AlignMap

From Nov. 3, 2008 American Medical News - By Doug Trapp

American Medical News Critiques West Virginia Medicaid Incentive Program

The graphic above is the heading for an American Medical News¹  story about the West Virginia Medicaid patient incentive plan.  The basics of the West Virginia plan and my perspective on it was discussed in this blog two years ago at West Virginia Medicaid Compliance Contracts – The Plan, The NEJM Perspective, & The Rest Of The Story.

See if you can guess AMA’s perspective from the clues in the headline:

When incentives lack appeal:
Medicaid reform meets confusion, skepticism

That’s right – in formal terms, this means  “Incentives used in the West Virginia Medicaid reform plan to encourage certain behaviors in patients lack appeal, thus causing confusion and skepticism.”

In less formal terms, it means “The West Virginia Medicaid reform plan stinks.”

Now, try the subheading:

West Virginia is one of the first states to offer inducements
for patients who pledge to follow physicians’ orders,
but most of those eligible aren’t taking the bait.

Let me suggest that the key words are “… most of those eligible aren’t taking the bait,” a figure of speech that leads me to suspect that it required the totality of the author’s self-discipline to forgo his impulse to add “Thank God” at the end. After all, I’ve never read a story in which good things happened to anyone who does “take the bait.”

At the risk of provoking the AMA to reconsider its position, I agree with their point that the bureaucratic implementation of the incentive plan is – hmmmm, let’s call it suboptimal. In fact, I am probably more critical of the plan’s structure than is the AMA. More about this a little later.

The Criticisms

The  article’s  basic argument is presented in the excerpts that follow:²

The program, which began almost a year ago in most parts of the state, is a novel attempt to use incentives to boost enrollees’ personal responsibility and ownership over their health care. Eligible enrollees who agree to a wellness plan, follow other physician directions, and show up on time for medical appointments can receive free additional benefits, such as help with quitting smoking and membership in Weight Watchers. Those who don’t take the option are relegated to a basic plan with somewhat fewer benefits than their existing plan.

Enrollment in the enhanced plan so far has been low. About one-third of West Virginia’s Medicaid beneficiaries — who numbered 392,000 in 2007 — are eligible for Mountain Health Choices based on their relative good health. But only about 15,500, or 12%, of those eligible had signed up as of Sept. 30, according to state counts. Another 3% had begun the enrollment process.

Why hasn’t the program been more popular?

Some patients simply might not know about or understand the program. Others might not read well enough to grasp the details. But even for those who want to pick the enhanced option, it’s not always simple.

For starters, Medicaid enrollees are instructed to call their primary care physician. “Many don’t have a primary care provider,” said Renate Pore, president of the patient advocacy group West Virginians for Affordable Health Care. “They don’t know who they’re supposed to call.”

Some eligible enrollees might not see a need for extra benefits, said Sarah Chouinard, MD, medical director of Primary Care Systems Inc., a health center in Clay, W.Va. For example, a 30-year-old woman with seasonal allergies might think she just needs her allergy prescription and annual Pap smear, not a wellness plan and extra hospital coverage.

The requirement that patients commit to regular office visits could pose a barrier for those with limited transportation options, said Rodney Fink, DO, director of clinical service for Access Health, a group of six health centers in southern West Virginia, including the Beckley facility where Dr. Bennett works.

Some observers say the state needs to do a better job of selling beneficiaries on the extra benefits. Dr. Fink said doctors also need to do a better job of focusing their patients’ attention on it.

… The Deficit Reduction Act of 2005 gives states authority to offer varying benefit levels to Medicaid enrollees. A few states, including Idaho and Kentucky, responded by offering incentives to beneficiaries who adopt healthier behaviors. Other states, such as Florida and Wisconsin, set up similar programs under waivers from the Centers for Medicare & Medicaid Services. The Deficit Reduction Act of 2005 lets states offer varying benefit levels to Medicaid enrollees.

But West Virginia took the concept one step further by limiting benefits for Medicaid recipients who do not promise to follow a wellness plan and listen to doctors’ orders. The state is now on the line to prove the tactic will work.

The ultimate goal of Mountain Health Choices is to forge relationships between patients and physicians that lead to healthier lifestyles and better preventive care, said Shannon Landrum, spokeswoman for the West Virginia Bureau for Medical Services in Charleston. …

Parents must agree to pick a medical home for their child, bring the child on time for a minimum number of office visits, and ensure that immunizations are up to date and prescriptions are followed. The agreement is similar for adults, with the addition of required screenings, such as colonoscopies, glucose levels and mammograms.

Some points of contention

The West Virginia program is more controversial than other states’ because it automatically bounces nonparticipating beneficiaries — possibly without their knowledge — into the basic plan. Once there they encounter more restrictions than in traditional Medicaid, such as caps on prescriptions and mental health services.

For example, children in the basic plan are limited to four prescriptions per month, even though a child with asthma and attention deficit disorder could easily hit that limit, said Fernando Indacochea, MD, president of the West Virginia Chapter of the American Academy of Pediatrics. Landrum, however, said a state review of data from three pilot counties prior to implementation showed that children on Medicaid average fewer than one prescription a month.

And while individual mental health therapy is covered under the basic plan, crisis intervention is not, said Bob Hansen, executive director of Prestera Center, a mental health and addictions treatment agency in Huntington.

Georgetown University’s Center for Children and Families on Aug. 9 issued a paper criticizing the state for automatically limiting kids’ benefits via the basic plan. If the program aims to encourage healthy behaviors among Medicaid enrollees, said Joan Alker, the deputy executive director of the center, “I don’t think there’s any evidence that they’re achieving that.”

West Virginia already has learned some lessons that could be applied by other states considering incentives for patient compliance.

Dr. Fink said programs such as Mountain Health Choices won’t work unless staff at clinics and health centers proactively advise patients about their health care options. He added that physicians should form a second line of support and also gauge their patients’ awareness.

Landrum said it can be difficult to engage Medicaid enrollees as they gain or lose program eligibility. About 40% of Medicaid beneficiaries in West Virginia don’t renew their benefits from one year to the next. States that want to change Medicaid from a program that simply pays claims into one that promotes health improvement and wellness need to be patient and look for ways to measure success in the long term, Landrum said.
Hope for the future

To improve physician awareness, the state could notify doctors of their Medicaid patients’ deadlines for choosing a new plan, said Violet Burdette, CEO of Northern Greenbriar Health Clinic in Williamsburg. Eligible beneficiaries receive a Mountain Health Choices enrollment packet 60 days before their Medicaid benefits are changed. They have 90 days to respond.

Burdette also said enrollees might be more engaged if they had to choose either the basic or enhanced plan instead of being channeled into the less generous plan by default. Landrum said only two Medicaid beneficiaries have actively declined the enhanced plan.

Work of enrolling can fall on physicians

Some physicians are excited about West Virginia’s pilot program that offers incentives for Medicaid patients to stick with a wellness plan, even though it does cause extra work for doctors.

Sarah Chouinard, MD, medical director of a health center in Clay, about an hour from Charleston, said her facility has convinced more than a few patients to take advantage of the enhanced benefits in Mountain Health Choices. The clinic, which is in one of the three pilot counties for the program, treats about 7,200 patients, a third of whom are enrolled in Medicaid.

Dr. Chouinard said explaining the initiative to patients requires additional staff time but coordinates well with the medical home model the center offers.

Terrence Reidy, MD, was less enthusiastic. He practices at a community health center in Martinsburg, in the eastern part of West Virginia.

A state Medicaid representative visited his facility about a year ago to explain the role the center would play in promoting the expanded plan. “It seemed like our office was then expected to be the ones to get the patients to sign up,” Dr. Reidy said. The internist hasn’t been contacted by state officials since then, he said in late September.

The center treats about 2,400 Medicaid patients, two-thirds of whom are children. Only about 2% of patients have opted for the enhanced benefits. “It really has not changed our practice a bit,” Dr. Reidy said. Still, consulting even a few patients about their choices of Medicaid benefits and crafting wellness plans adds another unpaid job to his already tight schedule.

One job West Virginia physicians will not have is that of enforcer. The state will review claims records to track patient compliance with the enhanced benefits agreement.

The West Virginia Medicaid Plan As An Example Of Misalignment

If I were a hot-shot psychiatrist – and, as it turns out, I am – I would diagnose a severe case of ambivalence on the part of the creators of the West Virginia Medicaid Incentive Plan.

On one hand there are significant rewards offered to reinforce those desired patient behaviors in the form of a greatly enhanced set of benefits.

