John Edwards On Patient Compliance
And Bloggers On John Edwards
Were one to draw the Venn diagram of patient compliance and presidential campaigns, one would anticipate the intersecting portion would be minuscule if it existed at all. Further restricting that intersection to an overlap patient compliance, presidential campaigns, and public controversy certainly, one would think, doom that result to the ignominy of the null set.
Well, as of 2 September 2007, one would be wrong.
That day, presidential candidate, John Edwards elaborated on his healthcare plan to the folks in Tipton Iowa in a speech described in Edwards Backs Mandatory Preventive Care, the AP news story by Amy Lorentzen:
From the lighting of that fuse to explosions of outrage in the conservative blogosphere required only a few hours.
Consider, for example, a Newsalert post published at 7:52 PM the same day the speech was given:
The AP reports on Comrade Edwards:
… [An excerpt from the AP story referenced above follows] …
Comrade Edwards is going to force you to go to the doctor whether you like it or not.You will not be free because Comrade Edwards wants a monopoly on your health care.
And, just in case the reader doesn’t pick up on the subtle political connotations of “Comrade Edwards,” the post is headed by the following emblem:
How about a few other examples, just for grins?
From the post with my favorite title, Healthcare Part VIII - Drop that Twinkie or I’ll Shoot! at Angry Bear,
No word if Edwards will give us veggies.
And from John Edwards: “you can’t choose not to go to the doctor for 20 years” posted at Althouse, come these passages:
Daystar51 goes beyond lambasting Edwards for promoting “mandatory preventive health care” to speculating on the possible origins of this notion buried in the candidate’s psyche:
Mandatory preventive health care? Come on, no one could think that.
But Edwards says he does. He says if you’re going to be in the system, “you have to go in and be checked and make sure that you are OK.” Only he doesn’t happen to mention any way to opt out of the system. His plan “requires that everybody be covered. It requires that everybody get preventive care.” Not only that, but mental health is part of Edwards’s plan. I can only take this to mean that annual check-ins with a psychiatrist would be required, cradle to grave.
I wonder whether Edwards’s plan is designed to fund pill police to make sure you choke down all the good things Doctor gives you.
Interestingly, medical malpractice litigation was Edwards’s specialty when he practiced law. He tried more than 60 med-mal cases, more than half of which brought verdicts exceeding $1 million. He reported an AGI of $11.4 million in 1997. Tidy.
Perhaps Edwards is now enthralled with doctors because his wife has breast cancer. Perhaps his compulsory exam plan is a token of his appreciation, a way of paying doctors back.
An blog/article, dated September 5, 2007, in US News & World Report wields the British healthy practices incentives plan as a blunt instrument to batter the obligatory preventive care Edwards espouses:
The dream of universal healthcare, as outlined so far in the Democratic presidential race, looks like this to me: Every American (says John Edwards) gets health insurance or at least most people (says Barack Obama). Will it mean higher government spending? Probably. But it can be paid for via higher taxes on wealthy Americans (Edwards). But who knows, maybe through greater use of technology, cost savings will be enough to avoid a tax increase (Hillary Clinton).
But as the various plans get looked over, explained, and debated, it seems very likely that all sorts of unanticipated aspects to them will pop up, such as this recent piece of insight from Edwards regarding his plan, via an AP story:
“It requires that everybody be covered. It requires that everybody get preventive care,” he told a crowd sitting in lawn chairs in front of the Cedar County Courthouse. “If you are going to be in the system, you can’t choose not to go to the doctor for 20 years. You have to go in and be checked and make sure that you are OK.”
