AlignMap

Shortly after publishing Patient Compliance And The F Word, my post about Jonathan Richman’s essay, The Only Way Pharma Can Improve Compliance: Fun, I serendipitously heard from Katrina Firlik, MD, who introduces herself as a neurosurgeon-turned-entrepreneur, now founder and chief medical officer of a new start-up in the medication adherence space: www.healthprize.net.

On checking that site, I found the above graphic (click on image to enlarge) which held out the promise of, as the title of this entry notes, “more adherence fun.”

Once is happenstance, twice is a trend, … one more linkage between compliance and fun and we’ll have ourselves a movement.¹

HealthPrize Technologies – Motivating Treatment Adherence With Incentives

I must admit that my immediate, automatic reaction to the HealthPrize Technologies site was a flinch.  Like most healthcare professionals, I am unaccustomed to seeing treatment adherence linked to winning prizes.

From the HealthPrize Technologies site:

It’s all based on the simple idea that people respond to two things: money and fun. So we’ve developed a system that links adherence-tracking technologies to a series of financial incentives, like points, prizes, and cash. And the better consumers are about taking their medication, the more chances they have to win and the more fun they’ll have.

Differing opinions about the appropriateness of offering incentives for compliance with healthcare regimens is hardly a new topic. A partial list of AlignMap posts on this issue includes

• Cash For Compliance & Other Ethical Dilemmas
• Cash For Compliance – Benefit or Bribe?
• Shopping Discounts As Incentives For HIV Screening Compliance
• Incentives To Enhance Compliance With Addiction Treatment
• Automated Incentives For Medication Adherence
• Monetary Incentives To Decrease Obesity
• Another Case Of Cash For Compliance
• Recurrent Themes: Health Literacy & Incentives

The contentiousness triggered by this methodology has more to do with cultural, philosophical, and ethical concerns than pragmatic results. There is an impressive amount of evidence that supports the notion that fiscally based incentives (e.g., cash, coupons, and merchandise) can increase rates of treatment adherence.

Currently, an odd dichotomy of opinions on the matter exists. There is relatively little criticism heard, for example, about  corporate wellness programs offering  prizes and other incentives to obese participants who lose weight or to tobacco-using participants who are able to stop smoking. Offering those same prizes or similar incentives, however, to participants for following a prescribed medication regimen or undergoing indicated medical screenings is likely to result in charges of unethical behavior, mind control, and disreputable motives.

Given that some bioethicists insist that only an absolutely neutral presentation of treatment options to patients is acceptable, the idea of offering prizes for executing a course of treatment is sure to result in controversy.

For my part, incentives seem one more tactic that has been shown to enhance treatment adherence in some patients. In that sense, it falls in the same category as reminders, the use of pill boxes or automated medication dispensers, regimen simplification, adding a second medication to ameliorate the primary drug’s side, educating the patient about the workings of the medication, …

The key ethical issue would seem to be distinguishing the use of incentives to drive the behaviors necessary to execute a prescribed treatment from the use of incentives to drive the mindless ingestion of one pill or another.

My (slightly paraphrased) summary from  Patient Compliance And The F Word about the importance of fun as a motivator  fits the aggressive incentivisation practiced by HealthPrize Technologies as well:

1. It’s important because incentives have been shown to be effective for a significant number of patients (albeit not all)
2. It’s important because, as I have pointed out on occasion, 2 repeating the same processes tends to produce the same results.  In the case of patient compliance, that means trying the same adherence enhancement that didn’t work the first 821 times probably won’t work the 822nd time.  Trying something new (not just another version of the same tired idea),  is essential; trying something that has only been used on a limited scale, such as incentives, is astutely logical.
3. Finally, it’s important because we need to be looking for methodologies that enhance compliance by enhancing the alliance of the patient with those involved in his or her healthcare, including clinicians, Pharma, third party payers, and other stakeholders.  Fun would be a potent force to effect that alignment.

I cannot predict how effective this particular take on using incentives to improve treatment adherence will be clinically, and I certainly have no idea if  HealthPrize Technologies will prove a commercial success. It does seem, however, that adding a potentially useful, currently unavailable weapon to combat certain kinds of unintentional noncompliance to our clinical armamentarium could be – well, fun.

1. Actually, we may already have more than three such instances linking compliance to fun. See Celebrating Compliance and Compliance Enhancement: Party, Pedicure, and Potables↩

AdherenceLand - Where Compliance is FUN

Adherence Enhancement – Fun vs Futility

Yesterday, Jonathan Richman at Dose Of Digital, published The Only Way Pharma Can Improve Compliance: Fun, a post with three commendable aspects:

1. The  perspicacious  identification of AlignMap as the  “ultimate in compliance resources”
2. The equally perspicacious and arguably more significant  observation that “…  the reason we haven’t made an impact is because we test and use one intervention at a time.  …  What we need to offer is a wide choice of different compliance programs with each individual enrolled in the programs that are going to impact them.”
3. The proposition that fun might well be a motivator for adherence behaviors

Why Fun Is Important In Transforming Compliance

The argument made for fun is convincing and – well, fun.

It’s also important.

It’s important because the Adherence Can Be Fun hypothesis looks like it might work.¹  Rather than repeat the argument Jonathon Richmond makes, I suggest you read his post and see for yourself.  I think you’ll be impressed.

