A June 13th article in The New York Times discussed a pilot program in Philadelphia where patients on anti-clotting medications such as Coumadin can win a small sum of money if they take their medication. Insurers and government agencies are also looking at innovative ways to create an incentive for patients to follow their doctor's orders. According to Pam Belluck in The New York Times article, at least one-third to one half of all patients do not take medication as prescribed and one quarter never even fill the prescription. Think of that!
As a physician I find that degree of non-compliance stunning. As all parties look desperately for ways to cut down on the enormous costs of health care in the U.S., it is not surprising that paying patients to stay healthy has become an option. By encouraging patients to stay healthy, it may be possible to avoid emergency room visits, eliminate surgeries or other expensive interventions, cut down or avoid hospitalizations and maybe eliminate some of the unnecessary trips to the doctor. Some insurers are paying for membership in health clubs and gyms. Can paying for healthy food choices be far behind?
While any program that succeeds where others fail, especially in the fraught area of soaring health care costs, should be applauded, there are possible unintended consequences for this novel approach of offering carrots to wayward patients. The "big brotherish" overtones of this program makes me wonder where we lost the concept of individual responsibility. For those patients who are mentally handicapped or those who are incapacitated by poverty or illness, any outreach and support makes sense. But do we really want to assume such a proactive stance when it comes to the majority of our citizens? We now have nurses going to homes, giving weekly telephone outreach, and transporting patients with chronic medical problems to doctor visits. Again, for those patients who are unable to access the medical system, this makes sense. But as with any program with good intentions, the risk of creating a passivity and childlike dependency is real. All these outreach efforts have enormous administrative costs.
The pay for compliance program sets up a wayward dependency that can backfire. One patient cited in the article admitted that as soon as the payments stopped, she went back to "forgetting" to take her medicine. If a patient chooses not to follow instructions, perhaps that patient should bear the consequences of her actions. But with health care it is always difficult to take too harsh a stance. For no matter how recalcitrant the patient, if he or she is ill and ends up in the emergency room, he will get whatever care he needs. I am proud to live in a country that supports that philosophy, that all people are entitled to health care. However, if current costs continue to skyrocket as technologies and medications become more sophisticated and costly, the rationing of health care that every American seems to abhor will only escalate.
So what to do with these so-called "non-compliant" patients? No doubt we all fall into that category at one time or another. Did we lose the weight that the doctor suggested? Did we take the antibiotic for a full 10 days? Did we stay off that sprained ankle until pain-free? Would we all like to be financially rewarded for being "good" patients? You bet. I am skeptical that this dollar reward for compliance runs the risk of infantilizing patients and creating a paternalistic ambiance around health care. We have come a long way in promoting consensus-based partnerships with patients where decision making around health care is shared and implemented together. This could be a step back, not to mention short-term gains with long-term problems. What do you think?
Victoria McEvoy, M.D. is the author of "The 24/7 Baby Doctor: A Harvard Pediatrician Answers All Your Questions from Birth to One Year."