Certainly at first glance, Edwards seems to be advocating a system where you get health insurance only if you follow certain government-prescribed healthcare routines, like regular doctor visits. Now after re-examining the Edwards plan, liberal blogger Ezra Klein concludes that patients “will have incentives to avail themselves of preventive options. But there won’t be any mandate for X doctor’s visits every Y years.” Maybe he’s right. But then again, maybe Edwards was accidentally describing the future of any government-directed healthcare system. Just look at Great Britain. That nation’s national health system already demands that obese patients lose weight before receiving hip replacements. But the out-of-power Tory Party wants to go further, according to London’s Evening Standard (via the Drudge Report):
Failing to follow a healthy lifestyle could lead to free NHS treatment being denied under the Tory plans. Patients would be handed “NHS Health Miles Cards” allowing them to earn reward points for losing weight, giving up smoking, receiving immunisations or attending regular health screenings…. But heavy smokers, the obese and binge drinkers who were a drain on the NHS could be denied some routine treatments such as hip replacements until they cleaned up their act…. Those who abused the system—by calling an ambulance when a trip to the GP would be sufficient, or telephoning out of hours with needless queries—could also be penalized…. Yet while the Health Miles Card would award points for giving up smoking and losing weight, it could penalise those who are already fit and well because they would receive no benefits under the scheme.
Weird Is Relative, writing in What’s the punishment for noncompliance? Endless jury duty?, implies that the Tipton Iowa speech may be fatal to the Edwards candidacy:
It would be difficult to misunderstand the perspective of Not Larry Sabato, who exclaims in John Edwards on Health Care,
This kind of crap is exactly what allows politicians like George Allen to talk about the “nanny state” and collect votes. I totally support universal health care so every American has coverage- but if some people choose not to use that coverage they are given- that is their decision. How is Edwards going to enforce this - will he send the police out to get people who miss their scheduled preventative doctor’s appointments?
In fairness, not every blogger or commenter was bashing Edwards, but pro-Edwards postings are difficult to find. Plunderchat is a one of those few who straightforwardly support the mandatory preventive care, declaring in John Edwards Looking Good on Health Care that
First: “It requires that everybody be covered.”
To make health care affordable for everyone, you need to spread the cost out across the entire population. Twenty-year-olds will often opt out of healthcare because they rarely need it while seventy-year-olds require constant medical- especially if they’ve had little or poor health care while they were younger. If you can keep the twenty-year-olds in the health care pool- then the cost goes down for everyone else.
Second: “It requires that everybody get preventive care.”
It is MUCH cheaper to prevent major medical problems than it is to treat them once they hit. Under the Edwards Plan “If you are going to be in the system, you can’t choose not to go to the doctor for 20 years. You have to go in and be checked and make sure that you are OK.”
If he keeps up like this, I might actually be able to look past his accent. Maybe.
Commentary
1. It turns out that the complete healthcare plan Edwards supports apparently allows folks to opt out of the program if they wish to manage their own healthcare without government mandates. This discovery disappoints me; when I read about the Tipton speech, I envisioned a post about Edwards declaring Patient Compliance “Mission Accomplished.” Then, I would go on to sardonically observe that “the answer to noncompliance was right in front of us - just issue a presidential proclamation that compliance was obligatory. And so on. If folks have the alternative of leaving the system, the obligatory preventive care lacks the extremity of arrogance that would otherwise render this notion an appealing target.
2. Few bloggers noted that we already have a batch of healthcare mandates on the books, including reporting and quarantine of various infectious diseases, undergoing certain vaccinations, obligating parents to follow doctor’s orders re their sick children, lest they be made wards of the state, and, more recently, restrictions on smoking and intake of some foods.
3. I have to wonder if Mr. Edwards and his advisers have considered the difficulty of monitoring, let alone enforcing patient compliance. While checking attendance records to determine who kept and didn’t keep a doctor’s appointment seems simple enough (although distinguishing between appointments missed because of traffic, scheduling snafus, and family emergencies from those missed through noncompliance may require compliance interrogations abetted by bright lights, good copy-bad cop tactics, and polygraphs), medication compliance, for example, is notoriously difficult to determine, and adherence to diet, exercise, and similar non-medication prescriptions is rarely even attempted. Enforcement methods, short of the Pill Police, are relatively easy to come by; e.g., dropping healthcare coverage for noncompliant patients or tying official authorizations such as driver’s licenses to certificates of healthcare compliance would be simple enough, but even a compliance-pusher like me recognizes that this would be a major shift in the patient-clinician relationship as well as in the role of government in this country.
