Self-Directed Care

If we reflect on our own health-related behavior, most of us know that when we directly have to pay out of our own pockets for health care, we tend to be more thoughtful and careful about our choices and when it is our money we feel that we have a wider range of choices to select among.  Public insurance programs in the United States, such as Medicaid, and in other countries, including England, Germany and the Netherlands, have explored whether a similar sense of self-responsibility can be created in these systems, by giving patients a personal budget for some or all of their medical needs.  An informative report from the Commonwealth Fund explores these innovations.  (Commonwealth Fund Issue Brief)

These “self-directed care” programs started with long-term care patients, who are often covered by Medicaid in this country and by the national insurance schemes in other countries.  These programs gave beneficiaries a set amount of money to use for certain covered services and helped them plan a budget for how to use it.  Controls are in place to minimize abuse and avoid failure to get needed care, but generally the individuals have wide latitude to pick the services and the providers they desire.  While most of the programs are small, to date patient satisfaction is high, quality of life is better and costs appear to be no higher and sometimes lower.  Now advocates want to expand these programs to other individuals, such as those with chronic diseases.

The success of these programs should be no surprise to those who understand human behavior.  People feel better when they are trusted to be in charge and act more responsibly when they must bear the consequences of their choices.  Assisting the people in these programs with information and training in planning helps them make good choices.  No one understands an individual’s needs, wants and preferences like the individual him or herself.  So why did we just enact a “reform” that does absolutely nothing to move the system in this direction, in fact exacerbates the problems caused by individual alienation from the economics of the health system?