Economic Stress Disproportionately Impairs Patient Compliance
The Frightening - And Typical - Scenario
Benjamen Brewer, MD, commenting in the 23 July 2008 Wall Street Journal on the effect the current economic problems have on his patients, describes this vignette from his practice:
A patient quit smoking so he could afford gas for the 40 mile commute to work in a packaging plant. He has been living paycheck to paycheck for years and his rent just went up. I was glad that something finally motivated him to stop smoking.
The bad news was that he came to the office with severe pneumonia two days after refusing to let an E.R. doctor admit him to the hospital. My patient was afraid of the expense and all the time he would go without pay from work.
To make matters worse, he didn’t fill the antibiotic prescription he was given either. The $50 co-payment was unaffordable, he said. This is a case when an insurer would have been better off picking up the antibiotic tab to avoid a larger expense. But there’s no easy way for a doctor to override a plan’s co-pay or to let an insurer know its rules are about to make something very expensive happen.
When the patient came to see me, his condition had deteriorated. I persuaded him to let me admit him to the local hospital. He was in such bad shape that he was soon transferred to the ICU of a large medical center. His care will end up costing tens of thousands of dollars.
Commentary
I suspect there are few physicians in clinical practice who could not relate similar stories these days. In addition to its poignancy, however, this episode is also instructive. Patient compliance rarely seems to hinge on a few dollars but our health system operates as a fiscally leveraged system in which huge costs and fees are pragmatically payable only through insurance and other third party payer plans. The loss of a job or a health benefit has consequences beyond a decrease in income or the dollar equivalent of a health benefit. Without insurance, the individual is vulnerable to costs that one can neither control or pay. One result is that financially dependent compliance is remarkably brittle. We should not be surprised that a downturn in the economy has a tremendously magnified negative impact on compliance.
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How The Economics Of US Health Insurance Work Against Compliance With Preventive Care
Taking Our Medicine - The bad economics of switching health-care plans
By Ray Fisman. Slate.com
September 7, 2007
Payment For Preventive Care A Bad Bet For Health Insurance
The notion that significant improvement in treatment implementation is possible only if the interests of all healthcare stakeholders are aligned has been and continues to be AlignMap’s central and recurrent theme. Taking Our Medicine, the September 7, 2007 entry from The Dismal Science, the ongoing economics column at Slate.com, sounds a resonant leitmotiv.
An excerpt from the article indicates its basic premise - that the economic nature of the US health insurance system militates against funding of preventive care, which, in turn, negatively influences compliance with this important segment of treatment by insured patients.
In the long-simmering argument over what’s wrong with American health care, recent polls show that many people blame our market-based system of private health insurance. Private insurance companies are faulted for, among other things, failing to do enough to prevent disease. They have no incentive to do so, argue advocates for reform, ranging from Michael Moore in Sicko to some of the current presidential candidates. And yet if preventive measures today result in savings on treatment tomorrow, then what’s good medicine should also be good business.
Diabetes management is a case in point. If they get help early on in managing blood-sugar levels, diabetics can stave off later medical complications that may result in expensive hospital stays. Yet many of these preventive measures aren’t covered or encouraged by insurers. Instead, patients are forced to haggle over reimbursement for insulin pumps, and most are rationed only four test strips per day to monitor their blood sugar (sometimes enough, but often not). If better access to insulin pumps and blood-sugar monitoring will save money in the long run, why are insurers so miserly with their diabetes customers?
A recent study (not yet published) by researchers from Case Western Reserve and Carnegie Mellon University1 explains that the culprit in poor diabetes management—and the lack of preventive care in general—may be the very high rate at which Americans switch among insurance plans. It takes about a decade for insurers to recoup their investment in early diabetes treatment, and by then odds are that their customer has moved on to another health plan. Alas, a lot of this turnover may be built in to the way Americans get health insurance. And it’s the doing not of individual patients so much as their employers, who are always on the lookout to switch plans for lower-cost coverage.
The essay goes on to explicate the specifics of the employer-based health insurance system and suggest solutions to the problems of frequent switching between programs.
The situation described in this article is an excellent example of the systemic factors that must be brought into alignment if compliance is to be enhanced on a large scale.
This brief and clearly written examination of the implications of a health insurance system in which insurers cannot count on benefiting from long term coverage of the same individuals is well worth reading and can be found at Taking Our Medicine.
Footnotes
- A preliminary copy of the referenced study is available at Employer-Based Insurance Markets and Investments in Health [back]
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Managing Noncompliant Patients
Thoughtful Commentary On Core Issues
Source: Dealing with non-compliance
The Pharmaceutical Journal Vol 263 No 7074 p922-923, December 4, 1999 Forum
While the majority of AlignMap posts deal with research, the topic today is an editorial emanating from a Drug and Therapeutics Bulletin seminar on “How to look after patients who fail to care for themselves.”
Although this seminar was held in 1999, its content, the economic, ethical, and clinical aspects of treating noncompliant patients, remains pertinent today. This brief (less than 2000 words) article consists entirely of a series of comments from seminar participants that are insightful, thoughtful, and sometimes provocative and is well worth reading.