Related Posts:
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]
Related Posts:
Payment For Medication Compliance: Incentive or Bribe?
Is it acceptable for people to be paid to adhere to medication? Yes
Tom Burns. BMJ 2007;335:232, doi:10.1136/bmj.39286.399514.BE
Is it acceptable for people to be paid to adhere to medication? No
Joanne Shaw. BMJ 2007;335:233, doi:10.1136/bmj.39286.422639.BE
The Issue
A program to reinforce compliance with drug abuse treatment by awarding shopping vouchers to patients who adhere to the program was recently approved in England.
This week’s British Medical Journal includes a concise debate between two experts on this issue. While the point each makes are predictable and I suspect few readers will be swayed from their convictions held prior to perusing the article, the opposing perspectives, which are stated clearly and thoughtfully, are useful in considering the ethics and clinical pragmatics of this methodology.
Rather than rehearse the points of these two arguments, I instead suggest that viewers read the original debate by clicking on the link that follows to download the two-page PDF of the paired pro and con articles, provided by the BMJ without charge: ~Is it acceptable for people to be paid to adhere to medication?~
Related Posts:
Health Incentives and Minnesota's Healthcare Alignment Plan
The QCare Gift Card
A proposal for Minnesota’s state-sponsored health plan to provide $20 gift cards as financial incentives to diabetics who control their glucose levels and smokers who quit the habit has resulted in a few news stories and some outrage from the public.1
The plan is relatively simple. Senator Linda Berglin, who leads the health budget panel, proposes offering $1 million in incentives to patients covered by subsidized programs including the MinnesotaCare plan for the working poor, pointing out that “These quality guidelines are not reached simply by the doctor. There has to be the patient involved in it, too.”
The incentives would be part of the QCare program, which offers bonuses to health plans and providers that score well on treating costly chronic conditions like diabetes and heart disease.
The Associated Press story ends with “It was unclear Wednesday whether there would be restrictions on what gift card recipients could buy with them.”
Commentary
While the Associated Press story worked the angle of offering gift cards2 for patient compliance, I submit that the core issue from the healthcare perspective is simply “Will the incentives efficaciously improve the health of the patients?”
Anyone following this blog probably knows that offering incentives for adherence, a tactic that has come and gone a few times in medicine over the past decades, is currently in ascendancy. On AlignMap.com alone, are posts about Incentives To Enhance Compliance With Addiction Treatment, Cash For Compliance & Other Ethical Dilemmas, and Shopping Discounts As Incentives For HIV Screening Compliance, among others. (Running a search for “incentives” at the site pulls up a half-dozen other posts.)
The question may well be why it isn’t more consistently popular. The fundamental paper on the topic in the medical literature is probably “Should we pay the patient? Review of financial incentives to enhance patient compliance,” by Giuffrida and Torgerson (British Medical Journal. 1997;315:703-707. 20 September), who reviewed “randomised trials with quantitative data concerning the effect of financial incentives (cash, vouchers, lottery tickets, or gifts) on compliance with medication, medical advice, or medical appointments” and found “10 of the 11 studies showed improvements in patient compliance with the use of financial incentives.”
Moreover, the improvements in compliance should save far more money than the program would cost.
I would suggest that the opposition to financial incentives has less to do with the effectiveness of that strategy than with social mores, politics, and personal philosophies.
As a political conservative, I’m not convinced that government should be micromanaging healthcare; as a pragmatist, I’m not convinced that any other currently existing agency with sufficient power to coordinate care for large populations is likely to do any better.
