AlignMap

As he is wont to do, Dr. House asks the right diagnostic question; in this case, the diagnosis is unintentional noncompliance:

Credit Due Department: My friend and colleague, Lord of Leisure, alerted me to this video.

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↩

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↩

Where Is The Quintessential American Compliance Setting?
Hint: It’s Not The Doctor’s Office

According to Robert Cialdini, writing in Influence: The Psychology of Persuasion, the quintessential American compliance setting is the Tupperware Party.¹ We’ll get to the “why” behind that claim and what the medical community might learn from get-togethers in suburban living rooms dedicated to retailing plastic food containers  in a moment; first we need to look at …

Psychology Of Persuasion, Decision-making, Influence, Motivation, Consumer Choices, … And Behavioral Economics

A widely varied group, including philosophers, economists, academicians, salesmen, psychologists, sociologists, retailers, manufacturers, marketing and advertising professionals, and others, has, for the past several years, invested much time and effort into understanding the psychological machinations which determine how an individual reaches a decision to take one or another action, such as determining the brand of blue jeans to buy, whether or not to buckle ones seat belt, which political candidate to support, who to marry, when to trade in the family car for a newer model, whether to attend religious services and, if so, which religious services,  … .

Of paramount significance in these efforts is the  focus on how these decisions are  actually – not theoretically – made.

The primary victim of this obsessively pragmatic process has been the paradigm of the Rational Man – the notion that individuals make decisions by calculating the advantages, disadvantages, costs, uses, risks, and similar factors pertaining to possible courses of actions and then choosing the option that best facilitates that individual reaching specific, predetermined goals at the least cost. ²

Decades of experiments, studies, observations, and sales data convincingly demonstrate that, instead, we routinely make decisions based on unfounded beliefs, unconscious  associations, buyer-seller dynamics, and illogical reasoning. In short, in the matter of decision-making, our confidence far exceeds our capacities.³

Back To The Tupperware Party

The Rational Man would, for example, presumably go about meeting his food storage needs by considering the price, warranties, size, sturdiness, experiences of others, and so on for implements available in the marketplace, comparing the findings with his personal preferences and then only then purchasing the items that best match his requirements.

In reality, as shown in a 1990 study by Jonathan Frenzen and Harry Davis, published in the Journal of Consumer Research, Tupperware parties were successful in merchandising the product because those attending liked the hostess, not the Tupperware. Fondness for the hostess was twice as important as whether they liked, wanted, or needed the product.

The Reciprocity Effect

Reciprocity, one element of “liking” someone selling an item or an idea, serves as a useful example of the principles underlying everyday decision-making.

The Reciprocity Effect describes the sense of indebtedness felt when someone does something for us or gives us something and our need to reciprocate in order to relieve that sense of obligation.

In a classic, much quoted experiment by Regan,⁴ subjects are instructed to rate, along with another person (the other person is actually a confederate of the researcher), the quality of a work of art. During a rest period, the confederate leaves the room. When he returns, he is carrying a Coke for himself and one for the subject. There was also a control condition in which the confederate leaves the room and comes back with no Coke for himself or the subject. So subjects in the experimental group receive an unsolicited act of kindness while those in the control group do not.

At the end of the ostensible art-rating experiment, the confederate informally tells the subject that he’s selling raffle tickets and is eligible to win a prize if sells the most tickets. He then asks the subject to help by buying some tickets. Subjects who receive the gift of a Coke buy far more tickets subjects who receive no such gift. Subjects receiving the 10 cent Coke (it’s 1974) buy at least two more raffle tickets at 25 cents each. In fact, the positive effect of the gift (buying more lottery tickets) maintains even if the confederate makes it clear that the Cokes are supplied by the research project so that there is no cost to the giver of the gift.⁵

Quoting Cialdini,

If what you give to somebody is meaningful, tailored and unexpected, that’s really the best you can do. All the evidence shows you will be repaid.

Which is why it is important that games were played and prizes awarded at Tupperware parties, why surveys come with a dollar attached, why the Disabled American Veterans organization sends personalized address labels. with its form letter asking for support (the DAV credits the inclusion of the labels with increasing their response rate from 18 percent to 35 percent), and why an especially smart business partner gave me an extensive collection of music he (correctly) guessed I would enjoy before we even began discussing working together.

The Ethics Of Persuasion In Clinical Care

The use of tactics associated with the principles of persuasion does carry with it significant ethical and moral implications that are beyond the scope of this single posting. While I will elaborate on this in a later entry, suffice it for now to note (1) the concepts of behavioral economics, not unlike the technologies of medicine, are intrinsically amoral; it is how they are put into use that is an ethical concern, and (2) casual observation at any clinic demonstrates that patients making decisions about treatment, one of the first steps in determining adherence, do not behave congruently with the Rational Man theory and are, intentionally or unintentionally, subjected to as many influences as the guest at the Tupperware party; the difference is that those influences were effectively applied to reach a goal at the Tupperware party.

