AlignMap readers will, I suspect, find little new in “Doctors Without Orders,” an article about medication noncompliance by Jessica Wagner at Slate.com.

In fact, the material may seem very familiar to those readers of AlignMap posts because much of the article is indeed based on an interview with me and data drawn from the AlignMap site.

Even the material dredged from these archives, however, seems altogether more impressive when Ms Wagner writes it under the Slate aegis.

Jessica Wagner’s Slate.com essay on medication noncompliance can be found at

• The Blog Is Back - Posting On AlignMap Resumes
• Welcome To The AlignMap Clinic
• More On AlignMap In Cites
• AlignMap In Cites - More Content, Less Delay
• New Posts on AlignMap In Cites

My delay in publishing posts to this blog is, in fact, fairly representative of most episodes of patient noncompliance in that I am uncertain how or why it happened, despite an intense effort to make that determination.

The degree of nonadherence is certainly significant, yet I have found myself repeatedly rationalizing that “one more day” until I made an entry in the blog would be inconsequential.

I am currently dealing with several generic, day-to-day problems, a number of which I could have anticipated and some that appeared without warning or precedent, that require my time and attention. I’ve undergone, for example, a bout of oral surgery, coped with the usual holiday obligations, suffered through the loss of one of the family cars secondary to an accident, managed some unexpectedly complex end-of-the-year financial issues, and begun working on a new project that involves patient compliance. On the other hand, I haven’t a clue how much impact any or all of these have had on my writing.

My declared intent was to write the next post or two on the practical problems involved in using pillboxes and similar compliance aids. On December 3, 2007, the date of my last AlignMap post, I thought I had a handle of the literature that addressed the pragmatics of pillbox use - primarily because that corpus of material was (or so I thought) notably sparse. Within hours of completing that last post, I found that simply substituting another set of search terms expanded the quantity of pertinent literature exponentially by accessing work done in other countries, especially Britain and Australia. This newfound vein of research does require time to read and organize, but when similar issues have come up in the past, I simply announced that one set of posts would be delayed while articles on other topics were published. In this case, however, no notification was given or substitutions made.

Finally, I have been considering dramatically decreasing the frequency of these posts or discontinuing this blog altogether. I’m not convinced that publishing my take on matters of patient compliance has had much impact. The alternative of doing something useful clinically or at least earning a buck or two has become more appealing. But, again, I didn’t do anything about this; I could easily enough, for example, have put a “On Vacation; Back Soon” sign in the blog window.

Which is, I suppose, what I’m doing now. I will follow up on the pillbox problems, primarily because I’m interested in this issue. Once I’ve gone through the research, I’ll post my findings and recommendations.

I’ll also figure out what I want to do about this blog and web site in general.

And for now, I’ll relax a bit and not worry about how many days have gone by since I put words on-line.

• Sick Call
• Semi-Hiatus at AlignMap
• The Misdiagnosed Patient
• In Today’s Post, The Role Of Professor Brindley Will Be Played By …
• I really cannot understand why it is so difficult to follow directions on the prescription bottle

Alignment of Healthcare Stakeholders Becoming More Prominent?

The ideas about alignment of healthcare stakeholders expressed in Aligning incentives: The promise of pay for performance by Dennis Schmuland, M.D., FAAFP are hardly novel but given that they carry the imprimatur of a business that is likely to become a major force in healthcare, thy may well take on more significance than the same notions published in, say, some guy’s blog.

While the article focuses on alignment as a compelling reason to use pay-for-performance programs and high tech software and hardware the value of aligning patients, plans, and providers, even independent of the latest Microsoft gadget, is obvious.

I’ve included two excerpts to provide a taste of the brief article:

Clearly I’m biased about the importance of healthcare alignment. That is exactly the reason I urge you to read about the concept elsewhere as well.