My concerns about the government’s involvement in healthcare and my recognition of the gap between the lofty goals of a plan and its execution notwithstanding, I am impressed with the stated objective of Minnesota’s QCare Program: … To apply QCare standards and align payments and es for all state purchased health care.
I am, you see, big on the alignment thing.
Sources:
Gift Cards Proposed as Health Incentive
State of Minnesota: Information on Quality Care and Rewarding Excellence (QCare)
Footnotes
- A sense of the response from at least a portion of the populace can be ascertained from scanning the comments to the news story at http://www.freerepublic.com/focus/f-news/1808798/posts [back]
- I’m not wild about gift cards myself; I can only guess that Minnesota will but them at a discount or that offering cash (my preference) would be bad politics. [back]
Related Posts:
Proposing Coerced Treatment Compliance
The Issues
In a drama that one can imagine scripted by John Kani or Tony Kushner, the post-apartheid politics of South Africa, the physiological and psychological dynamics of AIDS, a life and death struggle with a potentially global impact, the clash of national and ethnic traditions, cultures, and mores, medical research, the concept of individual freedom and dignity of the individual, the reality of clinical healthcare practice in places like KwaZulu-Natal, the sovereign authority of a recognized nation Vs the needs of the world community, the role of international public opinion, the pronouncements of a self-described institution of bioethics, and the socio-economic forces associated with poverty, homosexuality, and race are joined together in agonized battle by a paper issued in a forum with the prosaic, even by bureaucratic standards, title of the “Public Library of Science Medicine.”
The Proposal
In the January 2007 (Vol. 4) issue of the Public Library of Science Medicine Journal, Drs. Jerome Amir Singh and Nesri Padayatchi of the Centre for AIDS Programme of Research in South Africa and Dr. Ross Upshur, the director of the Joint Centre for Bioethics at the University of Toronto, propose that patients with XDR-TB, a drug-resistant form of tuberculosis, who refuse treatment be involuntarily detained in hospitals or other health care facilities in South Africa.
The following excerpt from that paper accurately reflects, I believe, the authors’ thinking, but has been significantly truncated. I heartily recommend reading the original paper, which is freely available at XDR-TB in South Africa: No Time for Denial or Complacency and is just over six pages, including references.
The Public Library of Science Medicine Journal paper carefully discusses the pragmatic difficulties of treating patients in South Africa, the epidemiology that threatens populations far outside the borders of that country, the criteria for determining when the risk to public safety abrogates individual freedoms and rights, and more.
The proposal specifically recommends that South Africa end its policy stipulating that those hospitalized at state expense lose their social welfare benefits, a regulation that encourages patients to avoid hospitalization and, all too often, treatment of any sort.
The Reactions
Official reactions to the proposal range from cautious agreement to cautious opposition.
The South African Department of Health released this supportive statement from its adviser, Ronnie Green-Thompson, “The issue of holding the patient against their will is not ideal but may have to be considered in the interest of the public. Legal opinion and comment as well as . . . the opinion of human rights groups is important.”
These excerpts from South Africa may lock up “killer TB” patients, written for the Associated Press (24 January, 2007) by Maria Cheng, is representative of the latter perspective:
Others worry that involuntarily detaining people would result in “driving patients underground,” said Dr. Tido von Schoen-Angerer, of Medecins Sans Frontieres, the international medical aid group.
Tuberculosis experts at the World Health Organization believe XDR-TB is as serious a threat to global health as either bird flu or SARS. But Dr. Mario Raviglione, director of WHO’s Stop TB department, isn’t certain involuntary confinement is warranted just yet. Without proper patient data from South Africa, Raviglione says it is unknown whether lack of compliance is a significant factor.
Commentary
While the threat to world health and the tragedy of those currently afflicted with XDR-TB are themselves compelling, even broader and more fundamental concerns are raised by this situation. The long-debated conflict between individual rights and the good of the community, the authority and responsibility of the state to protect all its citizens, personal morality and accountability, and the large scale economics of public health, among others, are unavoidably and usefully raised by a thoughtful review of this paper.
