No Doctor for the Obese?

by Nir Eyal

Yesterday, Boston public radio station WBUR interviewed a Massachusetts primary care physician who refuses to admit new obese patients. She claims that it’s because she lacks proper equipment, but she seems to have mixed motives. Earlier she had admitted that it’s rather because she feels that if they don’t lose the weight, “I’m paying the cost of other people’s choices.” I bet if she lacked the equipment for wheelchair-bound patients, she would go buy it.

In an upcoming post (09/07: update here), Holly Fernandez Lynch, who, along with Glenn Cohen, gets kudus for kicking off this blog, will explain whether it’s legal for doctors to reject obese patients. But before rejecting them becomes the next trend, is it right?

A whopping 35.7% of Americans are obese, and the trend continues upwards. Obesity increases risk for heart disease, stroke, type II diabetes, and various cancers. It costs the system a fortune. We must tackle this problem head on. But conditioning physician access on weight loss is not the way.

Assume for the sake of argument that providing attractive incentives for weight losers and repulsive disincentives for weight gainers—conditional “carrots and sticks”—would drive some obese people to eat less and exercise more (as though shame and discomfort cannot also drive binging on comfort food). Assume that the health risk and the social shame are insufficient to deter the obese from overeating, but that they would respond to some other (dis)incentives. Even so, it would remain wrong to make the primary care physician into a “carrot”.

One reason is that any conditional incentive for healthy choice should be in a currency that is not what we need to keep unconditional in the fight for that healthy choice—in this case, the preventative and treatment services that facilitate weight loss. Family physicians can help us lose weight and remain thin. They can pre-empt or bring down some of the personal and social costs of obesity. You might want to condition, on losing pounds, such prizes as iPods or museum tickets—not access to healthy food (like carrots), and not physicians.

This may seem obvious. Very often, however, the carrots on offer as incentives for healthy choices are the very means that people need in order to make these choices. A few years ago I discussed the following example. At the time, West Virginia’s Medicaid authorities experimented with conditional prizes for “adherent” patients only, for example, patients who keep medical appointments and take their medications. But one such exclusive prize was mental healthcare and chemical-dependency services. So thanks to the experiment, Virginians who needed psychiatric care or detox to restore order in their lives, potentially including the ability to keep appointments and take medications, now first had to have such order in their lives. Otherwise, psychiatrists and detox could remain out of reach. Makes you think—What were these West Virginian Medicaid officials smokin’?

[Edited 09/06/12 to hedge a bit on the legal issue addressed in Holly’s post]

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