The article can be found at

• Healthcare Alignment
• Health Incentives and Minnesota's Healthcare Alignment Plan
• A Physicianv's Experience With Patients Who Avoid Tests Until It's Too Late
• Patient-MD Alignment
• Systemic Alignment

Source: Getting patients to take their medicine Jessica Hopfield, Robert M. Linden, and Bradley J. Tevelow. McKinsey Quarterly No 4. Dec 14, 2006

Medication Noncompliance

A McKinsey study of hypertensive patients indicates that half of the 65 million people in the United States with high blood pressure don’t adequately follow their drug regimen. Moreover, “the usual interventions—for example, electronic reminders or easy-to-open packaging—tend to improve adherence only in the short term, largely because a one-size-fits-all approach fails to address the underlying causes of the way patients behave.”

A more powerful means of improving treatment adherence and effecting cost savings and better outcomes, according to the study, are compliance improvement programs that recognize and address variations in patients’ attitudes toward compliance with treatment.

Further, as the article notes, Creating and implementing these programs will require the combined efforts of physicians, patients, pharmaceutical companies, payers, and other health care stakeholders.

The Segmentation Process

810 hypertensive patients were surveyed, interviewed, and assessed via focus groups in exploring five themes:

1. The patients’ level of involvement and perceived control over their health
2. The patients’ knowledge of hypertension and its treatment
3. The patients’ level of concern about the disease
4. The patients’ beliefs about the safety and efficacy of medications
5. The quality of their interactions with physicians

A statistical analysis of the relationships between the attitudes and self-reported behaviors of patients, described six population segments, ranging from proactive patients, who scored high on all five themes to skeptical patients, who,deeply distrusted both physicians and medications and almost never complied with their treatment regime. Between these extremes are confident patients, concerned patients, confused patients, and resigned patients.

Using Segmentation Strategies

While similar segmentation approaches have been used effectively in marketing (including anti-smoking campaigns), this tactic has not yet been widely used to improve the adherence of patients to their treatment regimen. The authors suggest that it should, arguing that “different types of patients have very different reasons for not taking medication.”

They found, for example, concerned patients might respond well to information on their medication’s safety while the compliance of confident patients might be most affected by programs that reward consistent, long-term usage.

The article points out that more work is required to devise compliance-enhancing interventions that correlate with the different patient segments.

The descriptions of the patient groupings, the five themes investigated, and the possible correlations between patient segments and compliance enhancements are elaborated in more detail in the article, which can be found at
~Getting patients to take their medicine~

Commentary

Alignment Of Healthcare Stakeholders
A secondary but nonetheless significant point in this context is the afore quoted line from the article, Creating and implementing these programs will require the combined efforts of physicians, patients, pharmaceutical companies, payers, and other health care stakeholders, which I contend deserves more emphasis and explanation than it was given in the article. It is, one supposes, possible that this criticism has something to do with the fact that this sentence is virtually identical to the primary premise of AlignMap.

Patient Segmentation
Segmenting patients according to their attitudes pertinent to medication compliance is not a new concept. The scheme outlined in this article, in fact, is similar to one that colleagues and I devised over five years ago,¹ and other segmentation-based programs have been instituted on a limited basis.

The problem has been and continues to be the lack of openly available, non-proprietary evidence indicating the effectiveness of programs using this approach.² As we and others have discovered, clinical tests of this concept that are of sufficient scale and power to produce valid, reliable results are dauntingly complex and difficult to design as well as formidable and expensive to execute.

The process described in the McKinsey article is alluring, as are similar concepts, including our own, but it and its analogues remain untested and unproven.

The Potential Payoff Of Patient Segmentation
If, however, the effectiveness of compliance-enhancement programs tailored to particular patient segments can be successfully demonstrated, they would offer a solution for the conundrum described in the previous post, Health Literacy: A Clear Problem Without A Clear Solution, i.e.,

Such a breakthrough would have the potential to create a quantum leap improvement in outcomes and reductions of healthcare costs, dramatically transforming healthcare in the process.

