Patient Accountability: Is it reasonable?

I am puzzled by Canadian federal and provincial governments’ collective reluctance to make patients partners in their own healthcare by expecting them to accept certain responsibilities for their own health and for the sustainability of the healthcare system. Why does it seem unreasonable to governments to ask citizens to meet a minimal set of expectations in relation to health care? All Canadians pay taxes, follow traffic laws and remember to get their passports renewed. Why would they not manage similar expectations in relation to their healthcare? Healthcare is thought to be a right by many Canadians – don’t we expect to have responsibilities related to rights? Why wouldn’t we be as accountable for our health care as we are for our taxes?

The issue of patient accountability is important for me as a physician. Whenever I see resistance by the government to patients accepting reasonable accountability, it feels as though the government is saying that the responsibility for the sustainability of the health care system mostly rests with frontline providers, especially physicians.

The Government of Ontario seems to like many aspects of Kaiser Permanente’s model for health care delivery so I thought I would see what Kaiser expects of patients registered in their programs, just to see how far-fetched my notions of patient accountability are. This is a link to the section of Kaiser Permanente’s website called Your Rights and Responsibilities. The section has a list, first of all, of rights. A quick read through this will show that these are the same expectations of any Ontarian of the Ontario Health Insurance Plan, although some of these include such statements as: “Receive emergency services when you, as a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed.” The next portion is about patients’ responsibilities as a client of Kaiser Permanente. There are sixteen expectations in all, grouped under three broad categories: Promote your own good health; Know and understand your plan and benefits; Promote respect and safety for others. All are reasonable; all would be easily adaptable to the Ontario situation.

So what is the big deal? Unfortunately, Minister Hoskins has often said that health care is “free” – he did this last flu season, suggesting patients get their “free” flu shot at their nearest pharmacy. Leaving aside the fact that health care is not at all “free” from a financial perspective, it sounds as though governments believe that “free” should also mean “free from any inconvenience or expectation of the patient”. But we don’t say this for other government programs – try being free from the “voluntary” aspect of your income tax, or paying a parking ticket. You’ll soon learn that the government has ways of making you meet these expectations. When health care is the single largest budget item for a provincial government, why not expect the same attention to missed medical appointments, or seeing multiple doctors through walk-in clinics? It almost seems as though the government knows that this is one of those places where you can let someone else be the bad guy. You can let me be the one to say, “You missed two appointments with no notice and, as you were told at the outset, we will not continue to see you at the clinic if you miss appointments without letting us know.”

Now that Ontario’s ability to provide health care is being limited by the resources available to fund it, now that all other efficiencies in the system have been found, is it not time to turn to patients to ask them to contribute to the system? Is it not time to say, “There are some ways you could make the system more sustainable”? This is true in Ontario, but it’s also true in the rest of Canada as well.

The Ontario government is so desperate to find resources for health care that cuts to both physician and hospital services are continuing. However, it seems that legislators are not so desperate as to risk the anger of voters by asking patients to be accountable for those elements of health care that they control. I think that most citizens are committed enough to the health care system that they would welcome the chance to make it better. As baby boomers see how cutbacks are affecting health care, either through their own experience or that of family members, they are realizing that there is a role for them to play. It’s time to ask everyone to embrace accountability.

6 thoughts on “Patient Accountability: Is it reasonable?

  1. Pingback: Patient Accountability II | Dr. Gail Beck

  2. I remember trying to give an oral economics exam to a student who saw all the problems of the world in terms of corporate responsibility for individuals problems (some are, but not all). Finally I had to write the following definitions on the blackboard (yes I am old) – 1) Economics is the science that tells us how to best distribute our scarce resources while, 2) Sociology is the science that tells us why we have no scarce resources to distribute. I see the article by Dr. Beck as an excellent example of the difference, i.e., scarce resources (time/money/manpower) cannot be properly distributed unless they are considered valuable by the people receiving them. If they are not considered valuable, but still considered as an entitlement that individuals are free to waste without penalty then this a problem leading to why limited services may not be able to be provided to a greater population within available resources. Pedantic as this may sound it means that people wasting the resources are denying limited service availability to others who may require them. Since it is up to those responsible for the distribution of the resources (government) it is also up to them to make it clear to users that they are responsible for waste they cause and this has costs not only to the providers but to users as well. Unfortunately, governments are loath to deal with any problem that can be passed on to others such as the direct service providers so these problems are likely to continue for the foreseeable future regardless of the logic.

  3. While I agree with the idea of responsibility, the vagueness of “Promote your own good health; Promote respect and safety for others.” makes me very nervous. Who shall judge what promoting good health will mean? What if I am deemed ‘non-compliant’ because I’m burned out from managing a chronic illness and therefore denied provincial health coverage?

  4. Excellent article..we who are the consumers of healthcare should be mindful that there is no such thing as a free ride. We tend to abuse and disrespect those very services that we think we are getting for free. We must act responsibly and contribute to make the system more efficient and less costly. The point about missed appointments is so appropriate. Politicians are afraid to engage citizens to be responsible for their healthcare. It is more convenient to pass this on to the providers who must then be the ogres in the system. This should be explored more fully. Thank you Gail. Do you have any other thoughts as to how we can be more useful in this area. Worth exploring.

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