Patient Compliance And Tupperware Parties

Non-rational motivations are, incidentally, equally important in the purchase of a car, the choice of pharmacies, and the election of a Senator as they are in buying Tupperware. While I lack the specific data to prove it, I am willing to wager a significant sum (say, all the money I can lay my hands on) that the same is true in the case of patient compliance.

At the least, clinicians should be aware of and be able to address those influencing forces in the context of patient compliance. I also believe a compelling argument can be made (and I will be making that argument in another post) that clinicians not only have the ethical authority to use certain tactics of persuasion in the service of enhancing the chances that a treatment regimen will be successfully implemented but that they have a responsibility to do so.

I’ve long railed against the concept of the Rational Man as it applies to theories of patient compliance. (See, for example, Patient Behavior, Current Patient Compliance Models, Neuroeconomics, The Rational Man, & Noncompliance, and Decision-Making Processes Of Prostate Cancer Patients)) Ongoing readers could well accuse me of beating a dead horse were it not for evidence found everyday in the literature, conversations, studies, and clinical practice that this particular horse is alive and well.

The concept of the Rational Man continues to dominate – and misdirect – thinking in the field of patient compliance.

And that’s a damned shame – because we should know better by now.

1. It may be helpful to keep in mind that Influence: The Psychology of Persuasion was first published in 1984.↩
2. Rational Man and Economic Man are terms used in economics, law, and other settings to stipulate a hypothetical individual that uniformly and inevitably acts logically to achieve the highest possible well-being for himself using whatever pertinent information is available. More formally, The Washington University Economic Geography Glossary defines Economic Man as the “Highly abstract model of human economic behavior based on simplifying but extreme assumptions of perfect information and perfect ability to use such information in a rational way (i.e. to achieve optimal ends)” ↩
3. For details, descriptions, and data pertaining to behavioral economics, one can turn to a number of recent books written for the lay public. My personal favorite is “Predictably Irrational: The Hidden Forces That Shape Our Decisions” by Dan Ariely. HarperCollins. 2008↩
4. Regan, R.T., 1971, “Effects of a favor and liking on compliance,” Journal of Experimental Social Psychology, 7, 627-639.↩
5. Peter A. Ubel, Free Market Madness: Why Human Nature is at Odds with Economics–and Why it Matters↩

According to the Wall Street Journal article, UnitedHealth To Give Discounts For Adhering To Prescriptions,¹ UnitedHealth will offer

$20 discounts off monthly co-pays for members who refill certain prescriptions within about 30 days after the last prescription runs out – essentially rewarding patients for adhering to treatment plans,

The pilot program applies to only certain medications for asthma and depression and cannot be used for the initial prescription.

While the article speculates that program is triggered by “the weak economy has caused consumers to put off filling prescriptions or switch to cheaper generics,” the decrease or elimination of co-pays in return for high adherence made sense long before the current fiscal crisis erupted and is, in fact, a recommendation I have made for years.

Aligning the mutual interests of the patient, the payer, the pharmaceutical companies, and the clinicians is the key to enhanced compliance rates. Using a discount on medication costs as a financial incentive to effect this alignment is a great start.

I’ll be eager to see the results.

1. Peter Loftus, UnitedHealth To Give Discounts For Adhering To Prescriptions, Wall Street Journal. August 27, 2009↩

Epiphany Du Jour – Training To Be An Effective Patient That Begins Post-Diagnosis Begins Too Late¹

Question #1: What is the likelihood that an individual reaching  adulthood in the US will eventually find himself or herself in the role of a patient?
Answer #1: Almost certain, according to my calculations.²

Question #2: When and how does one typically learn to how to operate effectively in the patient role?
Answer #2: While  learning to operate in the patient role theoretically takes place whenever one visits a clinician for any reason, that process, which could charitably be called “learning by doing,” is a hit or miss affair that routinely receives little attention until one is concerned about the possibility of or diagnosed with an anxiety-provoking disorder.³

Question #3: What is the worst possible way and the worst possible time to learn to operate effectively in the patient role?
Answer #3: See Answer #2.

A Illustrative Scenario

Consider this example: An asymptomatic,  intelligent 34 year old woman with only minor interactions previously with organized medicine is diagnosed with breast cancer during a routine exam.  Her doctor informs her (accurately) that any delay in treatment increases her risk. She is immediately faced with the decision of whether or not to follow the primary recommendation for surgical intervention and, if she agrees, which of the 2-4 possible procedures she wishes.  If she declines  the surgical procedures, she must decide which, if any, of the alternative treatments she will undergo. She also has to deal with the impact the diagnosis and treatment will have on her spouse, her children,  her job, her friends, and her extended family.