That seems worth pursuing.

Footnotes

1. We ceased work on this project because we couldn’t directly validate it with clinical testing (a small scale effort did provide results that were encouraging but fell short of convincingly confirmatory). We finally ran out of money and time to donate to the cause and we weren’t clever enough to try publishing our system without proof. [back]
2. Some segmentation programs claim research-proven effectiveness but refuse to disclose that research or to make it available for others to attempt duplicating the results because the programs and the research are proprietary. My arguments that the support of the medical community and the publicity that would result from openly available research that was proven accurate and duplicable would outweigh the proprietary risks have not been persuasive in lifting the veil obscuring these secrets, even on the most limited basis - e.g., signing nondisclosure agreements. [back]

• Patient Compliance Subverted By The Temptation Of Now
• Treatment Adherence Not Affected By Patient Preferences
• Self-Reported Vs Actual Compliance With Mammogram Screening By Older Women
• Patient Compliance With Osteoporosis Medication
• Patient Compliance With Medication Prescribed In Emergency Department Visits

The Inspiration

In the movie, Miracle On 34th Street, Kris Kringle is hired to be the Santa for Macy’s store on 34th Street in New York City. He causes a storm of reactions of all sorts when he sends one woman shopper to another store, Schoenfeld’s, for a fire engine for her son and tells another mother that Macy’s rival, Gimbel’s, has better skates for her daughter.

And the result?

Kris Kringle’s unorthodox practice of recommending rival stores when they have better bargains generates so much good publicity and customer goodwill for Macy’s that Mr. R.H. Macy himself proffers bonuses to the executives who hired Santa and, in a show of cooperation, shakes hands with his biggest competitor, Mr. Gimbel (Herbert H. Heyes), owner of Gimbels Department Store.

And What Does That Have To Do With Patient Compliance?

Well, perhaps it’s time for pharma to acknowledge that running patient compliance programs that focus on only one medication the sponsoring company manufactures has resulted in neither improved compliance or good will from the public or healthcare professionals and consider the potential benefits of cooperating with their competitors to create a patient compliance strategy that is widely supported and targets a wide range of diseases and treatments.

Nor should pharma be the only group involved. Improvements in patient compliance would primarily benefit two industries financially: pharmaceuticals and healthcare insurance. From this admittedly oversimplified perspective, it follows that these two groups would have the most to gain by funding such a project.

To avoid both regulatory problems and divisiveness within the leadership, this consortium would fund a third party organized for the purpose from experts in the scientific or medical community to develop and administer the program with the funders and other stakeholders serving as a board of directors. To assure transparency, full and detailed reports of the activities of this patient adherence supergroup would made not only to the directorship and all funders, but also to clinicians and the public.

For their part, organizations representing healthcare professionals and healthcare organizations, such as hospital and outpatient groups would have a seat on the oversight committee in return for their support in urging their members to follow the guidelines produced.

Likewise patient support organizations would have an official role exchanging information and insights with the project leadership in return for their support of and cooperation with the programs.

Finally, the other major stakeholder, the government, also a major fiscal beneficiary, would coordinate the multiple regulatory agencies to streamline the program implementation and provide tax advantages for those funding the project.

That doesn’t seem very realistic

As Fred Gaily, who successfully represented Kris Kringle at the hearing to determine if he were actually Santa Claus, puts it,

Besides, there’s this Who’s Been Naughty & Nice List thing.

• Medication Adherence Reminders and Doctor-Patient Communication In The Wall Street Journal
• Wall Street Journal Offers Practical Compliance Tactics
• The Effect Of The Spouse Of An Autonomous Patient On Adherence
• Bandolier On Patient Compliance
• John Edwards On Patient Compliance

Improving Medication Adherence: Challenges for Physicians, Payers, and Policy Makers
Patrick J. O’Connor.
Arch Intern Med. 2006;166:1802-1804.




