The news of the day is that a program in Philadelphia is now paying patients to take their medications. Refer to the New York Times article For Forgetful, Cash Helps the Medicine Go Down. The concept makes sense in theory – the failure of patients to take their medications is one of the most common reasons that patients return to the hospital and are readmitted shortly after they are discharged. One of the most important components of a patient’s history and physical examination is the question of “medication noncompliance,” the term used by physicians to designate whether a patient is taking his or her medications – or not. Many a hospital chart carry to the notorious phrase “Patient has a history of med noncompliance…..”
This topic raises an important question: how can you convince a patient to take his or her medications? Those who take their medications do so because they want to live as long as possible; some simply do it because they are responsible, conscientious individuals by nature. But the hustle and bustle of daily life often get in the way of taking medications, especially those that are timed inconveniently (exactly at dinnertime, just before bed, or greater than two times per day). For the elderly, the mentally impaired, or the physically impaired, insurance companies will often pay for a visiting nurse to come by, at least once a day, to ensure that a patient gets at least one set of the most vital pills. But what about the rest of us? We are left to fend for ourselves in the world of pills – and it is not uncommon for patients in this day and age to have a laundry list (anywhere from 10 to 20) daily pills. I know this first-hand: I wrote an entire schedule for my grandfather’s medications on a detailed sheet for my grandmother a couple of years ago after his first heart attack. She has been following it ever since (there is a reason why married men come to the ED more often, tend to live longer, and tend to be more medication-compliant than men who live alone). And I assure this, this is no easy feat for people in their 80s with little to no education beyond the high school level: but she manages, and she does quite well. She has a strong motivation to make sure he never misses a dose and will interrupt any event to ensure this.
This brings us, in a rather disorganized fashion, to the news story I cited above: what to do about the patients who do not take their medications, and who therefore are a financial drain on the entire health care system because of the costly complications and hospitalizations that result?
My firm belief is that if these patients do not have a strong enough incentive to take their medications so they can live longer, healthier lives, then the long-term benefits of providing financial incentive are likely to be minimal. In the short-term, the rewards may be substantial enough to elicit a response. An isolated lottery-system or patient study is not an accurate depiction of the real-life scenario: patients will have to be taking these medications for decades. Secondly, the issue of monitoring medication compliance in a non-controlled setting, i.e. the real world, is also an issue: no method is sure-fire (unless perhaps it is prohibitively expensive). Lastly, one of the most important concepts about a “medication list” is that it needs to be revised (often 3-4 times a year) in order to deliver maximum benefit to the patient; so not only do patients need to take their pills, they need to see a doctor regularly and get re-evaluated in order to determine if these are the right medications and the right dosages.
The way to truly get at the question of medication noncompliance is to go to the source directly: the patients who do not take their medications. Why don’t they take them? Some people have access issues, financial or otherwise, and simply have not been able to get the medications they need (try making one phone-call to a health insurance company to address these issues, and you will immediately see the obstacle in the way). Increasing accessibility, through transportation or financial aid, would give these patients the chance to take their medications. Others have pills which are timed so frequently or so inconveniently (which require them to wake up in the middle of the night, for example), that it becomes a monstrous task to be fully medication-compliant. This may require either a re-working of their medication schedule (to take more pills at the same time), or perhaps a change in medication to something that is taken less frequently (doctors often forget how important this is when prescribing medications).
Still others have not been properly educated about the importance of their medications in the vernacular. Many patients have told me that they do not have high blood pressure because they were once prescribed a high blood pressure pill (which they may or may not have taken) – in essence, they view an antihypertensive as an antibiotic that can be used as short-term treatment for a short-term problem. I have had other patients tell me that they never had a heart attack because they were taken to the cardiac catheterization lab and were “fixed.” Nothing is farther from the truth, and as physicians we are responsible for making sure patients understand their own medical history and their own medications. I have had many patients raise their eyebrows at me and look at their medication lists with a newfound respect when I explain to them why these medications are essential to their health.
Other patients do not take medications because of the google-drome. When you ask a patient why he or she is not taking a particular medication, you may get an answer that sounds something like this, “Well, I went on google the other day, and there was a long list of side effects, and so I decided it just wouldn’t be a good idea.” The issue of side effects is one that can easily be combatted: a simple conversation with the patient at this juncture can change his or her perspective. Just like everything else in medicine, it’s all about risks vs. benefits – that is what we as physicians are trained to analyze. And with close follow-up, patients can be rest-assured that we will monitor them closely for side effects and address any that are unpleasant as best we can, either by treating them or by trying a different medication.
I am leaving one group of medication non-compliance offenders out. Let’s recap: there are those who don’t have access, who have a very demanding medication schedule, who don’t understand the importance of their medications, and who are wary of the side effects. All of these issues can be addressed. And then…drumroll please. And then there are those who simply do not want to take their medications. Astounding, astonishing, pure heresy. How could this be possible, in a country as pill-happy as we are? Because they’re depressed, or lazy, or simply don’t want to follow orders or to inconvenience themselves. Maybe they don’t believe in medication. Maybe they just don’t feel like it. And, if you refer to the quote which serves as the theme for this blog, maybe they aren’t totally off base anyway.
And for these people, there are fewer solutions. But again, I don’t believe that financial rewards are a viable long-term solution. If the fact that these individuals are a drain on the health-care system is an issue, maybe it should be addressed with negative incentives. For example, if patients do not take their medications or do not schedule or show up at visits with their primary care physician, maybe their insurance rates should be higher. It would only seem fair, given the extra financial burden they impose on society through their expensive hospital admissions. Or we could try a gentler approach: coddle them a little bit. Offer them the option of a visiting home nurse to help them administer medications, or even just to help them in the kick-off stage for a short period (2-3 months). This way, that they can get some assistance in setting up an organized system for taking their medications (pill boxes, alarm reminders, etc.), if they are genuinely interested in taking better care of themselves.
The long and short of it is that there is no easy solution, and although a simple financial incentives program has its appeal (after all, who doesn’t love a quick, clean solution to a hefty problem?), its complications abound. What’s worse, it sends the wrong message to society: as physicians, we send the message to our patients they we will not only work to serve and care for them as best we can, but we will now pay them to take better care of themselves (many a physician would roll over in their graves at this, but that, and the concept of the physician-patient contract, is a story for another day). And by the way, for all of you medication-compliant patients out there, you can have the inherent reward of a longer, healthier life, but we’re not going to bother sending you money. This is a bold statement. Whether intentional or not, it seems like some sort of implied punishment. Not to mention the effect this message will have on children: little Betty, you need to take this spoonful of distasteful medicine right now for your ear infection, but don’t worry, because when you grow up, life will get better: somebody will pay you to take it.
Providing a reward system to people for something that is inherently good for them, and that gives them many benefits on its own, is digging into a bottomless pit, where patients will want more and more and become more and more greedy until the burden on the system and on society is substantial. Perhaps a long-term moderate-reward lottery system for all patients who take their medications (let’s say one winner a year) could provide some form of incentive for some people…but again, it doesn’t make sense that any rational individual would suddenly and enthusiastically start playing a lottery for cash rewards, when he clearly isn’t setting himself up to win in the lottery of life in the first place. But it’s America after all, so maybe a few people will crawl out of the woodwork to surprise us. But we’d be going on a wing and a prayer – and maybe, sadly enough, that’s the best we can hope for.