On the other hand, it’s as though the administrators fear that the incentives will prove too popular so bureaucratic hurdles (e.g., the requirement that the patient designate a primary provider and take the initiative to sign up for the program)  were created to minimize the number of patients taking advantage of the more extensive, more expensive plan.

I do not believe, however, that the increased expectations placed on the physicians as an uncompensated, de facto administrative assistant and compliance monitor is part of that ambivalence. Nope, I believe that assigning uncompensated tasks, necessary for the functioning of the plan, to physicians and ther offices is merely one more instance of habitual legislative laziness.

Otherwise, one is face with explaining why a the plan’s administrators, who apparently believe in the power of incentives, would create a program that rewards patients but not only fails to reward the clinicians for reaching the same end-points but penalizes them by requiring them to perform work without pay.

Enough of the preliminaries – my contention is that the problems in the design of the West Virginia Medicaid Incentive Plan can best be characterized as a lack of alignment.³

There are so-called pay-for-performance schemes that reward or penalize clinicians, for example, based on the extent to which they follow treatment protocols or on the percentage of their  patients that follow specific pateint protocols, such as designated disease screenings (e.g., mammography or colonoscopy) or participation in disease management programs. There are programs like the West Virginia Medicaid plan that reward or penalize patients for specified healthcare behaviors.  I know of no programs that coordinate both clinician and patient reinforcement systems.⁴

In fact, many programs seem to follow the West Virginia model by offering to reward one group (patients in West Virginia’s case) and simultaneously punishing the other (assigning time-consuming administrative tasks to clinicians without compensation). In these situations, the issue is not a lack of alignment but misalignment.

Further, we’ve only addressed aligning two healthcare stakeholders, the clinician and the patient. In many cases, for example, a patient’s outcome depends primarily on the dedication and efforts of a non-professional caregiver such as a spouse, family member, or friend.  Yet, I find no programs that provide even token rewards for this group beyond generic support groups. Other stakeholders, such as community organizations with healthcare programs, likewise must be taken into account.

And third party payers, bless their hearts, have to be in alignment with other stakeholders if ongoing healthcare efforts are to be have a chance.

And – steel yourselves – on a macro level, pharmaceutical companies and medical equipment manufacturers have to be transformed from miracle workers/sources of all evil (choose one) into participants who gain and lose in unison with other stakeholders.

OK, I only said it was easy to understand the benefits of alignment, not that it was easy to design or implement a well aligned program .

1. American Medical News is a newspaper produced by the AMA for physicians.↩
2. While I have included a large portion of the text and have tried to keep the sense of the original article intact, there is always a risk of distorting the author’s intent. Consequently, I urge viewers to read the entire piece available here: American Medical News↩
3. I use “alignment,” In the context of healthcare, to indicate the condition of the patient, the clinician, and other stakeholders sharing mutual aspirations and grasping the complementary nature of their roles such that each individual or entity involved can support the treatment decision made, even if is not the first choice of a each stakeholder.↩
4. I have purposively chosen the “I know of no programs that … ” sentence format because I continue to believe that healthcare providers and patients benefiting in concert is such an obviously beneficial idea that someone somewhere must have tried it; I just haven’t run across it yet. ↩

Michelangelo's Temptation and Fall - from Sistine Chapel Ceiling

Increasing Ones Knowledgebase Is Not Without Risk

Treatment Adherence Data From Fields Beyond Healthcare

While I’ve previously written AlignMap posts about the value of alternative perspectives on patient compliance, most of the entries here focus on pertinent studies and review articles from the familiar genre of medical literature.

Readers interested in extending their thinking beyond the standard party line may find some of the material covered at AlignMap In Cites, the tumblelog companion to this blog, helpful.  The succinctly annotated links comprising AlignMap In Cites tend to be more catholic in content than AlignMap.com and often include information sources from outside the mainstream.

Moreover, thanks to the recent change in the AlignMap.com structure it now  easier for viewers on this site to follow AlignMap In Cites.¹ The section labeled “AlignMap In Cites Recent Posts” at the bottom of the column to the reader’s right is a list of links to the 10 latest posts at AlignMap In Cites.

The two most recent AlignMap In Cites posts  today, in fact, are examples of non-medical resources:² the first links to a review of Buyology By Martin Lindstrom, which examines how marketers, using magnetic resonance imaging scanners, record brain activity in minute detail, measuring how the products they are selling affect the brain’s pleasure centers while the second is a reference to Emerging Lessons, a WSJ article on “understanding the needs of poorer consumers,” which includes, by my reading at least, useful concepts for conveying information to patients with low healthcare literacy. Both of these have obvious implications that could affect how we understand treatment adherence.

Posting at AlignMap In Cites tends to happen in batches separated by fallow periods so I recommend following the titles here and checking out those that look helpful.

I’ll also be listing other nontraditional sources of information about patient compliance here at AlignMap.com in the future.

Bonus #1: Other AlignMap In Cites Posts

I’ll take this opportunity to explain that the content of AlignMap In Cites includes references such as those discussed above, connections to AlignMap.com posts,³ and many entries into what might charitably be called “Miscellaneous.” Among today’s recent posts group, for example, is a quote lifted from a medical student’s publically published blog, which evidences that political correctness has not completely eliminated the blatently obnoxious declaration and which reminds those of us grown perhaps a tad jaded to the basics of patient compliance that teaching the fundamentals to medical students remains an essential task.

Bonus #2: Heck Of A Guy Posts

Near the bottom of the column on the left is a list of links to the ten most recent posts at Heck Of A Guy, my personal blog, which has almost nothing to do with patient compliance other than the occasional post alerting readers there to AlignMap posts of general interest. The tag line at Heck Of A Guy is “A pastiche of posts, featuring song, dance, snappy chatter plus notes on prose, poesy, love, lust, life, and beyond,”⁴  which should clue in any blog reader that I have no idea, day to day, about the content of the posts I’ll publish. I recently published my 1000th Heck Of A Guy post, which included a list of random topics covered there:

• Leonard Cohen
• Anjani
• Ketchup decantation
• Recommendations for additional subtypes of quotation marks:Quid Pro Quotation Marks And 2 More Specialty Quotation Marks and Misquotation Marks & Quasi-Quotation Punctuation
• Love story Julie and I shared
• George Washington Carver 6 Posts (Link goes to first in series)
• The reaction of my hometown to the Gay Games Rowing Event being held here 5 Posts (Link goes to first in series)
• Broomcorn 2 Posts (Link goes to first in series)
• The proposed revision of The Seal Of McHenry County Illinois More Than 10 Posts (Link goes to first in series)
• Mom’s inventory  of Ozark tchotchkes Multiple Posts (Link goes to summary)

I know – I don’t understand why it’s popular either.

1. AlignMap In Cites has also transformed its look into one more easily read and one that is, well, way cool.↩
2. Quelle coincidence, eh?↩
3. The graphics featured in Robot Enhancement of Treatment Adherence, for example, were first displayed on AlignMap In Cites,↩
4. Until recently, the tag line was “If this has made just 1 person spew Pinot Noir through his or her nose, then it’s all been worth it … ,” which may be more indicative of the Heck Of A Guy tone.↩

From Medco Perspectives: A Prescription for National Healthcare Reform

The David Snow Healthcare Policy Speech: Background

On September 19  2008 at the National Press Club, David Snow, who by most accounts has performed well since being appointed Chairman and CEO of Medco Health Solutions in 2003,  moved beyond the boundaries of corporate healthcare to offer, in the words of his press release,

… a pragmatic blueprint for fixing America’s inefficient health care system that, for the first time, is designed to address the root causes of the problem. Unifying the strengths of both the public and private sectors, Snow’s plan is designed to reduce the nation’s health care expenses by as much as $1 trillion – almost 50 percent of current expenditures – while extending affordable, high-quality care to more Americans.

While this post focuses primarily on a reference within that speech to patient compliance as a major healthcare problem, the context in which that reference occurred is also significant. Because few of the accounts of the speech I have found devote any attention to this background material,  I am providing some basics before addressing the issue of treatment adherence.

Mr. Snow has more than 25 years of experience working in healthcare organizations prior to signing on at his current job. He previously held executive positions at Oxford Health Plans, American International Healthcare, Inc. and US HealthCare, Inc. as well as creating and running Managed Healthcare Systems, Inc. (now renamed AmeriChoice).

His ascension to the leadership of  Medco, described below in the excerpt from Newsweek, is itself of interest:

In March, it [Medco] named David Snow Jr. as its new CEO. In January, Snow bolted the No. 2 job at WellChoice (WC ) operator of Blue Cross & Blue Shield insurance plans in New York. Just weeks before, WellChoice CEO Michael Stocker was diagnosed with prostate cancer. Snow’s move left Stocker and others at WellChoice puzzled. Snow did not explain his move then and declined to explain it now. A Medco spokesman told me Snow left WellChoice when it became clear he was still some years away from realizing his ambition to be a CEO.