It’s important because, as I have pointed out on occasion, ² repeating the same processes tends to produce the same results.  In the case of patient compliance, that means trying the same adherence enhancement that didn’t work the first 821 times probably won’t work the 822nd time.  Trying something new (not just another version of the same tired idea),  is essential; trying something new, such as fun, which has proven successful in changing behaviors in other fields is astutely logical.

Finally, it’s important because we need to be looking for methodologies that enhance compliance by enhancing the alliance of the patient with those involved in his or her healthcare, including clinicians, Pharma, third party payers, and other stakeholders.  Fun would be a potent force to effect that alignment.

Now, hit that link and read  Jonathan Richman’s piece – heck, have fun with it: The Only Way Pharma Can Improve Compliance: Fun

1. Admittedly, I have no credentials as an expert on fun; still, …↩
2. See, for example, Why Today’s Treatment Adherence Paradigm Must Be Destroyed – Part 2, Patient Compliance – So Wrong For So Long, and The Tragedy Of Patient Compliance↩

The How To Fix Patient Compliance Now Series

This is the fourth in a series of posts offering  steps to improve the study of and communication about patient compliance.

These recommendations are simple and inexpensive; their implementation, in fact, is solely a function  of motivation on the part of those working in the field.

Finally, the benefits of these recommendations are magnificently  self-apparent.

Previous Steps follow:

1. Always provide context-pertinent definitions of Patient Compliance terminology
2. Differentiate between unintentional and intentional noncompliance
3. Support compliance claims

Don’t say “Adherence” when you mean “Brand Loyalty”

“Compliance,”¹ if it is to have useful significance as a term, cannot be used as code for “selling more medication X.”²

A helpful rule of thumb follows:

If an alleged Medication Compliance Program applies to only one drug  or one small group of drugs, all produced by the same manufacturer,  what you’ve got yourself there is not a Medication Compliance Program but a Brand Loyalty Program.

A Medication Compliance Program is concerned with all the medications in a patient’s regimen; eliminating or replacing a given medications from a patient’s regimen does not disqualify a patient from participation in a Medication Compliance Program.³

Again, I am enough of a believer in free market theory that I don’t seek to ban Brand Loyalty Programs for pharmaceuticals as long as the programs do not promote the inappropriate prescription or continuation of the medications on which they focus – and the intent of the Program (i.e., to sell more doses of Medication X) is made transparent to doctors and patients.

That one can certainly devise a lexicographical rationale for using “compliance,” “adherence,” and similar terms in association with Brand Loyalty Programs does not mitigate the ongoing confusion about the concept of compliance.

It’s simply a matter of clarity and trust.

1. In this post, “Compliance” and “Adherence” are used interchangeably↩
2. I hasten to add that I have no problem with the notion of selling more medication X. It’s one of my favorite pharmaceutical agents, useful for any number of ailments and almost devoid of side-effects. I object only to its marketing being confused with medication compliance.↩
3. The exception, of course, is a single-agent Medication Compliance Program that concerns treatment deemed so essential that its proper execution warrants special adherence protocols (e.g., DOT in the case of tuberculosis treatment).  One supposes that a Medication Compliance Program could also legitimately focus on a single given medication with inherent qualities, such as a particularly complex dosing schedule or overwhelmingly noxious side-effects, that rendered adherence especially difficult. I have, however, yet to find a Medication Compliance Program for a single drug that described its intent in that manner or its drug of focus in those terms↩

The How To Fix Patient Compliance Now Series

This is the third in a series of posts offering steps to improve the study of and communication about patient compliance. These recommendations are simple and inexpensive; their implementation, in fact, is solely a function of motivation on the part of those working in the field. Finally, the benefits of these recommendations are magnificently  self-apparent.

Previous Steps follow:

1. Always provide context-pertinent definitions of Patient Compliance terminology
2. Differentiate between unintentional and intentional noncompliance

Step #3. Support compliance claims

AKA Back it up or shut it up
AKA Don’t claim it if you can’t name it

Claims that, for example, medication compliance will be or has been improved by a new drug or the use of an automated reminder service has achieved X% adherence rate for participation in a disease screening program exam, must be accompanied by evidence.

Not doing so could mislead a naive audience; even worse, claims made without evidence to a more knowledgeable (or more cynical) audience may well play a role in making the entire field dealing with treatment adherence suspect. After all, if  retailers of compliance enhancements, developers of a specific compliance model,  and adherence promotions run by third party payers, pharmaceutical manufacturers, and independent firms boast of compliance rates so high they would mark a major breakthrough in the field but provide no support or only allude to vaguely defined “studies” that, if existent, can’t be found, readers and viewers will (and should) be suspicious of compliance claims in general.

An Example From Real Life

When a medication adherence program  administered under the imprimatur of a major health insurer claims a 95% compliance rate for treatments that typically carry a significantly lower rate of adherence, their press releases, especially those directed to clinicians, are, I contend, obligated to show the evidence. Was there a blind study with a control group? How was the rate calculated? If there was a study, was it run by an independent party or was it done internally?  Without that basic information, the claim of a 95% compliance rate is little more than puffery.

That my repeated emails to the program director asking for this information receive no response is, unfortunately, all too typical and tends to abet my suspicions that something is being hidden.

Proprietary Is Not A Magic Word

I’ve been involved in enough business matters to understand the value of trade secrets and necessity of not revealing proprietary information.

On the other hand, I also know the difference between abracadabra and proprietary.  And, I know there is something fundamentally wrong about declaring that the substance of a proprietary study must be kept secret while simultaneously claiming the alleged findings from that same study as evidence that a given compliance intervention or program is successful.