Taking responsibility

Neil has a BMI of 42.  He also has high cholesterol and hypertension.  While he hasn’t been diagnosed with diabetes, his blood sugar level is consistently on the high side.

His medical scheme picks up some of this from clever analysis of his claims, contact him and offer to enrol him on a lifestyle programme that will manage his condition and improve his state of health.  Neil says, “thank you, but I can manage on my own”.  He’s deluding himself.  In fact he continues to smoke, eat too much salt and visit his favourite steakhouse every week.  The most exercise he gets is picking up a six pack and tying his shoes (he hasn’t seen his own feet in years). To top it off he doesn’t regularly take the medicine his GP prescribed because “he forgets”.

Unsurprisingly Neil’s arteries look like corroded copper pipe.  One night he feels dizzy and short of breath and when he finally gives in to his wife’s nagging and seeks medical attention he finds himself in a hospital bed with a cardiologist telling him that he needs a multiple bypass.

Neil is an ass.  Not only has his irresponsibility caused his family distress but his behaviour has also affected thousands of other people he has never met.  If he’s on your medical scheme his operation just cost you and all the other members money.

The cost of a single Neil spread over several million medical scheme members doesn’t make much of a difference.  But Neil isn’t alone, is he?  There are hundreds of thousands of Neil clones and paying for them accounts for a fair proportion of your monthly medical scheme contributions.

Vitality is an example of trying to change behaviour using incentives – the proverbial carrot.  Discovery has amounted enough proof that it works for the people who participate and that it reduces medical scheme claims.  But what do you do with people like Neil who don’t like carrots (or any other vegetables for that matter)?

It is generally accepted that, if you are trying to coerce one of the less noble members of the Equidae family and carrots don’t work, you use a stick.  I submit to you, dear reader, that the current arrangement isn’t working – the prospect of having his chest cracked open and his heart stopped while they replace the blocked pipes with spares taken from his leg wasn’t enough to make Neil change his lifestyle.

The problem seems to be that people believe that they can live their lives however they want without consequences and when something goes wrong the docs will just fix them up, good as new.  Better yet you don’t even have to pay! Neil’s operation is a PMB.

Now let’s make something clear.  The dude needs an operation that will save his life. It would be unethical and inhuman to deny him that care.    If Neil were your dad or husband there would be none of that “it’s his own fault” talk either (not too much of it anyway).

I’m pretty sure my friends at the Council ‘for’ Medical Schemes would start and end their contribution to this discussion with “It’s a PMB and the scheme has to pay in full.”  Their thinking is neatly illustrated by a press release from earlier this year about an appeal ruling that says that medical scheme beneficiaries who are overweight cannot be denied benefits for joint replacement surgery if this is also a PMB.

“This is another victory for the regulator and, more importantly, members of medical schemes,” said Dr Monwabisi Gantsho, the Registrar of Medical Schemes and Chief executive of the CMS.  “We have once again shown that we stand up for what is right and fight to protect the rights of members.  We spare no effort to oppose any attempt to undermine the principles enshrined in the Medical Schemes Act.  One such principle prohibits unfair discrimination, including denial of benefits based on a member’s weight.”

With respect, Dr Gantsho, that is total B.S.  This isn’t a victory for all medical scheme members.  It’s a victory for fat medical scheme members who need joint replacements.  The rest of us lose out – having to pay more for operations that have a higher likelyhood of complications or outright failure because these patients are overweight without getting any benefit ourselves.

On some level you must admit that it is unfair to those who do take care of themselves.

Having thought about this for quite a bit it is clear that there is no easy solution to bring balance to the force.  We can’t punish them or withhold care but we can’t afford to keep paying for them either.  What we need to do is change an entire culture of diet and attitudes to exercise, which is really a very difficult thing to do.

Based on its track record I’m actually surprised that our government hasn’t already passed a law that makes it illegal to be fat.  The Japanese tried something like that which, in accordance with the law of unintended consequences, incentivised people to partake in dangerous behaviour such as crash dieting in an attempt to avoid the dreaded “metabo” and also induced workplace discrimination against obese people.

Why stop there?  Why not pass laws that tell people what to eat or have a government appointed handler come over to your house and poke you with a cattle prod until you get up off the couch?  Maybe we can borrow from Chris Rock’s ideas about gun control and push the sin taxes so far that a take-away hamburger and milkshake becomes a once-a-year luxury instead of a cheap and convenient meal.

Is the hamburger more dangerous than the AK-47?

Somehow I don’t see that happening.  Or working.

How about a pill?  This morning I read about a drug that has been approved by the FDA to treat obesity.  Of course if you read the actual article they are talking about it working in combination with reduced calorie intake and exercise. Now where have I read that before?

Anyways, time to come to a conclusion.

The C4MS needs to rethink what it means to protect the rights of medical scheme members.  All discrimination is not necessarily unfair.  The regulator seems to think that protecting the rights of medical scheme members means only protecting the rights of medical scheme members who claim.  The rest apparently simply need to pay up and shut up.

We are probably also going to need to think hard about a system of incentives and disincentives aimed at changing lifestyles.  Otherwise we will soon be challenging the Americans for the top spot in the heavyweight division.


3 thoughts on “Taking responsibility

  1. While I heartily agree with you, one wonders then why schemes (certainly mine) needed a doctor’s motivation and cholesterol test, prior to authorising a SINGLE dietician consultation, never mind follow up visits…

    1. Hi Polly

      I think part of the problem is that most medical schemes and their administrators still operate with the mindset of processing and paying claims. If they find a reason not to pay a claim then they saved money and did a good job!

      What we need it for medical schemes to play an active role in managing the health of their beneficiaries.

      This is particularly difficult for open medical schemes. The health and cost benefits of lifestyle changes take a long time to be seen. Why go to all the trouble (and expense) of making a patient healthy if he/she can just leave and join another scheme at any time?

      I have seen that restricted schemes (particularly corporate schemes) are more willing to take a wellness management approach.

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