This is, I submit, a suboptimal situation for learning to be an effective patient, the intensity of ones motivation notwithstanding.

The Solution – Teaching How To Be An Effective Patient In The K-12 Curriculum

An explicit goal of elementary, middle, and high schools is preparing children to undertake  adult tasks. Thus, in addition to  learning basic math, writing methodology, and reading comprehension, students also take courses in sex  education, nutrition, consumer skills, and managing relationships.

Learning the skills necessary to be an effective patient, such as what to expect from, how to communicate with, and when to seek help from healthcare professionals, how to understand medical reports, pharmaceutical ads, and other pertinent printed and online literature, … , is at least as important as learning about the risks of unprotected sex or the need to save a portion of ones paycheck against future needs.

Making “How To Be An Effective Patient”  part of the K-12 school Health curriculum is no panacea, but it seems a rational and promising alternative that is likely to substantially improve the current “just too late” methodology.⁴

Credit Due Department: The photo portrait atop this post was taken by Bhernandez. The schoolroom photo was taken by Rob Shenk

1. Author’s Note: Patient Effectiveness Training is part and parcel of the system I (ambiguously) envision as a replacement for the current, non-functioning patient compliance model. The focus of this piece, that such training should take be part of the public education curriculum, is, admittedly, a tangent, and I am willing to stipulate that I am devoting a post to the notion less because of its impact on treatment adherence rates (although that impact could be significant) than because I think it’s a clever, useful idea. … and, it’s my blog.↩
2. Almost all of us who make it to adulthood in the US (or Canada or Britain or Germany or Scandinavia, …) will sooner or later be a patient. The exceptions are at most a tiny fraction of the population: those who consciously and conscientiously  avoid doctors because of reasoned principles, irrational fears, religious beliefs, cultural mores, or psychological disorders and also manage to avoid membership in organizations such as the armed forces that insist on involvement by clinicians and remain  healthy enough that they are not forced into healthcare (e.g., taken in an unconscious state secondary to a cardiovascular accident  into an emergency department) until they die.↩
3. In addition, there are educational processes that are even more sporadic and variable in quality: individuals may, for example, read articles about “how to be a good patient,” attend a workshop at the local hospital about “how to communicate with your doctor,” or receive information through various ad campaigns recommending that viewers ask their doctor about using one or another medication.↩
4. This is one of those ideas that seems so obvious that one assumes it is being done already. And maybe it is, but I can’t find any discussion of it.↩

It’s Magic! “Resolution 710 – Identifying Abusive, Hostile Or Non-Compliant Patients” Changed To Procedural Code Issue

OK – Resolution 710, proposed at the 2009 Annual Meeting of the American Medical Association,¹ was always technically a procedural coding issue. Heck, it’s not even an unusual sort of procedural coding issue.

The Non-Compliant Patient Coding Resolution Isn’t Quite As Bad As Some Folks Are Making  It Out To Be

The Resolution would have caused certain data to be collected in order to formulate new modifier and/or add-on  Current Procedural Terminology codes² to identify services provided for “Abusive, Hostile Or Non-Compliant Patients.”

Those modifier and/or add-on CPT codes could have two possible consequences:

1. Clinicians could use the new codes to modify their usual charges for a treatment because of the special circumstances (i.e., that the patients being served are “Abusive, Hostile Or Non-Compliant”).

This is nothing new or nefarious. Psychiatrists, for example, may charge different rates for 30 minutes of psychotherapy, depending on the setting and whether medical evaluations are included:

• Psychotherapy, 20-30 minutes; office/outpatient setting (CPT 90804)
• Psychotherapy, 20-30 minutes; office/outpatient setting with medical evaluations and management services (CPT 90805)
• Psychotherapy, 20-30 minutes; inpatient hospital, partial hospitalization or residential care setting (CPT 90816)
• Psychotherapy, inpatient hospital, partial hospitalization or residential care setting with medical evaluations and management services (CPT 90817).³
  

And, surgeons may legitimately charge more for an operation if there factors present which require substantially more work.

For example, because no CPT code exists for a revision of an arthroscopic anterior cruciate ligament (ACL) reconstruction, a physician may report CPT code 29888 (arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction) with a modifier 22. The documentation must support substantially greater work for the revision, such as increased time and technical difficulty associated with approach through adhesions/scar tissue, removal of hardware, or tendon grafting. In box 19 on the claim form, add a note that the modifier 22 supports a revision ACL with increased complexity.⁴

Resolution 710 could conceivably have led to modifier codes associated with higher compensation based on the altogether credible notion that providing some direct clinical services for “Abusive, Hostile Or Non-Compliant Patients” is more difficult than providing those same services for patients who are cooperative.⁵

It’s a bit like United Airlines charging extra for passengers too overweight to fit comfortably into an airplane seat. It may not be compassionate or humanitarian, but it can be justified on an economic basis. (It’s also worth noting that the existence of a CPT code or modifier does not mean an insurer, government agency, or individual patient will automatically honor it by paying higher fees.)