His work at Medco has been well compensated.  In 2004, his total compensation, according to Salary.com, was a bit over $9 million.  His 2006 total compensation, calculated by a different formula and reported in Forbes, was $1.9 million. Pharmalot dec;ares Snow “earned a $1.18 million salary last year [2006], along with $1.7 million from a non-equity incentive plan, and stock and options that were valued at $7.2 million at the time these were awarded a year ago. Snow, 52, also received $44,809 in ‘other compensation.’” In any case, Mr. Snow earns a nice living.

At the National Press Club Speech, Snow, according to The  Kaiser Daily Health Policy Report, not only presented his healthcare strategy but also critiqued  the healthcare policy  proposals of both presidential candidates:

… Medco Health Solutions CEO David Snow on Tuesday at the National Press Club in Washington, D.C., said that the McCain health care proposal would “create chaos,” Bloomberg/Bergen Record reports. Snow said, “I’m very frightened of the conversations that try to shift responsibility away from employers to individuals,” adding, “There will be more uninsured.” Snow said that the health care proposal of Democratic presidential nominee Sen. Barack Obama (Ill.) also would pose problems, adding that he is “not a big supporter of either” candidate.

Finally, the tone of Snow’s presentation is, I believe, meaningful.  Consider this excerpt from the same press release:

“Despite the urgent need, experience shows that health care reform must be evolutionary, not revolutionary, to be accepted by the American public,” Snow said. “We must agree upon an end-to-end strategic road map now, so that we can begin the journey to reform in earnest. Our commitment to this road map needs to persevere over an extended period of time to realize this opportunity. The payoff for doing this right is huge; the penalty for failure will burden generations to come.”

Not exactly your standard businessman’s, matter of fact, Chamber of Commerce speech, is it?  Along with the implicit nationalistic evangelism and recruitment to a crusade, those phrases are convey  a certain political panache, not unlike, say, a future candidate’s speech?

I am a tad disappointed I couldn’t find a  “My fellow Americans” sort of cliche in the speaker’s notes or locate a form on the Medco web site for ordering “Vote For Snow” bumper stickers. Consequently, the only support I have for my speculation that this presentation was an audition of sorts for a potential political candidate is my observation that an ambitious, successful, experienced business executive gave a ruffles and flourishes speech before the National Press Club calling the nation to the task of fiscally responsible healthcare reform and criticizing the healthcare proposals of the two major presidential candidates.

Just call it a hunch.

David Snow On Patient Compliance – And Other Issues¹

One reason the context is important is that it may explain David Snow’s predilection for absolute pronouncements in this speech.

He offers, for example, “Three Rules for Reform:”

• First, keep it simple – in business, complex solutions always fail.
• Second, revolutionary reform is rejected by our society; instead, we need incremental, evolutionary change with a deliberate and phased approach.
• Finally, and most importantly, we must define the roles of the private sector and the government. Each has an important but distinctly different responsibility and every time we cross those lines it results in failure – without exception.
  • The government’s function is to promulgate and regulate.
  • The private sector’s function is to operate and innovate.
    [emphasis mine]
    

The final tally: three points, two explicit absolutes (with bonus points for the redundant “without exception”).²

I, for one, find it difficult to believe that someone with 30 years experience in the healthcare industry, a field enamored of needlessly complex responses to problems, has never once been aware of a complex business solution succeeding, if only by random chance. I can certainly call to mind a few strategies that succeeded in spite of their complexity (not to mention inaccurate premises, mediocre execution, and bad timing – being lucky is a wonderful thing).

I suggest, as an alternative explanation, that Mr. Snow may have been speaking figuratively rather than literally – in sound bites.

Keep that in mind when considering the compliance points from the speech.

The crux of the speech resides in the specific policy recommendations:

I have five suggestions.  Each is simple [emphasis mine] and leverages the appropriate roles of the public and private sectors in a manner that, taken as a whole and aggressively pursued in a phased approach, creates an opportunity to reduce current healthcare expenditures by as much as $1 trillion.  They include:

•  Wiring Healthcare
•  Fixing Medicare’s Financial Fundamentals
•  Eliminating Medical Liability and Defensive Medicine
•  Increasing Compliance and Reducing Errors
•  Promoting Healthy Lifestyles

Mr. Snow goes on to elaborate briefly on each of these points. I have excerpted the portion dealing with patient compliance:

Encourage Compliance and Reduce Errors
It has been independently documented that we could save another $177 billion related to improving compliance and reducing errors.

The fact of the matter is that doctors are well paid to offer their advice, but all too often, patients simply don’t follow the instructions. In the case of diabetes, which currently afflicts 5 percent of the population and whose treatment accounts for 15 percent of all drug spending, only 7 percent of diabetic patients are controlling the three primary factors that could mitigate the effects of their disease and allow them to live a healthy and productive life.

As a result, this noncompliance may lead to blindness, renal failure, amputations, increased hospitalization, and other complications that magnify the suffering and the expense related to diabetes.

The burden is not the patients’ alone. Research shows that it currently takes 17 years from the time a medical protocol is proven effective to the time that it becomes a widely used standard of practice by physician. …³

One cannot help but note that no solutions are offered for the “simple” problem of noncompliance. In contrast, Mr. Snow explicitly assigns responsibility for correcting the other four problems to the federal government and gives some direction on how to go about those tasks. Excerpts follow:

Wire Healthcare

This is an area where government leadership through policy could become a catalyst for an immediate positive response by the private market. It’s happened once before. In the 1970s, hospitals billed Medicare using a paper-based system that in its best day was inefficient and expensive. To stimulate change, the government promulgated  payment rules whereby hospitals would be reimbursed only for claims that were submitted electronically. The private sector stepped in with technology solutions and, virtually overnight, electronic claims clearinghouses sprang up and all hospitals began billing electronically. Problem solved.

Fix Medicare

Culturally, we are conditioned to expect and implement heroic methods, even in cases where treatment is futile, and often resulting in unintended negative and painful consequences for the patients and devastating financial consequences for Medicare. This inherently uncomfortable issue forces us to confront our own mortality and requires strong leadership with candid conversation – it can’t be left to doctors, hospitals, or insurers. Government needs to set policy and establish rational rules for the level of care based on medical science – it’s not the private sector’s role to pass judgment on hope. Protocols based on scientific standards would ease the burden on families, physicians and, yes, patients. This is not withholding or rationing essential healthcare – it’s stepping up to the important and necessary reality so that resources are available to those who can be helped.

Address Litigation and Defensive Medicine

Tort reform eliminates ridiculous litigation, averts the waste related to physicians performing unnecessary tests as they practice “defensive” medicine, and could reduce healthcare costs by another $200 billion a year.

Wellness and Prevention

Here’s where we must have inspired and credible political leadership to fill the current void and raise the collective national consciousness.

Most of us can remember how government-led campaigns changed behavior through vivid imagery that etched into our memories messages with impact:  Smokey Bear’s sad reminder that “Only you can prevent forest fires”; the crash-test dummies Vince and Larry, serving as a testimonial for seatbelt safety by suggesting that “You can learn a lot from a dummy”; …

The private sector can never be expected to drive behavioral change, although we’ve seen employers make valiant attempts at implementing programs to lower healthcare costs – efforts that unfortunately are doomed to fall short. These range from positive reinforcement – discounted health club memberships and bonuses for employees who meet certain fitness targets – to surcharges for employees who smoke. Meantime, HMOs and other insurers have adopted low- or no-cost preventative programs for baby wellness visits, routine check-ups, mammographies, and other procedures that are designed to detect issues early instead of simply providing treatment after the fact.  Such initiatives are only likely to succeed if we make wellness a national imperative, something that requires political leadership and personal responsibility. In the end, each of us must take on greater accountability for making positive choices in our lifestyle.

I do think one could make the argument that a parallel strategy to that suggested for enhancing Wellness and Prevention (i.e., “inspired and credible political leadership to fill the current void and raise the collective national consciousness”)  could also be implemented to enhance compliance. Even so, kind of public service announcements and ad campaigns to which Mr. Snow points have not, to my knowledge, shown more than short term gains when applied to patient compliance (e.g., ad campaigns to encourage participation in mammogram screening). And, more to the point, Mr. Snow did not himself suggest that as a compliance solution.

In closing, Mr. Snow observes that while the federal government, individual patients, clinicians, and hospitals have either directly caused this set of problems or failed to take advantage of opportunities to correct them, there are – thank goodness – some organizations making heroic efforts to save us from ourselves.