In his thought-provoking editorial, Dr. O’Connor succinctly summarizes the problems of noncompliance:

The Challenges

The majority of the paper consists of eight challenges:

CHALLENGE 1: Can we stop blaming patients for medication nonadherence?

CHALLENGE 2: Can we develop office systems or teams that provide necessary information on new medications at the time of prescription?

CHALLENGE 3: Can we develop communication and coordination systems to reduce medication errors at transitions in care?

CHALLENGE 4: Can we use more combination tablets and inexpensive “polypills” to achieve better medication adherence and lower costs?

CHALLENGE 5: Can we promote the use of especially beneficial drugs and reduce the use of less beneficial drugs?

CHALLENGE 6: Can we educate our patients to be nonadherent in a rational way?

CHALLENGE 7: Can anything good come out of drug formularies?

CHALLENGE 8: Can we resist the temptation to medicalize life from birth to death?

Commentary

Implicit in the range of issues encompassed by O’Connor’s eight challenges is the principle that has become my central theme: significant improvement in patient compliance is possible only when the interests of all the stakeholders, including patients, clinicians, and policy-makers are aligned. I’m especially supportive of the notion that patient noncompliance should be considered a potentially valid choice rather than automatically designated healthcare’s cardinal sin. I also admire O’Connor’s endorsement of financial incentives, one of the few compliance enhancements that has been demonstrated to be effective in multiple settings with different patient populations.

While the eight challenges are not of equal significance and do not exhaust the potential issues of adherence to treatment, they do represent the most comprehensive and, more importantly, most potentially useful battle plan for improving adherence that I’ve found. This editorial is an essential read for anyone interested in patient compliance with treatment.

• Effect Of CPAP Adherence On Memory Improvement
• Medication Adherence Is Half The Battle
• Patient Adherence To Antidepressant Regimen: Dramatic Improvement Claimed
• CME: Treatment Nonadherence Among Individuals With Schizophrenia: Risk Factors and Strategies for Improvement
• Dietary Adherence By Children On Dialysis

Hospitals Try Free Basic Care for Uninsured By Erik Eckholm. New York Times. October 25, 2006

While this article does not deal directly with adherence to treatment, it does describe an excellent example of one of my fundamental themes: aligning the interests of patients (in this case, uninsured patients) and healthcare providers (in this example, the hospitals committed to furnish care for that set of patients).

The Seton Family of Hospitals, when confronted with a repeat visitor whose disorders and healthcare costs might be attenuated if they received help prior to crises, have begun offering free primary care through its charity program.

As the WSJ article notes, “With the number of uninsured people in the United States reaching a record 46.6 million last year, up by 7 million from 2000, Seton is one of a small number of hospital systems around the country to have done the math and acted on it. Officials decided that for many patients with chronic diseases, it would be cheaper to provide free preventive care than to absorb the high cost of repeated emergencies.”

A few other hospitals, including some public systems in New York and Denver now direct uninsured patients to community clinics that charge low fees or provide free care.

While the extent of such programs is severely limited, they appear successful and could serve as a prototypal model for an alternative healthcare system - one organized to reward all participants for cooperation rather than one arranged as a zero-sum game.

• Effect Of Noncompliance On Timing Of Treatment Recommendations For Type 2 Diabetes
• The Neverending Search For Determinants Of Patient Compliance and Persistance
• Patient Adherence And Prevention Of Nontraumatic Amputations
• Running Patient Compliance Up The Flagpole
• Pharmacist-Driven Compliance Enhancement Programs

Using Motivational Interviewing to Promote Patient Behavior Change and Enhance Health by Belinda Borrelli, PhD, MA. Medscape. Release Date: July 28, 2006.