2. The new codes could lessen the impact of negative outomes on a clinician’s performance record.

Even more important than the money, however, is the concern that patients in these categories could make their physicians look bad.  This is, at least from my own hypervigilant perspective, an understandable concern. With everyone from the government to third party payors to consumer groups to rate-your-doc web sites collecting data on clinical performance, it’s easy to see how someone in the healing professions would worry about a treatment failure showing up on his or her record, not because of an error in prescribing treatment but because the patient didn’t follow instructions.

But The Non-Compliant Patient Coding Resolution Is Still Pretty Bad

First, I would have lots of questions about how “Non-Compliant Patient” would be defined, given that I have yet to find an acceptable all-encompassing definition of the term. Is anyone who misses an appointment non-compliant?  How about missing six of the last eleven appointments?⁶

Come to think of it, I’m not sure I can come up with a functional definition of “Abusive Patient” or “Hostile Patient” either.

But even as fundamental an issue as how one identifies these patients is, I suggest, secondary to the real problem.

The Real Problem – Nasty, Insulting Language

The real problem is the language and tone of the Resolution. The significant text of Resolution 710 begins

Whereas, Many patients are becoming more abusive and hostile toward physicians for many reasons not limited to the economy, increasing co-pays and deductibles, unreasonable expectations and demands, a lack of instantaneous cure, arrogance and/or the belief that they “own” their physicians;

As I noted in an earlier post, it really doesn’t get much better after that.

While I did not expect a ringing denunciation of this insulting-to-patients, embarrassing-to-doctors Resolution, I had thought it possible that a delegate would comment on the implicit message (you know, the one about “we hate patients”) conveyed by the document as presented, perhaps using filtering the criticism through the classic code so that it becomes, “The way it’s written now, it could be misinterpreted by others as insulting to patients even though I am sure Dr. Jones, who authored this Resolution, cares deeply for all his patients.”

Nope, Reference Committee G opted to mumble something about “concerns in labeling patients” and then  pass the problem to somebody else by implementing the classic technicality ploy – This isn’t my problem – this is his problem.

Here’s what happened, as excerpted from Report of Reference Committee G

RESOLUTION 710 – IDENTIFYING ABUSIVE, HOSTILE OR NON-COMPLIANT PATIENTS

Mr. Speaker, your Reference Committee recommends that Resolutions 710 not be adopted.

Resolution 710 asks that our AMA ask its CPT Editorial Panel to investigate for data collection and report back at Annual 2010 meeting:

1) developing a modifier for the E&M codes to identify non-compliant patients and/or
2) develop an add-on code to E&M codes to identify non-compliant patients.

Your Reference Committee heard limited supportive testimony on Resolution 710. The author stated that the intent of this resolution is to identify non-compliant patients, especially as there is an increasing focus on physician performance and releasing of physician data. Testimony was empathetic to the difficulty in working with non-compliant patients, but expressed concerns in labeling patients and acknowledged a desire to be sensitive to the possible mental health issues of non-compliant patients.

Testimony provided by the CPT Editorial Board stated that the appropriate forum for addressing CPT issues is through the CPT Editorial Panel process, not the House of Delegates. In addition, while there are no codes that exist to identify someone as specifically non-compliant, there are existing modifiers to identify patients who do not comply. For example, Modifier 2P (Performance Measure Exclusion Modifier Due to Patient Reasons) is available to report non-compliant patients. The list of reasons for Modifier 2P include (1) “patient declined”, (2) “economic, social, or religious reasons”, and (3) “other patient reasons”. This modifier is intended to be used with performance measure Category II codes. CPT Category II Performance Measurement codes are intended to facilitate data collection about the quality of care rendered by coding certain services and test results that support nationally established performance measures and that have an evidence base as contributing to quality patient care. These codes describe clinical components that may be typically included in evaluation and management services or clinical services and, therefore, do not have a relative value associated with them. Given that there exists an appropriate avenue to code for non-compliant patients and that this issue should be directly addressed through the CPT Editorial Panel, your Reference Committee recommends that Resolution 710 not be adopted.

Got that?  My unofficial translation follows:

Everybody knows that there are some patients so difficult that they make their doctors (and nurses and physician assistants and respiratory therapists and … ) miserable and they are capable of screwing up their own treatment. Everybody sane knows you can’t go around calling these patients nasty names. Besides, some of them have psychiatric problems, and no one wants to open that bag of worms.