After earlier bemoaning the unfair demonizing of HMOs, he approvingly notes that

HMOs and other insurers have adopted low- or no-cost preventative programs for baby wellness visits, routine check-ups, mammographies, and other procedures that are designed to detect issues early instead of simply providing treatment after the fact.

And, he modestly allows that “At Medco, we’re doing our part,” and goes on to list the specific ways in which Medco is indeed doing its part, including, with respect to adherence,

Leveraging the power of information to prevent errors and drive greater compliance, we’re a founding member of one of country’s largest organizations to process electronic prescriptions, creating the equivalent of a superhighway that shuttles information between the prescriber, payer, and pharmacy.

I suppose I should have expected the commercial; still, it hardly lends credibility to the remainder of the talk and it tends to polarize stakeholders in healthcare. As a physician who didn’t automatically follow every idiotic protocol shoved at me⁴ and as a sporadically noncompliant patient, I’m a tad miffed about the tenuous proposition that, in contrast to the sins of my fellow clinicians and patients, HMOs and Medco are “doing their part” to increase the effectiveness and efficiency of healthcare.

Conclusions

The good news is that David Snow wants to put adherence to treatment on the national agenda, albeit as part of a group of healthcare issues that inflate the cost of medical care. I may have mentioned once or twice my conviction that patient compliance should be a national healthcare priority.

And, some of his points are so on target (i.e., I agree with them) that they do seem to be no-brainers. For example, tort reform⁵ seems an area in which it is possible for government to act quickly and decisively to effect a sweeping change that could save huge amounts of money, in this case by eliminating the necessity to practice defensive-expensive medicine.

On the other hand, the idea that the Feds can, as Mr Snow suggests, shift public opinion and clinical practice sufficiently to rescue Medicare by curtaining care for those for whom there is little medical hope⁶ seems a mathematically valid concept formulated in an ivory tower than a politically pragmatic program. Perhaps it’s a negotiating point – or one of those ideas floated as a trial balloon early in a campaign.

Because, however, I am familiar with and have thought much about treatment adherence, I especially object to the notion that there is anything “simple” about noncompliance other than the fact that it is, indeed, a prominent and very expensive problem.

Providing a few of the many available statistics that indicate the extent and cost of noncompliance is hardly a step toward a solution. If that were so, every review of patient compliance and every web site on the subject (including this one) would have eradicated the scourge years ago.

I agree that noncompliance is a problem. The thrust of this speech is that straightforward solutions exist when I’m not convinced an accurate model or conceptualization of the problem exists.

Returning readers may recall an earlier post which dealt with the claim that a prosthetic tooth capable of releasing a controlled dose of medication at regular intervals would, in the words of its press release, “mean, finally, an end to the 2500 year-old patient compliance conundrum.”

Marshall Molar, Medication Modulator

My vision of the tooth hailed as the solution to patient noncompliance

The conclusion to that post included this admonition:

IntelliDrug [the drug-dispensing tooth] seems a legitimate, scientific project that could have an impact in some cases in which medication noncompliance is too dangerous or too costly to risk and the patient is cooperative.

Transforming an expensive potential tactic to improve adherence among a relatively small group of individuals into “an end to the 2500 year-old patient compliance conundrum” makes the project seem a joke and leads to mistrust of any future claims of effectiveness, however reasonable they might otherwise be.

My recommended solution to this problem follows:

Don’t make ridiculous claims for a
compliance-enhancing device or program

David Snow doesn’t claim he can put “an end to the 2500 year-old patient compliance conundrum,”  but in his National Press Club speech he does implicitly claim that noncompliance (or at least the cost of noncompliance) can be simply and significantly improved.  My contention is that this has a remarkable resemblance to a ridiculous claim and that no such simple solution is possible. In any case, none is offered in the National Press Club talk.

If there is a solution, Mr. Snow should spell it out.

Alternatively, I am available for appointment in Mr. Snow’s adminstration to a cabinet level position – say, Grand Exalted and Beloved Vizer of Healthcare Alignment – from which I could promulgate any treatment adherence policy necessary.

If nominated, …


Footnotes

1. Mr Snow’s complete presentation is available at Medco Perspectives↩
2. The absence of an “always,” “never,” “none,”   “without exception,” or similar absolute qualifier in the second point causes one to wonder if Mr. Snow is less confident of its validity.↩
3. Note that patient compliance with treatment recommendations and clinician compliance with medical protocols are conjoined. While both are legitimate concerns, combining them seems more complex and confusing than helpful. Consequently, this post focuses only on patient compliance.↩
4. For the record, not every protocol is idiotic. And, I did follow the idiotic ones that only robbed me of my time and effort but didn’t seem to hurt anyone↩
5. I suspect is is my occupational biases that prompt me to immediately think of tort reform as an example.↩
6. Snow phrases it as “Government needs to set policy and establish rational rules for the level of care based on medical science – it’s not the private sector’s role to pass judgment on hope.”↩

In my perpetual efforts to catch up with my reading in the area of patient compliance, I came across two recent entries at Medication Non-Adherence, Another Home Robot to Improve Medication Adherence and Would You Trust Your Eldercare To A Robot?, discussing the development of robots to enhance adherence to treatment among the elderly.

Both posts are thoughtful, insightful, and provocative and I can wholeheartedly recommend both as worthwhile reading.

And yet, those entries inexplicably lack two vital components, which I feel obligated to proffer as a supplement of sorts to the efforts of my brother blogger. This response, by the way, has nothing to do with the failure of Alex Sicre, the author at Medication Non-Adherence, to acknowledgment my own posts on the topic of Compliance-enhancing Robots, including Cute, Cuddly Robot Pets Remind Elderly To Take Pills, …

and my extrapolation from that post, Upping The Ante In The Pill Pet Scenario.

No, if I were going to have hurt feelings – not that I do, mind you – it would be over the diss implicit in the failure to mention my development and promotion of The RoboCop Compliance Program.  Based on the percepts electronically implanted into the hemi-mechanical hero who was the prototype for the law enforcement robots featured in the RoboCop movies, the Program is simplicity itself:

1. RoboCop (Dr. RoboCop to you) presents the healthcare recommendations.
2. RoboCop enhances compliance with his trademark line, which also serves as the Program’s slogan (Click to hear RoboCop Treatment Adherence Slogan)
   [audio:complyx.mp3]

But enough of that. Let’s move along to …

Elements Missing From the Robot Posts at Medication Non-Adherence:

1. A Misanthropic, Wildly Speculative, Tangential Soliloquy

In the literature I’ve found, as well as the sources quoted in the two posts at Medication Non-Adherence, the focus (and often the exclusive focus) is on caring for the elderly. I assume that choice is predicated on two of the fundamental driving forces in contemporary society:

1. Greed: The elderly are a large and rapidly growing portion of the population, and there is an often referenced, albeit rarely articulated, generic commitment from the government to fund their care.
2. Responsibility abrogation: My own cohort is facing the increasing likelihood that our parents, if not already in need of assistance, will require extra help in the near future, and I certainly intend to do everything I can to assure that the next generation, including my two sons, shoulder their obligation to care for their elders. It is clear, however, that few of us face this task with enthusiasm. Dispatching a robot to care for Grampa James may be a tad less empathic than Jimmy, Jr helping out, but, hey, it’s better than being pushed onto an ice floe.

I would, nonetheless, suggest that other population segments might provide good candidates for such services. The example that comes to mind is my son who suffered a head trauma followed by a coma and a recovery period of 1-2 years. Especially during the rehabilitation period just after his return home from the hospital, he required constant monitoring. Although 90%+  of his behaviors were appropriate, he would unpredictably have cognitive lapses, one consequence of which was that his adherence to medication doses and schedules was erratic. A robotic companion would have eased the burden on me as his sole caregiver and would, I suspect, have been easily accepted by him. A number of other diagnostic and age groups might benefit as well.

Specialized robots for specialized populations.

Just a thought.

2. Photos You can’t tell your robots without a program.

These carebots from GeckoSystems Inc. cost: $19,950 each, including delivery and two-day training.

This video is from the same company, GeckoSystems Intl. Corp, showing CareBots providing healthcare support of elderly, in this case, it presents “One family’s reaction to a CareBot™ for their mother.”

The graphic below is found at Carebots & the good life, a site produced by the Philosophy Department of the University of Twente, which is one of the three participants in the 3TU.Centre for Ethics and Technology. They are “looking for a PhD student to work on the project “Carebots and the good life: An anticipatory ethical analysis of human-robot interaction in (health) care”.

