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March 30, 2009
A lottery for patient compliance?

Certain patients do not take their medications. We are reminded repeatedly of this painful reality in our daily sign-out for new admissions. The all-too-common morning handoff goes something like this: “Mrs. Smith is back with a sugar of 400 and decompensated heart failure. I may not be William Osler, but I believe our differential should include, ‘Someone forgot to take her medicines again.’ ”

These patients go on to form lasting relationships with their neighborhood hospitalist. Some say that hospitalist medicine fragments care, and there is some truth to that. However, for this cohort of patients, hospitalists end up serving as their primary care physician.

Medical noncompliance is both costly and frustrating. Costly to the tune of $177 billion a year, according to a coalition of nonprofit medical organizations.

And frustrating for many reasons, not least of which is the fact that we are highly trained specialists providing state-of-the-art treatment that we hate to see derailed by something so simple.

But no amount of medical expertise can reform patients who just won't take their medications. Moreover, that noncompliance fosters learned helplessness on our part and leads to an unhealthy relationship with our patients. Cynicism takes hold, and we can’t help but ask ourselves, “If all I am doing is getting this patient well enough so that he can come back, why do I even bother?” While this may be understandable, that attitude can become pervasive and affect both our job satisfaction and our ability to provide outstanding, patient-centered care.

Because noncompliance is a daily reality, I found myself intrigued by recent research that combined one thing Americans love, playing a lottery, with one thing that they are not so good at: taking medicines as directed. According to an article in AMNews, the Aetna Foundation is funding a randomized trial of patients’ Coumadin compliance in which patients may hit the jackpot if Lady Luck calls their name.

Every day, patients, if they take their blood thinner as directed, will have a 1-in-10 chance of winning $10 and a 1-in-100 chance of winning $100. An electronic monitor will determine whether or not they have consumed their daily dose, and a text message will let them if they are a winner. Noncompliant patients, on the other hand, will get a text telling them that they could have won if they had only done as instructed (please play again!).

If past studies and common sense are any indication, a medical-compliance lottery is likely to work. A review of literature more than 10 years ago in the BMJ found 10 of 11 studies supported this conclusion: “Financial incentives can improve patient compliance.” Such research is akin to groundbreaking studies that show that cigarettes…drum roll, please…lead to lung cancer. To my mind, the only surprise is that one study did not support a link. Perhaps that cohort consisted only of patients who had taken a vow of poverty.

My suspicion is that some of you at this point are rubbing your eyes and shaking your heads at the prospect of directly subsidizing medical compliance (cue Jon Stewart’s signature gesture of shocked disbelief). Others may be ready to employ the "greater good" argument, claiming that broader compliance would result in a smaller health care burden for us all.

Although I strongly support health care reform and have personally considered trying to pay some of my bounce-back patients to take their meds, I find myself on the Jon Stewart side of things. The best solutions to problems steer clear of quick fixes and target the big picture. I believe reform should work to make medications more affordable, a major cause of medical noncompliance. Improving social support options is another important part of any solution. Financial incentives strike me as simply wrong on many levels, despite the potential to save the system money.

And any claim of cost savings remains a dubious one because it may not factor in what happens to currently compliant patients. Won’t it only be fair to offer them compensation as well? Here’s the scenario that is running through my head with a patient who learns there is gold to be found in medication compliance: “Dr. DeLue, I will take the aspirin for free. But the Coreg will cost five dollars a day and the Coumadin, well, it is a horse pill, so I can’t do it for any less than $10.” Second, in this era of patient-centered health care that mandates greater patient involvement in medical decisions, which I favor, what amounts to bribing patients to get them to take responsibility for their own health strikes me as inconsistent and ineffectual.

I am sure the Aetna research will prove to be the 11th out of 12 to demonstrate a positive relationship between financial incentives and compliance. Regardless, I believe we should keep the focus on providing everyone with affordable, accessible health care and medications.

If such reform takes place and patients still don’t take their meds, we may need to revisit the lottery idea. But my sense is that if we fix the big problems—unaffordable, unequally accessible, user-unfriendly health care—then the problem of compliance will diminish. I am not so naïve as to think it will ever completely disappear, but I think we can get a long way there.
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About Erik DeLue, MD
Erik DeLue, MD, examines the challenges of running and reinventing a hospitalist program. He is medical director of the hospitalist program at Virtua Memorial, a hospital in Mt. Holly, N.J.

This is the third community hospital program that Dr. DeLue has worked for in his nine years as a hospitalist. Join in the dialogue on issues that range from compensation and 24/7 scheduling to how to work with competing hospitalist groups.

The opinions expressed by Dr. DeLue are his own and do not necessary reflect the opinions of his employer or Today's Hospitalist.
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