Related Posts:
Patient Compliance Claim Triggers FDA Warning Letter
An October 11, 2006 FDA Warning Letter addressed, among other issues, the claim by Orapred that the addition of flavor enhancers improves compliance with its product. The FDA letter, excerpted below,1 focuses on the need for evidence of such claims.
The “NEW INSTITUTIONAL 10-PACKS” link on the main product website claims that Orapred is “ENGINEERED FOR COMPLIANCE,” and the main product website contains the tagline, “Perfecting the Science of Compliance.” Similarly, the “About Orapred” page on the product website claims that Orapred “helps mask the bitter taste of prednisolone, making it easier to take without experiencing the natural gag reflex commonly induced by other liquid formulations of prednisolone.” In addition, the “NEW INSTITUTIONAL 10-PACKS” link on the main product website contains claims such as, “Designed to taste better, ease administration.” We acknowledge that Orapred contains flavor enhancers. However, these claims misleadingly suggest that because of its formulation, patients gag less often when taking Orapred or that the taste of Orapred is superior to that of other formulations of prednisolone and thus that Orapred improves rates of compliance. FDA is not aware of any evidence to support these claims. If you have data to support these claims, please submit them to FDA for review.
Commentary
The FDA’s insistence on scientific evidence rather than the “common sense” assumption that better tasting medications will achieve higher compliance rates is laudable.
My impression is that compliance claims based on a specific quality of a medication (e.g., decreased side-effects, oral rather than parenteral administration, reduced dosing frequency) receive far more regulatory attention than claims made on behalf of non-pharmaceutical compliance enhancers such as adherence monitoring devices, medication reminders, and patient education compliance programs.
Because the notion of expanding governmental oversight gives one pause, and it’s difficult to imagine another source of funding for an independent agency that would serve as a sort of Consumer’s Union for the field, perhaps the message to those of us working with patient compliance is to maintain a high index of suspicion about such claims and to straightforwardly and repeatedly raise the expectation that claims of improved compliance be clarified (e.g., terms defined) and supported by evidence.
Footnotes
- The entire Warning Letter can be viewed at FDA Warning Letter To Orapred [back]
Related Posts:
Life Insurance For HIV Patients Contingent On Treatment Compliance
Aids causes life insurers to take stock
by Mariette le Roux. Mail&Guardian Online. 28 December 2006
This newspaper article reports on South African insurance companies that offer life insurance to HIV-positive individuals at prices that are significantly more affordable than traditional costs contingent upon adherence to a treatment program.
This innovation is summarized in this excerpt:
The link to treatment compliance is clearly delineated: “Clients have to commit to treatment once their CD4 count (a measurement of the strength of the immune system) falls below 200, with the company monitoring and encouraging adherence. Defaulters have their cover slashed. ‘Unlike traditional insurance companies, your history is almost irrelevant to us. It is how you are going to behave in the future that is important. We tell you exactly what you must do to live a long life,’ said [AllLife co-founder and managing director Ross Beerman].”
Commentary
While the availability of limited amounts of life insurance is hardly a panacea, the alignment of lower premiums and adherence, based on market forces rather than charity, provides a heartening model of compliance enhancement. Following the results of this naturalistic experiment should be enlightening.
Related Posts:
Lancet Recommends European Union Mandate Vaccination Against Cervical Cancer Virus
EU Urged To Vaccinate Girls Against Cervical Cancer Reuters October 5, 2006
An editorial in Lancet recommends that member states of the European Union mandate the vaccination of 11-12 year old girls against the human papillomavirus (HPV), a major cause of cervical cancer. Cervical cancer is diagnosed in 470,000 women each year and is the cause of death in 230,000.
