Making individuals more responsible for their own health seems intuitively like a good idea, but it’s hard to work out the details of any program to make that happen, and we don’t yet know what works and what doesn’t, according to articles in the August 24, 2006, issue of the New England Journal of Medicine.

If individuals do all the right things—exercise, maintain a healthy weight, don’t smoke or abuse drugs, practice safe sex--does that meet the personal responsibility requirement, or is there more—keeping doctor’s appointments, for example, and not using the emergency room except in emergencies? And is there a suspicion that a lot of the advice individuals are being given about their own health may not be saving money or improving health but just shifting the onus—and the cost—to patients instead of their insurers or healthcare providers?

One state, West Virginia, is currently trying the personal responsibility idea in its Medicaid program, and the journal’s authors see implications beyond its effect on needy West Virginians. Especially, they note, it raises a lot of issues for healthcare providers.

The West Virginia plan, which was speedily approved by the federal Centers for Medicare and Medicaid Services (CMS), was said by CMS administrator Mark McClellan to make Medicaid enrollees in West Virginia "part of an emerging trend in healthcare that empowers patients to make educated, consumer-driven decisions related to their own treatment." What that involves, specifically, is that West Virginia Medicaid recipients are being required to sign contracts pledging to take their medications, keep their appointments, participate in healthcare screenings, and adhere to health improvement programs as directed by their healthcare providers. Patients who don’t uphold their end of the bargain will have some of their Medicaid benefits reduced or eliminated.

Any healthcare provider would welcome patients who were so compliant, but in general, physicians and other clinicians continue to provide care even when patients do not cooperate, the articles note. The authors believe West Virginia’s plan violates all three fundamental principles enumerated in the Physician Charter on Medical Professionalism—the primacy of patient welfare, the principle of patient autonomy, and the principle of social justice. On the point of social justice, they point out that the plan will penalize Medicaid patients for circumstances that are frequently not in their control—missing appointments because of lack of transportation or the need to stay home with a sick child, for example.

And what physician, they wonder, would recommend that a person with diabetes who misses appointments lose the ability to attend diabetes education classes? And what physician wants to be faced with a sick child with asthma whose benefits have been reduced to four prescriptions a month, when she gets pneumonia and an antibiotic would make five?

Officials in the West Virginia Bureau for Medical Services point out that in addition to the penalties for noncompliance, Medicaid beneficiaries will be rewarded for adhering to their membership agreements with age-appropriate services that focus on wellness, including diabetes care beyond basic inpatient and outpatient services, cardiac dependency and mental health services.

The articles "Imposing Personal Responsibility for Health" and "Personal Responsibility and Physician Responsibility—West Virginia’s Medicaid Plan" appeared in the August 24, 2006, issue of the New England Journal of Medicine.