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Health Care Reform and the Elephant in the Room:
Personal Responsibility
by Cary Gutbezahl, MD


When an organization has a performance problem, managers seek information to identify and assess the causes of the performance failure. Similarly, an analysis of a social problem should require policy analysts to identify and assess all significant contributors to the social problem.

The national discussion on healthcare reform has failed to meet this expectation.

The debate about healthcare reform has focused on several significant issues, such as getting financial coverage for the uninsureds’ medical needs, building incentives for hospitals and physicians to provide better care, and removing inefficiencies from the fragmented delivery system.

However, there is an elephant in the room that is not being discussed – personal responsibility for health. For years, studies have shown that up to 70% of disease is influenced by personal (not provider) behaviors. As such an important aspect of healthcare costs, this issue cannot be ignored.

So why is personal responsibility being ignored?

As healthcare providers know, changing patient behaviors is extremely difficult. The first step is for the patients to want to make the changes and not all patients want to change their behavior to get better – even if to improve their own health.

Patients who struggle with emphysema still smoke.

Patients with diabetes eat cakes and candies.

They choose to continue the behaviors that got them sick despite the counsel of their physicians and other healthcare providers. From a psychological perspective, there are many reasons why this happens. Providing better access to care is not going to change this.

Talking about the need for personal behavior change is not politically popular. Then President Jimmy Carter advised Americans to reduce energy consumption. This unpopular message contributed to his failed re-election bid. Admonishing people is not an effective way to build a coalition of support. Yet, the failure of individuals to adopt pro-health behaviors will cause accidents and disease that will have to be treated, at great expense, after disease or injury occurs.

The elephant of personal responsibility has to be addressed.

Can we effectively control healthcare costs without including individual incentives?

Assigning responsibility for patient behaviors to healthcare providers is easier from a political standpoint. But it fails to address a known driver of healthcare costs. It also has the unintended potential for creating discrimination against people who struggle to control their behaviors. Providers may terminate care relationships with patients who fail to comply with medical advice. Similarly, physicians may screen patients to determine whether a new patient is likely to fail to comply with medical advice. Ultimately, these patients will wind up in emergency rooms and other venues that cannot turn patients away.

Policy makers have a public obligation to understand the complex dynamics of the healthcare system before they propose changes that may have adverse effects that are as undesirable as the problems within the current system. “First, do no harm” does not only apply to caring for individuals.


The Author

Cary Gutbezahl

Cary D. Gutbezahl, MD, understands what it takes to make, “Better American Hospitals.” In addition to being a seasoned consultant, Cary has worked as interim hospital CMO in three different organizations, as well as served as medical director for two multi-specialty medical groups and several HMOs. Cary has a solid history of leading medical staff through improvements in utilization management, changes in peer review practices, and corrective action procedures.

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Copyright 2009 by Cary D. Gutbezahl. All rights reserved.

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