As I suggested weeks ago, that in order for the Accountable Care Act(ACA) to work or become sustainable as a health care system for the USA, we need to have behavioral changes take place.

These behavioral changes need to come from both the patient as well as from the physician and the health care delivery system. We can reward the physician as well as the health care delivery system by increasing reimbursements or payments for the patient interaction, i.e. patient visits, patient care, surgical procedures. We negatively affect the physician and health care system by assessing penalties or decreasing what the ACA pays out for patient interactions or surgical procedures. We can also penalize health care providers by denying them licensing to practice or increasing their malpractice premiums. This way we weed out the bad players in health care, as well as bad behavior.

But how do we encourage good behavior for patients involved in their care, improving their health? How do we penalize the patient who does not want to participate in their care, persisting in their bad behavior, with no improvement in their health? In fact these patients get sicker and the demands financially and the man/woman-power investment become unrealistic.

The patients that pay their insurance premiums, we can increase the premiums, increase their deductibles, penalize them on their taxes, whether federal of state taxes. But what will the results be? Increasing their deductibles discourages the patient from seeking medical care because the majority of cost is now out of pocket. So, how does this encourage good behavior?

Increasing the premiums for patient’s bad behavior and decreasing their premiums and deductibles for good involved compliant behavior makes a lot of sense. But increasing their premiums or assessing tax penalties will not work, especially in the fully subsidized person or persons who will not feel the true effect.

In fact, will any of these ACA health care strategies work if we can’t change the overall behavior of the patients who are going to still delay their care, resulting in the continued use of the most expensive form of health care….. the emergency room (ER) for their routine care. This is a problem because using the ER sets the system up for failure due to the increase expense and the level of care needed for the patients who wait until it is often too late to for preventive care and then often result in the need for interventional costly procedures.

In a survey that I completed I had a number of participants want to deny coverage altogether for these noncompliant patients. Really? How does this contribute to a system, which is designed to provide health care for all potential patients blinded to their financial status?

Unfortunately, we are truly stuck in that we can not really penalize bad behavior in the portion of the demographic segment of patients who are completely subsidized by the government health care system or those who pay no taxes.

But we can reward good behavior. Here is the answer, I believe, to this dilemma. If they already have subsides like SNAP cards, can we increase or bonus them for good behavior? I think this is a workable solution. We may have to put on our thinking caps and design creative rewards so that these “bad behavior” patients are converted to patients who participate in their care lowering their blood sugars, their weight and who will stop smoking.

I love the idea of the British system, utilizing consumer taxing to subsidize their system, i.e. the Value Added Tax (VAT), which is being increased from 17% to 27%. Heck, raise the tax on cigarettes to 50-75% as well as increasing the tax on alcohol as well as on “bad” non-nutritious foods.

We need to be very careful in that we don’t proceed down the murky path of true social engineering. Do we deny hip and knee replacements for the obese noncompliant diabetics? Why not? They are the patients who will have the highest complication rates, costing the system a true financial burden.

Do we extend this thinking to the noncompliant patients who don’t take their blood thinners, medications for high blood pressure and heart medicines? Why not? Here we will eventual see these patients dying out and therefore decreasing the “bad” patient population. Wow, should we really conceive these strategies? Think about it. In the European system where the necessary surgery waiting times are often weeks to months, aren’t they also culling out the “bad” behavior patients? Sure, the high-risk patients and noncompliant patients then die from their underlying premorbid diseases or go elsewhere for their care. I truly cringe when I just mention these potential strategies. But what options do we have?

So, what are your solutions to these difficult problems? We have to consider these problems and come up with solutions otherwise the system will eventually fail or result in a multi-tiered health care delivery system.