Besides, the Resolution is a CPT issue.  This is the House of Delegates, not  the CPT committee. We aren’t the ones to deal with new CPT codes. In any case, there are already some codes that address these issues; they just don’t use the term, “Non-Compliant Patient,” thank goodness.

So, let’s put an end to this foolishness right now.  If the people pushing this loser want to pursue it, they can take it up with the CPT Editorial Panel.

I think I understand why this went down as it did, and I’m sympathetic to the internal  political demands the AMA and most such institutions face.

And, the Resolution was, happily, not adopted, so that’s good.

I believe, however, the AMA missed an opportunity to make it clear that the language of Resolution 710 is aberrant and does not reflect the medical community’s characterization of patients.

1. For background, see AMA Resolution On Non-Compliant Patients – What’s Up With That?↩
2. CPT codes “describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.” From Wikipedia↩
3. From Answers to Common Questions About New CPT Psychotherapy Codes↩
4. From Modifier changes for 2008↩
5. Of course, I suspect I could make an equally persuasive economic case for patients paying reduced rates if they have to deal with an abusive, hostile, or noncooperative doctor.↩
6. See  Patient Compliance – So Wrong For So Long for a list of hair-splitting examples that illustrate the problem of defining noncompliance.↩

AlignMap In Cites, the tumblelog companion to this blog, offers succinctly annotated links to web sites and online material pertinent to treatment adherence.

Typically, these are brief news stories, videos of compliance enhancement devices, and summaries of treatment studies that require little explication.  In addition, AlignMap In Cites posts frequently include information sources from outside the healthcare sciences mainstream.

Some of the most recent AlignMap In Cites posts follow:

• Poison information specialists concerned about callers who don’t adhere to their advice
• A new Research Chair in Patient Adherence to Drug Therapy at the University of Saskatchewan
• A discussion of the legal and ethical aspects of withholding state of the art AIDS drugs from non-compliant patients
• An educational and behavioral change focused game promoting Adherence

Excerpts from and links to the most recent AlignMap In Cites posts are listed in the right sidebar.

In the preceding AlignMap post, AMA Resolution On Non-Compliant Patients – What’s Up With That?, I was critical of a proposed Resolution coming before the American Medical Association House Of Delegates bearing the subject line, “Identifying Abusive, Hostile or Non-Compliant Patients” and beginning

Whereas, Many patients are becoming more abusive and hostile toward physicians for many reasons not limited to the economy, increasing co-pays and deductibles, unreasonable expectations and demands, a lack of instantaneous cure, arrogance and/or the belief that they “own” their physicians;¹

And, it really doesn’t get much better after that.²

Seized this morning by an altogether atypical compulsion to be fair to the AMA,³ I found A Responsible Patient,⁴ an article by Swathi Arekapudi published in Virtual Mentor, which is published by the American Medical Association Journal Of Ethics.

This thoughtful piece addresses the term “non-compliant” in language parallel to that I used in Compliance Versus Adherence and Beyond – The War Of The Words, definitively establishing the wisdom of the author:⁵

The move from overt paternalism towards increased patient autonomy is illustrated by the change in the adjectives used by medical authorities over the course of a century to describe patients who do not follow medical advice. The terms evolved from the “vicious” and “ignorant” TB patients of the early 1900s, the “recalcitrant” after World War II, to the “non-compliant” patient that emerged in the 1970s. Ironically the term non-compliant, which was developed specifically to be a non-judgmental phrase, has been criticized for its implication that patients should necessarily follow physician recommendations. “Non-adherent” is suggested as a better term because its lacks the implication that patients must necessarily follow their physicians’ advice. No doubt this new term will face a slew of criticisms in time.

Even more pertinent to the AMA Resolution is the concluding section:

The modern patient-physician relationship is grounded in the autonomy of the patient and the need for the patient to make informed decisions. As we move away from the paternalism that formerly characterized patient-physician relationship, we see that active communication between the physician and the patient is invaluable in the patient’s informed decision making. The goal of a physician, namely to improve or maintain the health of his or her patients when possible, can be accomplished by increasing the number of patients who adhere to recommended therapy. Though collaboration and cooperation are necessary they do not necessarily put the physician and the patient on equal footing in terms of medical knowledge. But through a patient-physician relationship built on a mutual understanding of what is expected of the other, patients will be able to understand their role in their own health care. Though physicians can no longer “order” patients to follow medical instructions they must now educate patients about the medical consequences of accepting or refusing treatment. The best method for achieving the goal of patient health is open communication between physician and patient. Labeling a patient “difficult” or “non-compliant” will weaken the bond of communication between doctor and patient.