Infanoid  (pictured below) is from CareBots Project (Robotic Platforms). Many other photos and movies of human-emulating robots can be found at this site

Graphics Note: The image atop this post is my adaptation of a scene from Lost In Space. The role of the patient is played by the nefarious Dr Smith. The caregiver robot is, of course, Robot from the show. As everyone knows, Robot is a Model B-9, Class M-3 General Utility Non-Theorizing Environmental Control Robot.

Source: Psychotropic Medications for Patients With Bipolar Disorder in the United States: Polytherapy and Adherence Ross Baldessarini, Henry Henk, Ami Sklar, Jane Chang, and Leslie Leahy, Psychiatr Serv 2008 59: 1175-1183

Medication Regimen Adherence And The Bipolar Disorder Polytherapy Trend

In the 1970s when I began my residency in psychiatry, a movement denouncing the scourge of polypharmacy in the treatment of psychiatric disorders was being mounted in the literature. Not long afterward, those physicians who tended to use only one medication for the treatment of these same disorders were similarly criticized.  This is not necessarily a matter of clinicians succumbing to fads (although medical professionals are as susceptible as others to unscientific influences, including peer pressure); advances in research, changes in the concepts of a given pathology or the criteria of successful treatment, and the development of new biological agents may cause shifts in the recommended course of treatment.

In any case, the use of a combination of medications in the treatment of bipolar disorder is currently in favor.

In addition, the popularity of the diagnosis of bipolar disorder has steadily increased. Over the past 10 years, according to Moreno and colleagues,((Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007 Sep;64(9).)) clinic visits by adults that resulted in a diagnosis of bipolar disorder doubled and visits by children and adolescents that resulted in that diagnosis increased by a factor of 40.

Consequently, the widespread – but not universally held – contention that adherence to medication regimens decreases  as the complexity of a dosage schedule increases makes the examination of compliance by this group of patients especially important.

The Study

Baldessarini and colleagues studied national health plan claims data (2000–2004) of 7,406 patients with bipolar disorder (bipolar I: 55%, bipolar II: 15%, bipolar disorder not otherwise specified: 30%).

I have excerpted some of the findings pertinent to compliance:

Treatment adherence
Additional new findings included identification of factors independently and significantly associated with long-term adherence to an initial mood-stabilizing treatment. Perhaps not surprisingly, only a minority (30%) of U.S. patients diagnosed as having bipolar disorder were nominally continued for a year on an initial mood stabilizer, and only 28% of this subsample were considered to be treatment adherent, on the basis of an MPR =80% averaged over 12 months.¹  Factors associated with greater treatment adherence included being older, use of lamotrigine or lithium, lack of substance abuse, and treatment by a psychiatrist rather than a primary care physician. Inferior adherence was associated with use of valproate (the most commonly prescribed anticonvulsant mood stabilizer), use of carbamazepine or oxcarbazepine, use of supplemental anticonvulsants that lack FDA-approval for use in bipolar disorder, alcohol or drug abuse, and greater illness complexity.

… However, no significant association were found between MPR and co treatment with antidepressants or antipsychotics, nor with sex, diagnostic subtype, comorbidity index, or geographical region.

… Finally, we found complex associations between treatment adherence and utilization of health services. Office, and especially emergency service, visits for bipolar disorder–related care were more frequent in association with greater treatment adherence, whereas emergency service utilization for other indications and days per year of hospitalization for any reason were lower with greater adherence to mood stabilizer treatment). The lesser utilization of emergency and inpatient services suggests potential cost savings with greater adherence to mood-stabilizing treatments. On the other hand, greater use of ambulatory and emergency services for bipolar disorder–related indications suggests that greater treatment adherence may reflect relatively close monitoring, with more frequent clinician contacts. However, the available data do not permit clarification of cause-effect relationships between treatment adherence and utilization of clinical services.

Conclusions
… Adherence to long- term mood stabilizer treatment, although uncommon, was associated with several plausible clinical factors. Our findings of heavy reliance on antidepressants and polytherapy, low mood stabilizer utilization and adherence rates, and high rates of dropout from long-term mood-stabilizing treatment strongly suggest that more effective and better-tolerated mood – stabilizing treatments are required for patients with bipolar disorders, along with redoubled educational efforts to underscore the importance of sustained, longterm prophylactic treatment of such patients, even through periods of relative euthymia.

Commentary: Sadly, No Surprises

It is important to keep in mind that, as indicated in the article, the study used claims data as the information source and, congruently, defined adequate adherence as a medication possession ratio (MPR = the percentage of the past 365 days with apparent access to the medication) of at least 80%. This methodology is a rational research approach but is subject to limitations, one of which is that access to medication tends to define the maximum number of patients who may actually take sufficient amounts of their medication (i.e., patients cannot take their medications if they don’t have access to them, but  having access to medication does not necessarily mean those medications were administered appropriately).

The most significant finding is also the least surprising: Of the 30% of patients diagnosed as having bipolar disorder that were, on paper at least, continued for a year on an initial mood stabilizer, only 28% were found to be adherent.

The associations between treatment adherence and utilization of health services is, as the authors note, “complex.” The connection between better adherence and decreased use of emergency service utilization for indications other than those related to bipolar disorder  and days per year of hospitalization are heartening.  But, as the article points out, one cannot establish a cause-effect relationship. It may be, for example, that, as other studies have suggested, patients who tend to be adherent to treatment are also healthier, independently of the effects of their treatment.

I am also hesitant to subscribe to the authors’ positive spin on the data reflected in their speculation that “…  greater use of ambulatory and emergency services for bipolar disorder–related indications suggests that greater treatment adherence may reflect relatively close monitoring, with more frequent clinician contacts.”

Other explanations are possible. One alternative hypothesis, for example, is that a subgroup of noncompliant patients whose family or friends assure that doctors’ appointments are kept and that the patients are taken to the ER during exacerbations of their disorders might also be more likely to have prescriptions filled, again because of the insistence and assistance  of  friends and family. Those patients, who might rarely take the medications, would be accounted adherent because the medications are  accessible to them.

Of course, the difference in those interpretations may have less to do with a cognitive assessment of the data than with the difference between the research team’s world view  and my own perspective.

Those differences could also explain my lack of enthusiasm for the paper’s recommendations that “more effective and better-tolerated mood – stabilizing treatments are required for patients with bipolar disorders, along with redoubled educational efforts to underscore the importance of sustained, longterm prophylactic treatment of such patients, even through periods of relative euthymia.”

Before I start getting nasty emails, I will point out that I’m not against “more effective and better-tolerated mood – stabilizing treatment” or “redoubled educational efforts.”

I am, in fact, 110% in favor of producing treatments that are more effective for every disease, that are better tolerated by patients, that taste like cherry pie, and that render those patients more attractive, all of which could enhance compliance.  I am also in favor of clean streets, lower taxes, an end to world hunger, and a World Series championship for the Cubs.

And, I’ll call your  “redoubled educational efforts” and raise you a  retripled educational  effort. Heck, I’m willing to go as high as an exponentially increased educational effort.  I just don’t find much evidence that quantum leaps in educational effort beyond a competent communication of information have a significant positive effect on compliance.

As explained in my introduction, adherence to polytherapy of bipolar disorder is an especially significant area and Dr. Baldessarini et al have provided an important confirmation of the catastrophically low proportion of bipolar patients who are receiving an adequate course of treatment.

I suggest, however, that the appropriate primary response to these findings is not better drugs and more patient education but further research that would explain  why these results, that less than 30% of bipolar patients even have access to sufficient medication during the 12 months studied, isn’t on the front page of today’s New York Times and Chicago Tribune and broadcast as the lead story on CNN and the ABC Evening News.

Footnotes

1. The research group measured adherence to mood stabilizers by using a medication possession ratio (MPR).  MPR is the percentage of the past 365 days with apparent access to an initial mood stabilizer.↩

Check Out AlignMap's New Digs

In case you’re new to AlignMap or you’re a returning viewer with a rapidly deteriorating visual memory that can no longer retain an image overnight, this blog, until an hour or two ago was clad in a theme called “Phrixus Elements.”

Now, the AlignMap.com has, for the first time in its 2 year history, popped for new school clothes. The new duds are in the form of a theme called “Cutline 3-Column Split,” which you see before you now.

In addition, I’ve taken advantage of the required implementation of new codes to make other shifts in the graphics and some titles to emphasize my primary focus: transforming the current concept of patient compliance, treatment adherence, concordance, … to – well, to something useful. Those readers who have passed this way before may detect some of these nuanced changes.

Changing Themes

While Phrixus Elements and I have split up, the relationship was a fruitful one and the breakup was one of those “It’s not you, it’s me” sort of things. In fact, the look of the Phrixus Elements theme was a good fit for those long AlignMap posts. Cutline can be a bit distracting.

