Monday, May 7, 2012

How to Improve Medical Care (and Save Money)

     I have been reading many articles recently about this plan and that plan to improve the medical care of patients, to reduce medical expenditures, and generally to make us a healthier society. All of these different suggestions have one point in common: they neglect basic human psychology. In what follows I list several interventions and modifications that should help all of us reach these lofty goals. And like any CEO, I am setting forth goals and techniques and leaving it to others to work out the nuts and bolts of implementation.

     It has been said many times that man is an economic animal, at least on an individual basis (so I am here neglecting mob psychology). A universal method that improves performance is the reward method and for humans, unlike Pavlov's dogs, the most successful reward has been money. There have also been several test programs, usually in inner schools with students who are less than interested in their schoolwork: when these students received a financial reward for not being late, or not being absent or doing all of their homework, their school habits improved. I would add the obvious statement that jockeys and college and amateur wrestlers and boxers  all seem to be able to keep their weight down, and in their cases the rewards are immense. Similarly, most runway models manage to remain ultra-slim, as do the majority of movie stars and stage actors.

    OTOH your brain is remarkable in its ability to maintain your weight by a continuous  process of homeostasis.  If we start to gain weight, our metabolic rate increases, in the brain's attempt to return us to where we were. Similarly, if we start to lose weight, the body's metabolism is slowed down by the brain, for the same reason. In addition, our metabolism slows by the equivalent of 3 to 5 pounds per year, so each year it becomes more difficult to lose weight (until about age 75 or 80). To realize how remarkably the brain does its job, consider that burning one pound of fat releases 3500 calories of energy. Thus  if you ate an extra 3500 calories in one year, you would gain one pound. This works out to micromanaging your caloric intake to within TEN calories per day, a feat that even Superman would be unable to do. So the brain is always on the job, micromanaging our metabolism to keep our weight as constant as possible.

     The Motz proposal for better health simply involves offering financial awards for achieving certain benchmarks. It makes much more sense to reward the patients, who are the direct agents, than to reward the doctors in a Pay-4-Performance program for what their patients do. We could award (possibly by income tax credit) patients who lost ten pounds in a year, or who had annual pap tests or mammograms, or had their blood pressure or cholesterol measured in the previous year. Then goals could be set, with an annual reward for achieving and maintaining a certain weight, or blood pressure, or average sugar.

     There are of course many details to be worked out and considered: should doctors also be rewarded? how and where is the weight and weight loss and annual blood pressure etc. measured and certified? Perhaps we could start a trial pilot program in a county with a low population since it would be easier to track behaviors. We would all lose 10 pounds for a reward of $1,000,000, but not for a reward of $0.01. The question then becomes: how much would they have to pay you for you to lose and keep off 10 pounds in the next year? And should these successful patients also get a medal, or ribbon, or have their names posted in the newspapers?

     I am certain that if we paid cigarette smokers $1,000/year to quit we would save much more than 60 x $1K = $60,000 in the future medical fees that would be caused by his/her continuing to smoke.




  1. It just occurred to me that perhaps rewarding all students on how well they did on their nationwide tests might create better results than rewarding the teachers.

  2. I have been asked by many readers if this proposal of mine is serious, and I have replied that if education does not work and we have no way to threaten people into good health (outside of fines for not wearing a seatbelt or a bicycle helmet) then we are left with bribery.

  3. There was an article this week in JAMA about the problem with medical compliance. The article showed that the compliance with taking daily Coumadin could be improved if the patients were entered in a daily lottery for $10, but they were only eligible for the lottery if an electric signal from the bottle showed that they had taken their Coumadin that day.