Being Fair

Despite the risk of losing my credibility as a blogger, I must admit that, while the language used and the ideas set forth in A Responsible Patient are especially well-constructed, they are otherwise far more representative of the professional literature, symposia, and AMA publications dealing with noncompliance I’ve read over the past 30-40 years than is the “Identifying Abusive, Hostile or Non-Compliant Patients” Resolution.

Further, all I know for certain about the AMA’s stance on this issue is that somebody in the Michigan delegation to the American Medical Association House Of Delegates thought this was a good idea and managed to get it to a vote of the House.

Even if, however, this embarrassment is voted down, I fear the publicity it has churned up will have negated much of the work the medical community has done in improving doctor-patient communication, the tone of which is reflected in A Responsible Patient.

This short article, well worth reading by clinicians and non-clinicians alike, is available without charge at A Responsible Patient.

1. The entire Resolution can be found at AMA Resolution On Non-Compliant Patients – What’s Up With That?↩
2. I was hoping the final paragraph would be something along the lines of “Fooled you. You’ve been punk’d.”↩
3. Full disclosure: I once belonged to the AMA. I can’t find my records, but my most recent payment of AMA dues was at least 10 years and probably closer to 20 years ago.↩
4. A Responsible Patient by Swathi Arekapudi. Virtual Mentor. April 2003, Volume 5, Number 4.↩
5. I’ve omitted references from the following  excerpts. Those footnotes are, of course, available in the original article that is available online.↩

In one of those instances of serendipity about which one hears so much, the AMA and I have each been independently engaged in changing the current perspective and policies on management of non-compliant patients.

Our proposals, it turns out, are not identical.

The result of my efforts today can be found in the preceding post, Beyond Patient Compliance: Patients Who Lie, in which I hold that

optimal treatment is most efficaciously pursued by aligning the doctor, the patient, and other stakeholders to maximize mutual trust, a strategy which takes priority over the percentage of prescribed pills taken by the patient.

The AMA Resolution

After hitting the “publish” button for that post, I checked  the patient compliance news alerts I  follow, only to discover that the American Medical Association House Of Delegates was considering Resolution 710, “Identifying Abusive, Hostile or Non-Compliant Patients,” which comes up for a vote tomorrow (June 16, 2009). The text of the resolution, taken from http://www.ama-assn.org/ama1/pub/upload/mm/475/refcomg.pdf, follows:

Resolution: 710 (A-09)
Introduced by: Michigan Delegation
Subject: Identifying Abusive, Hostile or Non-Compliant Patients
Referred to: Reference Committee G, (J. Leonard Lichtenfeld, MD, Chair)

_____________________________________

Whereas, Many patients are becoming more abusive and hostile toward physicians for many reasons not limited to the economy, increasing co-pays and deductibles, unreasonable expectations and demands, a lack of instantaneous cure, arrogance and/or the belief that they “own” their physicians; and

Whereas, There are decreasing numbers of physicians both in primary care and specialties especially in terms of access; and

Whereas, Increasing noncompliance with treatment can reflect negatively on physicians during black box audits by insurance companies and oversight governmental agencies; and

Whereas, Abusive, hostile, and noncompliant patients result in increasing office resources, adding to office overhead and added stress on all of the office personnel, which can lead to potential ill health; and

Whereas, The stress of dealing with ungrateful patients is adding to the stress of physicians leading to decreased physician satisfaction; and

Whereas, Any complaint to any oversight investigative regulatory body leads to uncompensated expenditure of time, resources, and monies to defend physicians or the “guilty until proven innocent” principal; and

Whereas, Physicians need to own the data to simplify patient collection and identification to defend themselves as well as alert outside investigating agencies to the potential nature of the patient’s records; therefore be it

RESOLVED: That our American Medical Association ask its CPT Editorial Panel to investigate for data collection and report back at Annual 2010 meeting: 1) developing a modifier for the E&M codes to identify non-compliant patients and/or 2) develop an add-on code to E&M codes to identify non-compliant patients. (Directive to Take Action)

Fiscal Note: Staff cost estimated at less than $500 to implement.
Received: 05/06/09

The Implications

I have little to say about the AMA’s Resolution, which seems all too straightforward. From others, however, there has been an  (understandably)  vehement  response to the AMA resolution.  Googling “AMA non-compliant patients” displays a  batch of these venomous criticisms of arrogant doctors.

I, of course, believe my ideas on non-compliance are far superior to  those implicit in this Resolution the AMA is considering. I’ll be publishing further posts in the near future outlining this  new vision that goes beyond Patient Compliance.

Meanwhile, I’m desperately hoping that there is an explanation for the AMA even considering a resolution that threatens, by its very language, to alienate doctors and patients, exacerbating rather than alleviating non-compliance.

Keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed.
- Hippocrates¹

Launching A Guerrilla Attack On Patient Compliance – The Battle Of Patients With Pants On Fire

The publication of  Lots Of Patients Fib, Sometimes By Accident, a  nicely done article by Karen Ravn in the June 8, 2009 LA Times about patients who  lie to their physicians  provides a circumscribed clinical scenario that  demonstrates  both the problems with the current patient compliance paradigm and the rationale for the kinds of changes necessary to transform it into a useful concept.

An excerpt from the Lots Of Patients Fib, Sometimes By Accident follows:

It’s well-known that patients don’t always do a perfect job of following — or “adhering to” — the treatment plans their doctors lay out for them. A paper published in 2004 in the journal Medical Care analyzed more than 500 studies on that matter and found that, on average, about 75% of patients met the adherence standards researchers had set.

But these figures may overestimate adherence because some patients are probably fudging. “Patients who say they always take their meds may not be,” says Dr. Steven Hahn, professor of clinical medicine at Albert Einstein College and an internist at Jacobi Medical Center in New York City.

“Patients who say they don’t always take them are likely to be missing significant amounts.”

One indication of how much people fib is how things change when they know they’re being watched.

In a 2001 study in the Journal of Hypertension, scientists followed 41 patients who had been unsuccessful in lowering their blood pressure with three prescribed drugs. Patients continued taking the same three drugs during the study, but they now knew they were being monitored electronically: The drugs came in special packages that recorded the date and time whenever they were opened.

After two months of being monitored, about one-third of the patients had lowered their blood pressure to the normal range. Chances were good, the researchers concluded, that those patients had not been taking the drugs properly before.

A number of other studies have found that patients in clinical trials sometimes “dump” their medication — i.e., simply dispose of it — so it will look as if they’ve been using it as prescribed even though they haven’t.

Also, in the above-mentioned 2000 study published in Chest, 236 patients used inhalers to take medication intended to help them breathe. The inhalers were fitted with electronic monitors that could record the date and time whenever patients used them. Not all of the patients knew about the monitoring feature.

During one year of the study, 30 of the 101 patients who did not know they were being monitored — about 30% — dumped at least once. (Dumping was defined as activating the inhaler more than 100 times within a three-hour period.)

Of the 135 patients who did know they were being monitored, only one dumped.

Most of the dumping incidents occurred just before a clinic visit, and researchers concluded that patients dumped in order to give the impression that they had used their inhalers more often than they had.

No experienced clinicians, I suspect, will be surprised by this information. And, I’ve found few non-clinicians, who, on reflection, fail to recognize that misleading a doctor about treatment adherence, whether by omission or commission, is common.

The potential consequences, however, may be less apparent.

I examined the difficulties created by patients misleading their doctors about their compliance with the prescribed treatment in an earlier post, Treatment Adherent Refusal Of Prescribed Medications.  There I pointed out the risk that the patient would undergo unnecessarily aggressive treatment:

Clinicians cannot efficaciously deal with treatment failure caused by noncompliance if they do not know that the patient did not follow the treatment plan. At best, physicians will be less efficient in providing appropriate care; at worst, they may modify the treatment with disastrous results.

Moreover, the dangers to the patient’s health and the financial cost to the patient and society can increase exponentially. Consider this example from Noncompliance Costs of a nonadherent patient who hides the noncompliance from his doctor:

A Case Of Routine & Tragic Patient Noncompliance

A patient with an respiratory infection does not complete the full course of the antibiotic prescribed by his physician. When symptoms persist, the patient returns to his doctor but fails to report the noncompliance. The physician consequently believes that the original medication was somehow inadequate (e.g., the pathogen was resistant to the medication or not covered within the therapeutic range of the medication) and prescribes a different agent, one that is more costly and more prone to side-effects.

Already in this scenario, noncompliance has resulted in

• At least one unnecessary clinic visit
• Two medications in a situation in which one might have sufficed
• A potentially erroneous shift in ongoing treatment
• An increased risk of adverse medication effects, both because the second drug causes more side-effects than the first and because the patient is exposed to two medications instead of one
• A deviation, based on misinformation, from the initial treatment plan which, by design, should provide the optimal combination of safety, affordability, and effectiveness for that patient. At best, the new treatment plan will be similar to but somehow less advantageous than the original therapy. At worst, the noncompliance-caused treatment failure will cause the clinician to mistakenly alter the diagnosis and treatment such that the actual problem is not addressed.