The European Commission last week licensed the first HPV vaccine (Gardasil) for use in children aged 9–15 years and women aged 16–26 years. The vaccine has already been used in the United States in girls as young as nine and women up to the age of 26.
The Lancet editorial also noted growing support for vaccinating boys as well as girls but held off this recommendation pending more data from clinical trials.
Commentary
Compulsory vaccination is interesting arena for patient compliance. This nexus of government and medicine highlights the inherent conflict between private freedoms and the public good. Consequently, competent medical advice should be a necessary but not sufficient element in a political entity’s decision to demand any medical procedure, including preventive ones such as vaccination. Lancet’s endorsement of the cervical cancer vaccination certainly qualifies as competent medical advice. How the countries making up the European Union react to this recommendation by a medical source that is medically reputable and publicly prestigious but unendorsed by any government.
Related Posts:
Public Policy & Healthcare Compliance: In The News
In The Trib
Yesterday’s Chicago Tribune carried at least three unrelated stories about public policies on healthcare compliance. Although none of these three are, literally, front page news, that all three happened to be featured the same day does emphasize the frequently overlooked fact that governmental or institutional enforcement of adherence is common in our society.
1. Immunization Laws
Are Lenient Laws Linked To Pertussis Outbreak? By Lindsey Tanner
This article summarizes a study pointing out that those states with more liberal immunization exemptions had about 50 percent more whooping cough cases.
2. State Restrictions On Snacks Sold At School
Tougher Junk Food Rule OKd By Crystal Yednak
New rules were approved in Illinois that prohibit the purchase of snacks with high fat, sugar or calorie content before and during the school day by students in elementary and middle school. Henceforth, juice drinks sold in schools must contain 50 percent or more juice, no sweetened or carbonated drinks can be sold, and snacks must be under 200 calories and meet specifications re fat and sugar content.
3. Government Imposed Quarantine
Halloween Guard Set For Woman With TB By Jeff Long
By judge’s order, “… a community service officer will steer trick-or-treaters away from the home of a Lake in the Hills woman who McHenry County health officials say has tuberculosis … .” There is a dispute whether the woman, a 67-year-old great-grandmother, is contagious, her doctor claiming she is not while county officials maintain that tests performed last summer indicate she is contagious. In a compromise, the woman agreed to continue taking medication that both sides agree should either “prevent her TB from becoming active or cure the disease if it is already active.” A court order prohibits contact with anyone other than family members living in the same home.
Related Posts:
Contracting For Compliance
Personal Responsibility and Physician Responsibility — West Virginia’s Medicaid Plan by Gene Bishop, M.D., and Amy C. Brodkey, M.D. NEJM Volume 355:756-758 August 24, 2006 Number 8
The West Virginia Medicaid Plan, The NEJM Perspective,
& The Rest Of The Story
The West Virginia Medicaid Plan
West Virginia plans to require that residents of that state who are eligible for Medicaid because of low income sign the “West Virginia Medicaid Member Agreement.”1
The agreement lists “member responsibilities and rights,” the former of which include, for example, taking medications as prescribed, appearing for appointments on time, and using the emergency room only for emergencies.
Failure to meet these terms would result in the decrease or elimination of some benefits.
According to the legislation, West Virginia will track four indicators:
- Participation in health care screenings
- Adherence to health improvement programs indicated b their health care providers
- Attendance at medical appointments
- Compliance with medication schedules
The NEJM Perspective
As Drs. Bishop and Brodkey point out, albeit in more measured terms, this scheme of contracting with patients has been justified and, I believe, pseudo-beatified, by its supporters invoking personal responsibility, an understandably popular concept.
The authors note that “[the policy’s] speedy approval by the Centers for Medicare and Medicaid Services (CMS) demonstrates the agency’s enthusiasm for such an approach” and that the head of the CMS, Mark McClellan declared that “Medicaid enrollees in West Virginia will now become part of an emerging trend in health care that empowers patients to make educated, consumer-driven decisions related to their own treatment.”