This editorial can be found at ~ Dealing with non-compliance ~
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Managing Medication Expenditures Without Cost-Sharing
Controlling Prescription Drug Expenditures:
A Report of Success
David P. Miller, MD; Curt D. Furberg, MD, PhD; Ronald H. Small, MBA; Franklyn M. Millman, MD; Walter T. Ambrosius, PhD; Julia S. Harshbarger, PharmD; and Christopher A. Ohl, MD
Am J Manag Care. 2007;13:473-480
Using Multiple Clinical Administrative Strategies To Control Pharmaceutical Costs
To hold the line on prescription medication costs without decreasing the necessary use of drugs ordered for treatment of chronic conditions, the health plan covering the 11,000 employees of Wake Forest University Health Sciences and North Carolina Baptist Hospital instituted four administrative level interventions, none of which resulted in higher out-of-pocket charges to individual patients, even if they were, as a result, shifted to a more expensive medication.
The four policies, their fiscal impact, and their effect on clinical utilization are summarized in this excerpt from the article:
Commentary
This article serendipitously came to my attention shortly after I published the previous entry in this blog, Another Case Of Cash For Compliance, which focused on monetary incentives and disincentives, including cost-sharing,1 implemented to improve healthcare habits and cut costs.
The decision of this organization to eschew shifting some or all of the costs of more expensive drugs to patients to discourage their use made this article a striking counterpoint to the accounts of plans opting for cost-sharing.
While the results for the Wake Forest University Health Sciences and North Carolina Baptist Hospital health plan have been encouraging thus far, especially given that prescription medication costs have increased between 8% and 15% annually in this country since the year 2000, caveats are in order.
Most importantly, the study, as the authors note, only looked at one clinical parameter, the utilization of chronic medications; the effect of these interventions on other clinical outcomes (e.g., hospitalization rate) must also be determined.
Moreover, the clinical offerings and the pricing structure of the pharmaceutical industry have been and are likely to continue to be in flux (a factor also acknowledged in the article). Today’s successful price-cutting tactic can be rendered ineffective or even counterproductive by a policy shift at one of more of the medication manufacturers.
For example, pill splitting, used in this study to “yield substantial cost savings,” could be eliminated overnight by a simple change in the nonobligatory one pill, one price policy (i.e., a 25 mg dose and a 50 mg dose of a medication is typically sold for the some price, allowing a patient to split one 50 mg pill into two 25 mg doses at a saving of 50%) of many pharmaceutical producers which, as I’ve pointed out in a previous post, Intentional Noncompliance With Treatment, already consider the tactic subversive and seem well along toward the rationalization that it could be dangerous to patients.
And, of course, clinical discoveries can have analogous results, although cataclysmic changes may be less likely to occur without warning.
Nonetheless, the findings of this study support the notion that health plans willing to continually track, evaluate, and reassess pertinent changes in the clinical and business spheres of healthcare and adjust their own benefit structure accordingly can make impressive progress toward the goal of affordable healthcare.
Footnotes
- Previous posts on cost-sharing:
-
Cost-sharing and Adherence To Prescribed Medication
Healthcare Cost-sharing And Medication Compliance
More On Cost-sharing And Medication Compliance[back]
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Cost-sharing and Adherence To Prescribed Medication
After publishing two posts dealing with cost-sharing (More On Cost-sharing And Medication Compliance and Healthcare Cost-sharing And Medication Compliance) earlier this week, I realized I had other articles on this topic stashed for potential use in future blog entries.
Because I can’t predict when - or if - those articles will make it online on this site and because of the importance of the effects of healthcare cost-sharing on patient compliance as well as the current interest in the topic, today’s post references some of this material for the interested reader.
The Integrated Benefits Institute Report
The Integrated Benefits Institute (IBI) has issued the a report, A Broader Reach for Pharmacy Plan Design, that, according to the press release, “finds pharmaceutical cost shifting leads to increased disability and lost productivity.” Funded by IBI, the full report is available to IBI members,1 but others can access the Executive Summary.
The American Journal of Managed Care Special Issue
In June, the American Journal of Managed Care published a special issue devoted to medication cost-sharing that included, among others, these titles:
- “Fiscally Responsible, Clinically Sensitive” Cost Sharing: Contain Costs While Preserving Quality
- Effect of Copayments on Drug Use in the Presence of Annual Payment Limits
- Effect of a Medication Copayment Increase in Veterans With Schizophrenia
- Relationship Between Generic and Preferred-brand Prescription Copayment Differentials and Generic Fill Rate
- Consumer Response to Dual Incentives Under Multitiered Prescription Drug Formularies
The complete articles are available in PDF format online at The American Journal of Managed Care (June 2007 Issue, Part 2): Prescription Drug Cost Sharing
Commentary
Both the Integrated Benefits Institute and the American Journal of Managed Care have a specific point of view that may influence their take on this topic. Of late, however, I have found it difficult to find research that it free of potential influence. These days, I am grateful when the researcher’s point of view and potential biases are at least clearly presented.
Footnotes
- The full report is also offered to media; consequently, I have requested a copy. If that request is granted, I’ll review the report on this blog. [back]
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