This example is, admittedly, oversimplified. Some disorders improve despite noncompliance with treatment. Some clinicians might have suspected noncompliance when the patient did not improve. Some patients do confess their failure to follow the treatment plan. Nonetheless, a plethora of evidence demonstrates that noncompliance clearly increases the risk of treatment failure, that clinicians rarely recognize or even suspect noncompliance, and that patients even more rarely reveal nonadherence to treatment. This example is, in fact, statistically condensed but conceptually accurate, and countless analogous cases occur every day throughout the healthcare system. …²

Because of the complexity and interdependent nature of the contemporary healthcare system, the impact of patient noncompliance is rarely limited to wasting one medical treatment that would have been successful if implemented. Instead, any treatment failure caused by noncompliance is subject to an array of multipliers, some obvious and some invisible, that can easily increase the potential fiscal, physiological, and social cost exponentially and connections, both direct and indirect, that distribute a similar range of losses to others. Moreover, the extraordinarily high value western culture places on both the individual and health heightens the stakes and further drives the process.

Not only is this a common problem and one with serious consequences but it is also one nurtured by the contemporary patient compliance model.

Patient Compliance Is A Self Defeating  Strategy

In Treatment Adherent Refusal Of Prescribed Medications, I also pointed out that the conflict between patient and clinician that is part and parcel of our perspective on patient compliance motivates the patient to lie to the doctor:

The currently prevalent models of noncompliance management have a final common pathway: their objective, their only measure of success, is the patient following the medication regimen as prescribed – whether this goal is attained by coercion, persuasion, incentives, moral appeals to responsibility or concern for ones family, patient education, or other methods. Even so-called “patient empowerment” can be accurately translated in this context as “the patient is empowered to choose to take the medication as prescribed.” Consequently, patients who do not take their medications as prescribed are powerfully but covertly encouraged to actively or passively mislead clinicians about the noncompliance, perpetuating this vicious cycle.

This realization led to what I then modestly called …

The Incredibly Revolutionary Idea

1. We quit pretending that noncompliance will disappear if patients are properly educated, persuaded, empowered, informed, motivated, coerced, bribed, threatened, influenced, or reminded. We acknowledge the obvious – that except in a few cases,³ the patient makes the final choice about following a prescribed treatment.

2. Rather than continue the unrequited efforts to eradicate noncompliance, we try, as a first step in breaking the vicious cycle, fixing that part of the healthcare system that multiplies the damage caused by noncompliance: the miscommunication between clinician and patient about noncompliance.

I went on to suggest how the reader might address this issue directly with his or her clinician, but precise tactics are, in this case, less important than the big picture, i.e., the afore mentioned Incredibly Revolutionary Idea.

Storming The Bastille

The New Order Of Things – Replacing Patient Compliance

While only one aspect of the healthcare process, the problem of patients lying about adherence does spotlight the need for and the type of change in patient compliance I am promoting.

Continuing to emphasize the requirement of adhering to a prescribed treatment regimen also continues the conflict between patient and clinician, which, in turn, encourages the patient to lie to the doctor about following treatment. Because every doctor has had the experience of patients lying to him or her, the mistrust has become pervasive. Wary doctors may well mistrust all patients since discerning who is and isn’t telling the truth is difficult and often impossible.   Consequently the entire system has become corrupted.

My contentions are (1) the goal is not good compliance by a specific patient but instead optimal treatment for each patient and (2) optimal treatment is most efficaciously pursued by aligning the doctor, the patient, and other stakeholders to maximize mutual trust, a strategy which takes priority over the percentage of prescribed pills taken by the patient.

To dismantle the patient compliance apparatus that has hindered improvements in treatment outcomes, a systemic shift in perspective is necessary.

As an integral element of that shift, the doctor must convincingly transmit to the patient that valid and reliable communication between them supersedes a compliance scorecard.

Or, I suppose we can invest in electronic compliance monitoring devices, lie detectors, and a spy network.

One option for managing patients who may be lying

By the way, we might want to consider changing the name from “lie detector” to something like “trust enhancement processor.”

1. I know – I’m tired of seeing this quotation too. It just fit so well, I felt compelled to use it.↩
2. This scene is extended beyond this point in the original example at Noncompliance Costs, . I recommend reading it in its entirety to gain a perspective on how  impressively simple it is to conjure up plausible scenarios in which initial noncompliance which is compounded by lying  about it leads to severe incapacity or death and, by extrapolation, how likely it is that this sort of thing happens with some frequency.↩
3. E.g., cases involving children or adult patients incompetent to handle their own healthcare and cases in which forced compliance with treatment is legally sanctioned and is pragmatically feasible↩

If the same principles currently prevalent in the field of patient compliance were applied to the study and management of side-effects, …

Intercosmic Journal Of Treatment Side-Effectology

Searching for the cause  of treatment side-effects & its cure

Articles

Patients  equipped with new  side-effect reduction device report  disappearance of  rashes caused by medication

Patient shown operating  Visual
Side-effect Detection Modulator

An AlignMap.com Publication – Allan Showalter, MD, Editor