Motivational Interviewing is a technique specifically designed to work with a patient’s issues regarding behavior change. Essential components of Motivational Interviewing include

• A mutual understanding between patient and clinician that the focus is on understanding the patient’s concerns rather than coercing the patient to change
• Enabling the patient to make an informed decision about changing
• A nonjudgmental stance on the part of the clinician that emphasizes listening and questioning rather than instructing or problem-solving
• A focus on the patient that requires gathering information about the patient’s issues prior to an exposure to the clinician’s views

A primary benefit derived from the insistence on an interviewing model is that, by definition, it fits the patient’s current position vis-à-vis behavioral changes. The Transtheoretical School holds that patients may be anywhere on a spectrum from not considering changing to be ambivalent about the change to ready to change. (See Current Models Of Compliance) It seems intuitively apparent that varying ones approach to patients, based on their position on this spectrum, could be effective.

The bulk of this article covers specific tactics of Motivational Interviewing , including

• Using OARS (open-ended questions; affirmations; reflective listening; summaries)
• Managing patient resistance
• Enhancing motivation to change

References supporting the effectiveness of Motivational Interviewing are listed but not explicated.

A brief section acknowledges the inherent problems of instituting any new element into a primary care practice, especially one such as Motivational Interviewing that requires specific training.

Commentary

While I’m a proponent of Motivational Interviewing, I admit to experiencing a degree of cognitive dissonance when considering the claim that it espouses a nonjudgmental point of view. It seems to me that motivational is closer to persuasive than to nonjudgmental, and it seems apparent that the goal is to promote specific behavioral changes that the clinician has determined are appropriate. It seems, in short, a clinician using Motivational Interviewing is about as nonjudgmental about the outcome as a car salesman is unbiased about his customer buying a car – i.e., the salesman is unbiased about which Ford the customer buys as long as he buys a Ford from him. Medically, a genuinely nonjudgmental stance would require making it explicit to the patient that an available – and acceptable option – is for the patient to reject the recommended treatment plan.

Other than that incongruity, which is inherent to the philosophy of Motivational Interviewing, this is a well done, carefully written introduction to Motivational Interviewing, which may, ironically, mitigate its persuasiveness. My nonscientific take on the piece is that, were I a busy primary care physician without prior knowledge of Motivational Interviewing,

1. I doubt that I would succumb to the temptation of reading an article entitled “Using Motivational Interviewing to Promote Patient Behavior Change and Enhance Health”
2. If I were to read it, the apparent cost/benefit ratio of introducing Motivational Interviewing into a practice would discourage me from investing my own time to learn the techniques, let alone take on the Herculean task of convincing colleagues and staff to integrate them into the practice.

I’m not suggesting that the article should have been sensationalized. I do believe those promoting Motivational Interviewing, which does seem to hold significant potential in enhancing compliance, would do well to make use of some of its own tenets, specifically the idea of finding out how a particular clinician feels about making such a change before providing instructions. And, until the benefits of Motivational Interviewing are more widely known, information about tactics should be paired with more extensive evidence of its effectiveness.

The bottom line, however, is the point I find myself repeating in many such circumstances:

Even if a clinician were convinced that Motivational Interviewing was effective, he or she would have to sustain the cost, in time, money, and hassles) of introducing this technique to the practice with no other incentive than the sense that “it’s the right thing to do.”

Surely, we can do better than that.

CME Information:
Valid for credit through July 28, 2007.
Credits Available: Physicians - maximum of 1.0 AMA PRA Category 1 Credit
Credits Available: Nurses - 1.2 nursing contact hours (None in the area of pharmacology)

• Monetary Incentives To Decrease Obesity
• Effect Of Targeted Interventions On Patient Compliance With Screening
• Promoting Compliance With Pharmacy Benefit Incentives
• AMA Passes New Policy On Adherence To Treatment Plans
• Laws & Public Health Compliance

I originally posted the following document on Heck Of A Guy, my other, … uh, less businesslike blog, where I usually deal with weighty matters such as The How-To Of Ketchup Decantation, Dishwasher Salmon , or If Mom Were Muslim. I mention this to explain the relatively casual writing style and snarky tone of this post.