The change was occasioned by the need for a beefed up and updated infrastructure.

Because I had no clue about how web sites and blogs operated when I began, the AlignMap software code has been revised, jury-rigged, re-revised, and all but rendered inoperable by too many homemade fixes.

Cutline is, in comparison, squeaky clean and is capable of operating all manner of gizmos, gadgets, and whizbangs so you have that to gleefully anticipate.

Another advantage to using Cutline is that I’m familiar with it. Cutline is the theme for 3 other blogs I manage: Heck Of A Guy, LeonardCohenSearch, and EnrichMap.

Still, I suspect Cutline is an interim theme that will be replaced when a more content-congruent format is found.

Imperfection

- From Anthem by Leonard Cohen

If Leonard was right, then this is going to be one well lit web site for a while.

While I have already made a number of edits and the major functions seem to working, there are no doubt a bundle of flaws that haven’t become apparent yet. Email me if problems arise. I hope to have things calmed down in the next week or so.

At the risk of diminishing my reputation for cynicism modulated only by profound pessimism, I feel compelled to recommend to clinicians, patients, and families and friends of patients Never Give Up! Don’t Let Statistics Rob Your Hope And Joy, a thoughtful and exuberant (adjectives altogether too rarely found in tandem) post found at Jay’s Family Health Neighborhood.

The tactic recommended, in oversimplified form, is reframing the statistical correlation between treatment adherence and clinical outcome from an obligation backed up by the threat of physical deterioration and shortened life span into an opportunity associated with realistic rewards.

That tactic is impressively clever, but, even more significantly, it is incredibly empathic.

An excerpt follows, but I urge viewers to read the entire piece.

With many medical conditions, there is a strong correlation between good self-care and longevity. Parents can use statistics to inspire hope and spark an “I can beat this” attitude. Parents who give off positive, “we can beat this” vibes generally raise kids with the same determined spirit. We have met many CF parents and their children who demonstrate this indomitable and inspiring attitude.

In summary, wise parents handle statistics and medical predictions by:

• Emphasizing that significant medical progress is being made in almost all areas, and that health and longevity are increasing for almost all illnesses.• Realizing that for all individuals, the future is unknown. Many lives are shortened by unexpected illness and traumatic events.
• Encouraging their children to believe that they have every chance of being one of those children “who fall on the high side of the bell curve because you take such good care of yourself.”• Understanding that the quality of a life is measured not by its length, but by the amount of love, accomplishment, and giving that fills it.
• Understanding that worrying about the future and chewing on the mistakes of yesterday rob both today and tomorrow. The resulting hopelessness, negativity, and worry can shorten lives and certainly diminish the quality of life.
• Believing that those who bravely face life’s obstacles build a character that not only leads them to be more capable people and leaders, but sets an example that enhances the lives of all with whom they come in contact.

The more characteristically sardonic tone I’ve established for this blog over the past couple of years will return with the publication of the next post.

One of my patient compliance alerts this morning linked to Drug Compliance: Barriers to Care at Endo Blog where I found the attractive chart atop this post along with a discussion of the data it displays. Those findings are summarized in this excerpt:

From my reading of the post, it appears that the focus is on extracting from the chart (and the article whence the chart originated) practical recommendations for diabetic patients to enhance their ability to follow their treatment regimens. And from that perspective, the post is on target. The author advises, for example,

I’ve issued similar suggestions to my own patients, after learning (the hard way, of course) not to assume that patients were not born with the knowledge that orders for prescription refills could not always be issued immediately nor could the pharmacy always immediately produce a bottle of pills.

So far, so good. But I do want to use this post as an example of the risks of summarizing a study’s findings too concisely or, as I suspect is the case here, to present that summary in a public forum with only one segment of the potential audience in mind.

The Alternative Interpretation

On tracking down the source of the chart from the legend on its lower left corner, I recognized the article, Barriers to Medication Adherence in Poorly Controlled Diabetes Mellitus,¹ as one I had previously read and, in fact, had referenced one conclusion, the link between difficulty reading the text of the prescription and poor control of diabetes as indicated by the A1c biological marker, in my own post, Check The Fine Print For Noncompliance – Part 1.

Excerpts from the study’s abstract follow:

The problem lies not in what was written about the study but in what was not written.

Specifically, the following information wasn’t available to those who read only the post about the study:

1. The patient population was selected in part because of their poor control of their diabetes, as signaled by A1c values of 9% and above
2. Data re adherence and the challenges to adherence were collected exclusively by self-report
3. As noted in the abstract, “Self-reported adherence was not related to A1c control,” but “Taking more than 2 doses of DM medication daily and difficulty reading the DM medication prescription label were significantly associated with higher hemoglobin A1c.”

Now, the absence of that information has little or no impact on the advice offered to patients in the post. And the phrase, “according to patients, … ,” does indicate the source of the information.

Nonetheless, that declaration of results, while hardly egregious, is problematic, as can be seen by comparing the statement as written to a more complete version of the information.

As written:

More complete version:

My contention is that those two versions may have significantly different impacts, at least on certain readers.

And that is the point: public blogs are – well, public. Posts can be read by, among others, patients, clinicians, reporters, elected officials hoping to find justification for public policy changes, students writing doctoral papers, nurses from Africa caring for HIV patients who deny they are infected, lawyers working the compliance angles on behalf of their clients, colleagues with points of view congruent with the content, colleges with opposing points of view, marketing folks from pharmaceutical companies, and other bloggers.

That is only a partial list of those who have contacted me after reading something at AlignMap.com; that list is also the reason I write – and urge other bloggers to write – with the assumption that their readers will come to their posts with an extraordinarily wide variety of experience with and knowledge of the topic and with an even wider range of motivations.


Footnotes

1. Peggy Soule Odegard and Shelly L. Gray, Barriers to Medication Adherence in Poorly Controlled Diabetes Mellitus, The Diabetes Educator, Vol. 34, No. 4, 692-697, 2008↩

Alternative Perspectives On Patient Compliance

We Interrupt This Rant, …
As ongoing readers know, recent AlignMap posts have been a series of jeremiads lamenting both (1) the repetitive nature of patient compliance research, programs, and theoretical thinking and the resultant paucity of advances in the field and (2) the questionable value of  recurrent skirmishes over details such as the most appropriate appellation du jour for the system currently known as patient compliance, a battle which strikes me as the equivalent of a bidding war for naming rights to the Titanic breaking out just after the collision with the iceberg.

Well, to invoke the astoundingly convenient Monty Python pseudo-segue, now for something completely different, i.e., an atypically positive post suggesting a pragmatic means of expanding the conventional knowledge base of patient compliance. While that appropriately modest goal falls short of a universal panacea for treatment failure, the redemption of men’s souls, or the establishment of cosmic justice, it’s not a bad way to start the week.¹

Patient Compliance Information Source Alternatives:
We Are Not Alone

The key to unlocking a wealth of information and thoughtful research with direct and inferential links to treatment adherence is the willingness to consider the possibility that the two-part iconoclastic hypothesis presented a few lines below may, however incredible  it may seem, be valid.

Before revealing this fundamental reshaping of the intellectual firmament, authorial responsibility  dictates that I issue certain caveats. Those easily shocked, those with sensitive temperaments, and those diagnosed with high anxiety, severe cardiac conditions, or other disorders known to be  exacerbated by strong  emotional or intellectual challenges may wish to confer with their personal physicians before continuing. Medications, if appropriate to the situation, should be at hand. Ladies and older gentlemen, even those in superb health, should be seated or recumbent upon reading the remainder of this post. Those who feel they cannot tolerate further chaos in their lives at this point should cease reading no later than the end of this paragraph.  Knowing ones own limitations is a strength, not a weakness. The  official AlignMap Blog position holds that  there is no shame in dropping out now rather than risk ones wellbeing.

Those intrepid souls determined to pursue this idea should now prepare themselves.

Precursor Principles For Expanding The Patient Compliance Model

Principle 1. Patients are not exclusively patients. Reliable evidence has begun to accumulate, for example, that some individuals, despite meeting rigid criteria identifying them as “patient,”  also hold  jobs, sometimes devoting 40 hours or more a week to their occupational roles. Others are now known to operate as parents, grandparents, brothers, sisters, friends, partners, and a myriad of other roles. Rumors have even arisen that many patients have strong positive and negative feelings toward others that seem to have nothing to do with health or healthcare. There have been confirmed sightings of patients functioning simultaneously in several social, cultural, and spiritual spheres independent of their medical treatment status. Further, many patient brazenly and casually admit to these non-clinical identities and invest considerable psychological resources in them. At a minimum, these observations cast doubt on prevailing Patient Theory which holds that patients, when not in the presence of a clinician or in the act of executing a prescribed treatment, are maintained in a state of suspended animation until awakened for their next clinic appointment or medication dose.

