Salmon Upstream, LLC

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One of the difficulties we are seeing in the world of healthcare parallels an underlying issue throughout our society: personal responsibility.

One of the difficulties we are seeing in the world of healthcare parallels an underlying issue throughout our society: personal responsibility.

Sitting in the office of Virginia State Senator Mark Peake listening to a discussion between another Lynchburg physician and his aide (Senator Peake was in a committee meeting). The aide talked about how the right of a patient to choose a particular treatment option, even if not in their best interest, needed to be preserved. It’s not the state’s job to say what is best for people.

“But when that choice comes back and results in serious medical issues that the state has to pay for, that’s a problem.”

The new law that is changing the way providers in healthcare are reimbursed (MACRA) is leading a shift to pay for performance, a very good thing. But how much of your health is the responsibility if the healthcare system, and how much are you responsible for?

We have good data that shows under-resourced people, those struggling below the poverty line, do not have the same outcomes as those with better access to services. I am going to leave that discussion for another day, because it also has implications that reach far beyond just healthcare. Instead, let’s just focus on the average Joe and talk about where we think the line should be.

One in five American’s smokes. It’s a right, it’s a personal choice, and provided others don’t have to breathe the second hand vapors, it doesn’t have anything to do with anyone else. Or does it? This is an area I take particular issue with as a member of our multidisciplinary lung cancer program, a program that wouldn’t exist were it not for smoking.

Based on data from the national cancer institute, the cost of the initial treatment of a new lung cancer patient is about $60,000. (2010 data). There are about 210,000 new cases of lung cancer per year. (2013 data).

That’s $12,600,000,000. Just on lung cancer. Per year. Yes, it’s true that not all lung cancer is from smoking (only about 90%). But only 15% of smokers get cancer, and many more get other debilitating lung disease and heart disease, so you are only scratching the surface of the costs. Is it right for the other 80% to pay the costs of the habit of 20%? Not everybody thinks so. Australia continues to raise taxes on cigarettes, with the primary goal of reducing use.

As emotional as I am about this topic, even I know it’s not that easy. Ask any ICU provider about the costs of alcohol. We have tried banning it. It didn’t go well. So where does the level of responsibility start and stop? As someone who enjoys activities (mountain biking, sports car racing) that some might consider unnecessarily dangerous, I want to preserve personal liberties.

What about just going to your doctor? There is enough data to support the benefits of an annual physical that Obamacare requires insurance companies to completely cover such visits outside any deductible. Many of the performance metrics that physicians are going to have to meet require a patient shows up to that visit. But you can’t require it.

Education is critical to self-sufficiency. How much responsibility falls on the teachers and the school system? How much is on the student? How about the family? You can’t force someone to get an education. But failure to do so greatly increases the chances that the person will end up needing public assistance.

And vaccines. Allowing people to opt out of vaccinations not only increases their own risk of disease, it also ups the risk for the rest of the population. I have heard parents object to the HPV vaccine (which is working even better than hoped) because the targeted virus is primarily sexually transmitted. Since I see things when they go a bit further (cancers related to HPV virus), I often wonder if those parents would object quite as loudly if they had to sign a statement saying that their child would be ineligible for treatment of any disease related to the target of a vaccine, for life. Even stating that as part of a hypothetical discussion sounds completely barbaric. But sometimes we see bad outcomes despite our best efforts of treatment. We have dramatically reduced the death toll of cervical cancer, and yet over 4000 US women died of the disease in 2013. It’s hard for me to imagine denying my daughters any level of protection against such a fate.

Like most issues, it’s complicated. And there are more than just 2 views. But it does need to be worked out – preferably in a civil and productive manner.