How To (Correctly) Not Take Medications As Prescribed, which describes the benefit of communicating about noncompliance with ones physician, generated significant interest from an audience more accustomed to finding something more along the lines of my recipe for chocolate vodka rather than an essay on adherence to treatment, leading me to believe promoting something like this (the communication thing, not the vodka thing) could be more successful in enhancing compliance than more typical compliance enhancement efforts which focus on making the patient behave better.

Of course, it’s just an idea; I could be wrong.
___________________________

Want to improve your healthcare and the healthcare system at large?
… and, in the process, decrease medical costs?
… without changing doctors, moving into an ashram, or giving up any of your disgusting vices?

Remember this promise from Take Your Blog Reader To Work Day?
Finally, sometime in the next few days, I’ll let you know about a particularly vicious cycle caused by inadequate patient-physician communication vis-à-vis noncompliance and offer some free advice, guaranteed to be worth the price, about how to protect yourself from falling prey to this potentially expensive and health-endangering trap.

Well, it’s been more than a few days, but here it is. So, pay attention.

The Background

First, it’s important that you understand these facts:

1. Although patients who take medications¹ as prescribed will, as a group, have a statistically significant better outcome than the patients who refuse the medications altogether or patients who take the medications but not as prescribed, a significant number of patients (a 20-80% range of noncompliance would cover most cases and a 50% noncompliance rate would be a fair estimate of an overall average) will not take medications as prescribed – regardless of the disorder being treated, the severity of the potential outcome, the medication prescribed, the age, education, experience, or demographics of the patients. Patient noncompliance has been a pervasive and persistent healthcare phenomenon despite the best efforts of the healthcare community to combat it since at least the time of Hippocrates (born 460 BC; died 377 BC).

2. Most of those patients who do not take medications as prescribed do not inform the prescribing clinician of this and may even claim that they have taken the medications as prescribed. In the overwhelming majority of such cases the prescribing clinician never discovers that the medications were not taken as prescribed.

3. 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, the physician will be less efficient in providing appropriate care; at worst, they may modify the treatment with disastrous results.

4. The currently prevalent models of noncompliance management have a final common pathway: their objective, their only measure of success, is that the patient follows the prescribed medication regimen, 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” has come to mean “the patient 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.

That wasn’t so bad, was it? Is everybody still with me? OK, now we come to

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,² 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.

And How Do We Do That?

Well, the easiest and best way would be for everyone to read the Heck Of A Guy and AlignMap blogs, acknowledge the wisdom and power of this idea, and change overnight.

Just in case that plan inexplicably fails, there is a Plan B, but it’s a tad more complex. Plan B involves adjusting the interaction between clinician and patient to reinforce rather than discourage open communication about noncompliance. This will require the cooperation of some significant players from the healthcare field, those who pay for healthcare, and government bureaucracies as well as patients and their families. It probably won’t happen overnight. This is what my work at AlignMap is all about.

In The Meantime

If this concept appeals to you, you can take a baby step or two toward opening communication with your medical team on your own and at your own risk by simply informing your prescribing clinician if you didn’t take your medications as prescribed, whatever the reason (e.g., you lost track of the prescription schedule, the medication caused side-effects, it didn’t seems as though the medication was working).

Here’s the catch. While telling your physician that you aren’t following his or her prescribed treatment seems rather straightforward (after all, what objection can there be to a patient telling the doctor the truth?), the risk is that your clinician could respond to your efforts in a suboptimal manner³ because, for example, of personality conflicts, fears of malpractice lawsuits, misinterpretation of your motivation, or pressure from peers, third party payers, or administrative overseers.

The possibility of a negative outcome from this interaction, while incalculable, does exist and precludes my enthusiastic endorsement and encouragement of patients taking unilateral action.