Principle 2. The processes that culminate in Patient Compliance or Noncompliance do not operate exclusively in matters of health and healthcare. In fact, the manner in which a patient responds to treatment recommendations from a clinician and the extent to which that patient follows those treatment recommendations may be similar to the manner in which that person responds to and follows recommendations from a lawyer, a broker, a business consultant,  a teacher, a military superior, a friend, a mechanically derived algorithm, …  – even if those  recommendations have no direct implications for healthcare.

Heady stuff, eh?

It’s a lot to digest, but there is a payoff. Because of the extensive data, research, and literature available about how people respond to and follow those non-healthcare recommendations (often called “advice” in the non-medical world), these metaphysical musings transform into something real – and something immediately useful. In the fields of psychology (in this case, that portion of psychology not directly linked to medicine), sociology, economics, political science, education, business, and market research, among others, a plethora of data, interpretations, studies, and reports exist under topical headings such as decision-making, the spread of ideas, purchase resistance, learning processes, behavioral influences, … .

And, even better, most of that material is not a rehashing of the medical literature on patient compliance, but, in fact, may offer  perspectives that are unique from yet could be applicable to clinical adherence.

Serendipitously, an example is at hand.

The Impact Of Emotion On Patient Compliance

Source: Feeling the Love (or Anger): How Emotions Can Distort the Way We Respond to Advice Knowledge@Wharton, October 1, 2008

Knowledge@Wharton is the online newsletter of the Wharton School of the University of Pennsylvania. Wharton is, of course, an eminent business school and the newsletter is congruently oriented.

I’m not covering the article in depth. Instead, I will present excerpts to give a flavor of the entire piece, point out some specific elements I think are significant to those of us invested in understanding patient compliance, and, finally, invite the reader to review the original essay itself along with the relevant research on which the article is based. Both the article and the essay are available on the same Knowledge@Wharton web page.

Here’s a piece of advice: Don’t read this story if you have just had a fight with your spouse or a co-worker. You will probably ignore it, despite its grounding in solid academic research. At least that’s what Maurice Schweitzer, a Wharton professor of operations and information management, would most likely suggest. In a recent paper written with Francesca Gino of Carnegie Mellon University, he shows that emotions not only influence people’s receptiveness to advice but they do so even when the emotions have no link to the advice or the adviser.

“We focus on incidental emotions, emotions triggered by a prior experience that is irrelevant to the current situation,” the two scholars note in their paper, titled “Blinded by Anger or Feeling the Love: How Emotions Influence Advice Taking.” “We find that people who feel incidental gratitude are more trusting and more receptive to advice than are people in a neutral emotional state, and that people in a neutral state are more trusting and more receptive to advice than are people who feel incidental anger.”

… until recently, economic analysis has taken as its premise the idea that, when it comes to dollars and cents, people can wall off their emotions. “Classical economics is predicated on this rational-man idea and also on the idea that mistakes will get extinguished by the market,” Schweitzer says.

But Schweitzer and Gino’s research suggests that emotions can systematically distort people’s receptiveness to advice and thus their rationality. And if everyone errs in similar ways, that could skew the classicists’ perfect calculus. “My intuition was that we often base complicated decisions on how we feel,” Schweitzer says. “If I ask you something complicated like, ‘Should we hire this person or should we buy this house?’ you have to consider a lot of attributes and compare a lot of complex things. So we often use a simple summary statistic, which is how we feel about the job candidate or the house. When we do that, we open ourselves up to the possibility of making a mistake based on emotion.”

That makes sense, but how do you prove it? Schweitzer and Gino designed experiments in which they — as difficult as it sounds — manipulated their subjects’ emotions, gave them advice and measured the effects. In their first experiment, they recruited college students and asked them to make a judgment about something they were sure they could not know for certain. In this case, they showed each subject a photograph of another person and asked them to estimate the body weight of the person in the photo. They then induced an emotion by having each subject watch a short movie clip. Some subjects saw an anger-inducing bit from The Bodyguard in which a man gets treated unfairly. Others viewed a gratitude-inducing clip from Awakenings in which another man receives an unexpected favor from his co-workers. And the rest saw a neutral outtake from a National Geographic documentary about Australia’s Great Barrier Reef.

In a separate study, the two scholars assessed how the videos induced different emotions. Because the students had no real connection to the scenes, the researchers could classify their reactions as incidental as opposed to integral. If you watch The Sopranos and then get angry with your spouse, that’s incidental emotion. If your spouse slaps you and you get angry with your spouse, that’s integral.

After watching the clips, the students reflected in writing on what they had seen and how it had made them feel, and then had a chance to re-estimate the weights of the people in the pictures. This time, they also received estimates that the researchers told them had been done by another participant. Though the subjects didn’t know it, everyone received the same set of second estimates. These estimates — the advice — were helpful, not misleading. “The emotion manipulations significantly influenced the accuracy of participants’ final estimates,” the two scholars state.

Participants “who experienced incidental gratitude weighed advice more heavily than did participants in a neutral state,” they write. “Participants who experienced incidental anger weighed advice less heavily than did participants in a neutral state. Even though the emotions induced in this study were unrelated to the judgment task, we find that these emotions significantly changed the extent to which participants relied upon advice.”

In the real world, as opposed to a behavioral lab, these findings play out in all sorts of ways. Co-workers, for example, often annoy each other, sometimes for legitimate reasons, like missed deadlines, and sometimes for silly ones, like how stupid someone’s laugh sounds. And sometimes, a person will get ticked off and fail to heed another’s good counsel just because of a bad mood.

“If I’m angry at my wife and therefore trust you less and am less receptive to your advice, then that’s clearly irrational,” Schweitzer says. “The fact that my wife crashed my car has nothing to do with you. But maybe I’m angry because you cancelled our last meeting and now we’re interacting again. Maybe there’s some real information about your reliability in the fact that you cancelled our meeting. It takes a controlled, clean experiment to disentangle rational reasons from biased ones. What we haven’t shown [with this study] but I’m confident would work is that, if you do something that makes me angry, then I trust your advice differently.”

Schweitzer says that people with what he calls “high emotional intelligence” are probably already putting his and Gino’s insights into action without even knowing it. “Emotional intelligence is the ability to recognize emotions and understand how they operate and also the ability to manipulate or change them. If I have emotional intelligence, I know what the right time to talk to my boss is. I know that my new partners had a terrible flight and lost their luggage and aren’t going to be receptive to what I’m saying, so I shouldn’t make my pitch right now. Or I know that, if I take them to this particular restaurant or I buy tickets to this Indy car race, I can shift their emotional state to feeling more gratitude toward me and listening to me.”

Skilled negotiators tend to have high levels of this kind of aptitude, and they apply it in small, subtle ways when they are doing their work. They might, for example, apologize for a perceived wrong, even when no apology was expected or required. Or they might, during a particularly tense time, call for a break, go get a soda and also bring something back for the people on the other side of the table.

Schweitzer sees what he and Gino observed operating in all sorts of business interactions. When a sales person takes a client to a ball game, for example, he’s not just cozying up in the obvious way. He’s also creating a sense of gratitude. When a drug rep brings lunch to a doctor’s office, she’s doing the same thing. “Can this backfire?” he asks. “Yes. If it doesn’t seem genuine, people aren’t going to believe it. Suppose that I try to induce gratitude and I go over the top. That’s the sales rep who’s giving too many gifts.” Push it too far, in other words, and you could end up making someone angry.

Observations On Patient Compliance Articles Not Presented As Patient Compliance Articles

Those accustomed to reading about patient compliance in publications such as The New England Journal Of Medicine, The American Journal of Psychiatry, The American Journal of Managed Care, white papers put out by pharmaceutical manufacturers and benefits management companies, and, of course, AlignMap.com, may find my free form observations helpful in orienting themselves in this brave new world.

