The Medication Blister Pack Lottery Ticket1
Aetna-sponsored Clinical Trial Of Lottery As Incentive For Coumadin Therapy Adherence
This story has been kicking around for over a month, evoking a variety of responses from the lay press, healthcare-oriented blogs, bioethicists, and the occasional patient compliance junkie.
Apparently, I can’t resist getting in on the action.
The Clinical Trial
The Aetna Foundation is funding a University of Pennsylvania clinical trial to determine if chances to win a daily low-stakes lottery effectively promotes adherence among coumadin patients.
According to the Hartford Courant,2
Patients who do not report taking their medications are also notified if they would have won the cash but were ineligible because they did not follow their medication regimen.
Many reports provided a straightforward account of the trial, but others have played up the cash incentive and the lottery/gambling angles. An example of the those focused on the money, by my subjective evaluation, is Bribe Me, Doc.3 The title notwithstanding, the reporting is reasonably balanced (several articles and, especially, posts attacked the use of cash incentives more aggressively on moral grounds), but the questioning of the compliance enhancement strategy being studied is reflected in these excerpts:4
A full discussion of compliance-enhancing incentives is beyond the scope of this post and has been addressed in this blog previously. Instead, I’ll offer some comments on pertinent issues that were not been covered in the 20 or so articles about this study I’ve read.
Several healthcare professionals raised similar points to that made by Richard Ashcroft, i.e., the use of cash incentives diminishes the personal responsibility of the patient.
My first and almost automatic response is that adherence to healthcare is not exclusively an individual’s personal issue. Noncompliance increases healthcare costs for all of us, one way or another, and unnecessarily uses the resources to the loss of all those individuals (that would be you and me) who may require healthcare services. Productivity is decreased when health problems of workers are not properly treated. Noncompliance may lead to lack of treatment or inadequate treatment of communicable diseases that consequently puts others at risk for the same disorder in the short term and for even more virulent or more difficult to treat forms of the disorder if inadequate treatment leads to the formation of resistant strains of the disease. If the consensus is that forced treatment or quarantine is necessary in some cases to protect the public, then it is difficult to condemn a less rigorous tactic if that is sufficient for public protection.5
On consideration, I’m not fully convinced of the premise that cash incentives necessarily destroy personal responsibility. To make that argument, it seems to me, one would also have to protest against penalties for noncompliance on the same grounds. E.g., fines for traffic violations are unethical because they diminish personal responsibility. Individuals should stop at red lights and adhere to speed limits because of internal motivators rather than external coercion. Of course, my reaction may be skewed by too many years on the parent-child battle line, efforts that long ago caused me to abandon the second half of the proposition “you [my son] must do the right thing and do it for the right reason.” A more pragmatic attitude toward motivation prevails on the home front these days.
I do enthusiastically agree with Richard Ashcroft’s observation that “in the health field that people aren’t always rational in their decision-making.” In fact, if I ever ascend to the role of Universal Emperor Of Healthcare, my first decree shall be to require all healthcare theorists to write that line 1,000 times on the chalkboard. Today, however, I will only add that there are few, if any, fields of personal functioning (e.g., caring for ones health, managing money, finding a career, falling in love, … ) in which decision-making is rational.
I find almost no discussion of the impact the lottery aspect of the incentive might have on the patient-doctor relationship. Is there, for example, any risk that the patient who forgot to take his pill for the first time last night, might, on receiving word that he would have won last night’s jackpot had he been compliant, be miffed at the doctor, who will inevitably be seen as representing the incentive system? Or if there is a snafu,6 are the folks whose legitimate winnings dissipate in a computer error going to blame the clinician? Who will be responsible for explaining this to the patient, re-establishing a working relationship, taking the time to fix the errors, etc?7
As long as incentives are being passed out to patients, how about providing parallel incentives to the responsible clinicians and any family or friends who take the role of care provider on an everyday basis so that all those involved in treatment are headed toward the same goal? Gee, what’s the word for that? Oh yeah, that would align the stakeholders.
In any case, by using the electronic monitoring device described, the researchers are actually testing if chances to win a daily low-stakes lottery effectively promotes the pressing of a “Yes, I took my medicine” button among coumadin patients. My hunch is that it will.
I will also repeat the recommendation I made in a previous post
- Consider the Medication Blister Pack Lottery Ticket AlignMap’s contribution to pharmaceutical packaging↩
- The Courant story, the primary source of this information for most of the blogged and printed reports, is no longer available via live link. I accessed it through the Google cache at Courant Page 1 and Courant Page 2.↩
- Misty Harris , Bribe Me, Doc, Canwest News Service. July 01, 2008↩
- It should be noted that those involved in the Aetna funded University of Pennsylvania study also recognize the ethical issues involved. Their stance holds that if the incentives prove successful in enhancing compliance, the moral and ethical points should be debated after the study is complete.↩
- Some of the argument I make in this paragraph may be implicitly included under “public health” references made in some articles.↩
- Oh my, I just flashed on the concept of the healthcare system as I know it taking on the management of a lottery system. What could possibly go wrong?↩
- For what it’s worth, classic contingency management, a behavioral system with much supportive evidence, would provide each patient with $X in his account on day one and remove a fraction of that every day the patient was noncompliant. Regardless of how effective the scheme might prove in improving compliance, I cannot imagine approaching, say, my borderline patients, at every session to announce that their compliance last week had cost them $29. It would not be a pretty sight.↩