Here’s an interesting question for your primary doctor/nurse practitioner/physician’s assistant that might help you assess his/her attitude: “Say, Dr. _______, I was wondering. If you prescribed some pills for me and I called you a week later to tell you I had taken them for a while but became convinced they weren’t going to help and quit taking them, what would happen then?”

Footnotes

1. This post focuses on treatment with medication only because that is a familiar concept and one that is relatively easy to understand; the same principles apply to treatment plans featuring prescribed diets, exercise programs, screening tests, etc. [back]
2. 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 [back]
3. ”Your clinician could respond to your efforts in a suboptimal manner” is code for ” Your clinician could be a jerk,” ” Your clinician could find a reason to refuse to treat you,” or “Your clinician could retaliate against what he or she sees as ungrateful, uncooperative, or crazy behavior.” [back]

• Adherence To Treatment: Tips To Patients
• The Oath
• Status Of Improving Patient Adherence To Cancer Treatment Project
• Improving Patient Adherence in Chronic Heart Failure - Online Continuing Education
• My Adherence Sucks

I’m on a one week break. Posts will resume 19 June 2006

• Thanksgiving Holiday
• Semi-Hiatus at AlignMap
• Posting To Resume At Later Date
• Sick Call
• I really cannot understand why it is so difficult to follow directions on the prescription bottle

The news story, Study: Drug Caps Mean Sicker Patients, No Savings,
summarizes research at Kaiser Permanente published in the New England Journal of Medicine which reviewed 200,000 patients who had Medicare+Choice coverage (now called Medicare Advantage) in 2003. One-fifth of the patients had unlimited drug coverage; the rest had a $1,000 annual drug benefits cap.

In contrast to the predicted savings from more judicious management of healthcare by individuals who would be responsible for a portion of its cost, patients who hit the cap stopped taking their medications, were more likely to get sick, and required more treatment.

“Although there were lower drug costs, the higher costs for hospitalizations and emergency-department visits offset those savings,” concluded study author Dr. John Hsu, “This study showed that a $1,000 drug-benefit cap had consistent unfavorable health effects — and failed to save money.”

Commentary

This is yet another bit of evidence supporting the notion that the entire healthcare system, including patients and third party payment schedules, must be in alignment for compliance to improve.

• Drug Courts
• Promoting Compliance With Pharmacy Benefit Incentives
• Noncompliance Despite Life Or Death Stakes
• Strategies To Increase Adherence To Antabuse
• Results Of Differing Methods Of Communicating Treatment Benefits To Patients

AllignMap

AlignMap’s primary theme is the improvement of treatment implementation, which is similar but not identical to compliance and adherence, by bringing the patient, his or her clinicians, and other stakeholders into alignment with a single, shared objective: to implement the best workable treatment plan for the patient.

The Blog

This blog is designed to serve as a workshop of sorts, exploring relevant research and thought.

The Resources

The Resources Archive, accessible via the Resources button top right of any page, is an annotated listing of links, located at Furl.net, to web sites that relate to patients’ implementation of treatment plans, patient compliance, adherence, concordance, and related topics. This archive has a reasonably good search function which can be used with key words or to filter by category. The following partial listing of the categories in the AlignMap Archive may be helpful in providing an inkling of the content:

• Bioethics Of Compliance
• Culture & Ethnicity Effect On Compliance
• Economics & Compliance
• Prevalence & Persistance of NonCompliance
• Public Health & Compliance
• Special Populations & Compliance: HIV
• Special Populations & Compliance: Lifestyle Disorders
• Special Populations & Compliance: Organ Transplants
• Systemic Conflicts Affecting Compliance

The Rest

An overview of the AlignMap.com site can be found at the AlignMap Home button at the top right of any page. The web pages with self-explanatory titles can be accessed by links in the right column.

• AlignMap SiteSearch Results
• AlignMap SiteSearch
• Welcome To The AlignMap Clinic
• Web Policies
• NY Times Coverage Of Patient Compliance