1. The referenced article does not mention healthcare but does list an extensive set of business scenarios in which emotional content could affect ones decisions. The application of the content to compliance seems, as I read it, strikingly apparent. This is not, in my experience, unusual. Literature with a business, sociology, or economics orientation, for example, seem less concerned about how decision-making (in this case) works in specific, well defined situations than finding general principles that are valid in many settings. When healthcare is mentioned, it is often as one of many examples.
2. The article’s primary finding, that emotions experienced by the individual affect how that person responds to advice, even if the origin of those emotions have nothing to do with the immediate decision to be made – or, to extrapolate, the patient’s disorder or the healthcare situation, has not been emphasized in the medical literature.² Although in this example the findings are only moderately different from the conclusions of analogous articles with medical orientations, other instances will demonstrate entirely different, but not necessarily contradictory, approaches.
3. The experiments designed to test the hypothesis in this article lie closer to the basic research pole of the pure science-applied science spectrum than do the typical patient compliance studies and, not incidentally, are more akin to the animal behavior labs than naturalistic clinical trials favored in healthcare journals. Experimental approaches to similar questions vary dramatically from field to field.

My contention is not that the compliance-pertinent material available from non-medical fields is of higher (or lower) quality, that its experimental style is more (or less) valid, or that its findings are more (or less) useful. My contention is that the work done in non-medical fields often asks different questions, approaches solutions differently, presents findings in different contexts, … .³

Given the lack of progress in comprehending the workings of, let alone improving, compliance after many years of effort by the mainstream healthcare fields, the exploration of the potential contributions from these legitimate, well credentialed alternatives would seem a wise investment, if not an obligation, for anyone invested in understanding the phenomenon that most of us know by its healthcare-names, patient compliance or treatment adherence.


Footnotes

1. Re the more optimistic tone of today’s post, not to worry; this blog’s normal apocalyptic programming will resume forthwith↩
2. There has been significant material published in the medical compliance literature on stress caused by the medical problem being treated, the coping styles of the patients, and co-existing psychiatric diagnoses, especially depression.↩
3. Research and theoretical work in each of these non-healthcare fields may be as restrictive and narrowly focused as that done in healthcare. I am only pointing out that these fields view and treat issues that are part and parcel of patient compliance differently than do those of us in medicine.↩

Re Compliance Vs Adherence Vs Concordance, …

I have another instance to offer that demonstrates the significance of re-naming the same phenomenon.

In the middle of his career, contract disputes led to Prince changing his stage name¹ from “Prince” to the unpronounceable symbol shown under the middle picture in the above graphic. The press circumvented the symbol by referring to “The Artist formerly known as Prince.” The performer has since returned to the hardly prosaic “Prince” appellation although sardonic sorts will still, on occasion, refer to him as “The artist formerly known as ‘the artist formerly known as Prince.’”

Note the transformations wrought by the shifts in names.

1. For the record, Prince’s given, non-stage name is Prince Rogers Nelson↩

Abe Lincoln¹

What Does Abraham Lincoln Have To Say About The Uncivil War Between Compliance and Adherence Proponents?

Another quotation pertinent to the contentiousness over the appropriate name for the phenomenon most clinicians call patient compliance has occurred to me. This one is attributed to  Abraham Lincoln. More about the provenance later.

In most of the myriad versions used today in sermons, debates, business presentations, and political speeches, Lincoln is confronted with a difficult situation in which the decision seemingly rests on the interpretation of a linguistic nuance. Lincoln ponders, then asks the individual pressing him for a response how many legs a dog would have if one called the dog’s tail a leg.

The questioner, apparently the only individual in western civilization who hasn’t heard this before, does the mental arithmetic and answers “5.” Lincoln then sagely observes that no, the dog still has four legs because – here it comes – calling a dog’s tail a leg doesn’t make it a leg.

The application to the compliance Vs adherence Vs concordance Vs a rose by any other name competition is, I trust, obvious.² Incidentally, in pithy anecdote land, such a comment squelches its target, instantly and irrevocably wins the debate, and redirects the course of world events. Of course, in the real world, the opponent says something like, “What are you talking about? What do dog’s legs and tails have to do with adherence to treatment?” Sometimes, I wish I lived in pithy anecdote land.

The Tangential But Arguably Interesting Issue Of Provenance

The good news is there is an interesting story about the 5-legged dog story. It has nothing to do with patient compliance – which may be off-putting or a blessing.  In either case, read on at your own risk.

In an attempt to track down the provenance of the quote attributed to Lincoln, I found Millard Fillmore’s Bathtub, a site “striving for accuracy in history, economics, geography, education, and a little science” which houses a post about this quotation. An excerpt follows:

I have a source for the quote: Reminiscences of Abraham Lincoln by distinguished men of his time / collected and edited by Allen Thorndike Rice (1853-1889). New York: Harper & Brothers Publishers, 1909. This story is found on page 242. Remarkably, the book is still available in an edition from the University of Michigan Press. More convenient for us, the University of Michigan has the entire text on-line, in the Collected Works of Abraham Lincoln, an on-line source whose whole text is searchable.

Rice’s book is a collection of reminiscences of others, exactly as the title suggests. Among those doing the reminiscing are ex-president and Gen. U. S. Grant, Massachusetts Gov. Benjamin Butler (also a former Member of Congress), Charles A. Dana the editor and former Assistant Secretary of War, and several others. In describing Lincoln and the Emancipation Proclamation, George W. Julian relates the story. Julian was a Free-Soil Party leader and a Member of Congress during Lincoln’s administration. Julian’s story begins on page 241:

Few subjects have been more debated and less understood than the Proclamation of Emancipation. Mr. Lincoln was himself opposed to the measure, and when he very reluctantly issued the preliminary proclamation in September, 1862, he wished it distinctly understood that the deportation of the slaves was, in his mind, inseparably connected with the policy. Like Mr. Clay and other prominent leaders of the old Whig party, he believed in colonization, and that the separation of the two races was necessary to the welfare of both. He was at that time pressing upon the attention of Congress a scheme of colonization in Chiriqui, in Central America, which Senator Pomeroy espoused with great zeal, and in which he had the favor of a majority of the Cabinet, including Secretary Smith, who warmly indorsed the project. Subsequent developments, however, proved that it was simply an organization for land-stealing and plunder, and it was abandoned; but it is by no means certain that if the President had foreseen this fact his preliminary notice to the rebels would have been given. There are strong reasons for saying that he doubted his right to emancipate under the war power, and he doubtless meant what he said when he compared an Executive order to that effect to “the Pope’s Bull against the comet.” In discussing the question, he used to liken the case to that of the boy who, when asked how many legs his calf would have if he called its tail a leg, replied, ” Five,” to which the prompt response was made that calling the tail a leg would not make it a leg.

Update: October 5, 2008
Those taken by the Lincoln-Lyle Lovett link referenced in Footnote #1 may wish to check out an expanded discussion with better graphics (including the new Lovett Penny) at today’s post on my personal Heck Of A Guy blog, Lookalikes: Lincoln and Lyle Lovett

1. Does the image of Lincoln atop this post remind anyone else of Lyle Lovett?
   

   ↩

2. If not, a PDF of the complete answer is available for a nominal fee of $63,200. See, that was a joke about assigning an arbitrary meaning to the name, “nominal fee.”↩

I’ve run across another batch of articles in which the authors have flashed onto the epiphany that “adherence” is an altogether morally, ethically, and spiritually superior term to the malignant, inhumane, and generally repugnant “compliance” for designating the degree of a patient’s cooperation with a given treatment recommendation.¹

Given that I’ve been on a rant roll of late, it probably won’t be a surprise that I’m preparing a post on the Adherence Vs Compliance Vs Concordance Vs Whatever issue and how it at best misses and may well distract from the point. Heck, I may as well show the entire spoiler – I contend that the discussion itself implicitly sustains a fundamentally flawed concept of compliance.²

It will be some time before my full diatribe is completed and posted. I’m publishing this prelude now because of a quote from  a news story I recently read. The story is about the economic crisis rather than the patient noncompliance catastrophe, but I think the words are precisely applicable.

John McCain has a piece of advice for the House of Representatives when it reconvenes later this week for a second go around at a $700 billion financial package, call the bill a “rescue” rather than a “bailout.”

“The first thing I’d do is say, let’s not call it a bailout, let’s call it a rescue because it is a rescue. It’s a rescue of Main Street America,” McCain said in an interview on CNN’s “American Morning.

Well, thank goodness we now have the names straight. I’m sure that soon, this repair by renaming tactic that transformed an evil “bailout” to an all-American, virtuous “rescue” will somehow result in an improvement in my fiscal well being and an increased confidence about the future.

Any time now …

Footnotes

1. Has anyone else noticed these name game pieces seem to be published in packs? I am, in fact, now suggesting that a group of articles focused on competing names of phenomena is herewith to be called an appellation of names.↩
2. I hereby confess that 15-20 years ago I had the same revelation about the names and, had I been blogging at that time, would no doubt have self-righteously led the inquisition to re-educate those medical miscreants who dared use “compliance.” It is, trust me, a blessing to us all that I recovered before blogs evolved onto the scene.↩