlipidemia (and for damn good reasons) than there are men who forget to take their diuretics on a day they're going to have a couple hot dogs and sit in the sun without drinking a beer. The only reason we think it's the other way around is because the women are quiet and the men are conspicuous.

ETA: There are companies in the US (loose talk on fora suggests Japanese auto manufacturers running plants in the south) who have mandatory calisthenics breaks, apparently with the goal of reducing on the job injury rates (the claim is that it works). If giving employees a health club benefit is only used by the people who are in great shape anyway, why jump straight to a medical solution for chronic conditions? If the authors are talking about chronic conditions like, say, myopia or Type I diabetes, that's one thing, but they were really vague and the surrounding text suggests they are thinking more along the lines of obesity, smoking, type II diabetes, and related issues. Why go all medical on that stuff? Why not just require everyone to spend 20-30 minutes of their day in an onsite gym? Make it a job requirement, schedule it into the day, provide a trainer benefit to make sure they know what they're doing and to make sure their routine is adjusted periodically to reflect changes in health and fitness status? If we're going to be intrusive, _let's be effective, too_.

ETAYA: This guy _really_ likes the idea that your employer in conjunction with a "disease management organization" could reduce health care costs by "profiting from wellness". I'm still trying to figure out what this means, but I'm fairly certain that it's another one of those ideas that sucks money out of the system for the people who need it least by promising huge savings that somehow never actually materialize. Or do, but mysteriously materialize for non-participants even more so.

As near as I can tell, from encountering UnitedHealthCare's version of this for prenatal care and for asthma, these operations basically call you on the phone and read you a list of questions from a script which includes what they should then tell you based on whatever answers you may or may not have supplied. It's intrusive and unhelpful, altho the people deploying the scripts are, at least in my experience, kind and sensible women who are doing their best in what is presumably a less evil gig than telemarketing. I'm still looking around for _any_ indication that this kind of thing improves outcomes by _any metric whatsoever_. It looks like it's still in the hey-it-seems-reasonable-so-it-must-work stage.

If you have run across a study of outcomes for operations like Optum Health, Healthways, etc., I'd be interested in whatever you have seen and what your opinion of it is (define it freely: your opinion of Disease Management Organizations, of any study or write-up you saw of them, etc.).

I should probably give a specific example of what I mean by "unhelpful". When I was pregnant with A., I was hoping for a VBAC and had found midwives who were willing to help me (of course, when I was at 42 weeks and still not in labor, that was the end of that plan). I explained some of this on the phone during one of the prenatal care calls, and the woman had no idea what "VBAC" meant. "Unhelpful".

ETA still more:

Great story about QuadMed of Quad/Graphics, altho I can't help but note that this is just wrong-headed: "we'd expect that Quad/Graphics won't be in the business of managing employees' health care forever." QuadMed has already opened another clinic for another company (maybe more than one); given what's happening to printing, I sort of expect QuadMed to survive Quad/Graphics in the same way that the DCU survived DEC.