[Note: Shouldn't someone alert Dr. McClellan that the rest of us of figured out the code so we know that whenever a bureaucrat from the government or a healthcare organization says "empower the patient," that bureaucrat actually means "give the patient two poor choices instead of one mediocre one and tell him it's his responsibility to choose wisely."]
While personal responsibility is the mantra, it seems apparent, at least to me, that this program would change the dynamics of the doctor-patient relationship dramatically, shifting it from an autonomous patient negotiating his or her health care with a clinician to something that would more resemble an employee being instructed by a superior with his job on the line if the employee resists or fails to meet production goals.
Medicaid patients will assume obligations and be required to meet standards significantly beyond those demanded of other patient groups. Not only does this violate the basic principles of fairness but it also overlooks the fact that Medicaid patients are more likely at the mercies of public transportation, have fewer funds, less access to wholesome foods, less opportunity to participate in exercise programs, and, since 75% are children, have no authority to enforce their own wishes.
The authors use an all too realistic scenario of a 53 year old obese woman with diagnoses of diabetes and schizophrenia who is unable to lose weight as required and misses appointments, probably because of her psychosis. Under the new regulations, she stands to lose her health benefits, including those funding her mental health care.
While such patients are not unusual, the plan is fundamentally flawed regareless of the patient group(s) it would cover.2 The fact is that roughly half all patients with any diagnosis prescribed any medication will fail to comply. Complete compliance with complex treatment programs, such as diabetic treatment, is quite rare with rates in the single digits. Further, it’s not difficult to imagine, say, a surgeon who sincerely believes that an aggressive surgical approach to a problem is a given patient’s best hope for survival while the patient is less convinced and is frankly fearful of the risk of the operation. If this patient makes a reasoned, defensible decision to forgo or defer the surgery, should he or she lose health benefits? Or, as the authors rhetorically ask, “Is it irresponsible to refuse to take a medication if it makes you ill and you cannot reach your physician to ask for advice?”
The Rest Of The Story
It is not clear, however, from the NEJM Perspective that the West Virginia plan actually offers a Basic and an Enhanced plan and that only the extra benefits (i.e., those offered in the Enhanced plan but not in the Basic plan) are contingent on fulfilling the compliance contract. Failure to sign or successfully fulfill the contract does not eliminate the patient’s benefits entirely but rather shifts him or her from the Enhanced to the Basic plan. See thumbnails marked “West Virginia Plan,” “Benefits Package – Adults,” and “Benefits Package – Children” for details.
I agree with Bishop and Broadkey that, in toto, the problems of the West Virginia plan significantly outweigh its potential benefits. The specific details of the Basic Vs Enhanced plan are problematic. Mental health services, for example, are available only through the Enhanced plan; a psychotic patient would, according to my reading of these documents, lose his psychiatric benefits if, because of his psychosis, he were unable to keep his appointments and take his medications. Moreover, implementing this idea with the population with the fewest resources to follow through on their personal health plans seems a mistake. Most importantly, however, the current West Virginia plan demands the most primitive form of compliance – obedience.
I find it difficult, in fact, to reconcile the contractual demands with these excerpts from the “Members Rights” section in the second half of the same document:
I will not be treated differently because I am in the Medicaid Program.
My objection to the NEJM Perspective stems from my convictions that (1) reinforcing cooperation between clinicians and patients is a worthwhile strategy and (2) providing an enhanced healthcare package is itself a valid and potentially useful methodology deserving of more consideration. Denouncing the program without at least considering its potential benefits seems a case of throwing the baby out with the bathwater.
Documentation From The West Virginia Medicaid Plan
The documents below (thumbnails linked to full size images) are from the West Virginia Medicaid State Plan Amendment as approved by the Center for Medicaid and Medicare Services. (Accessed August 23, 2006, at http://www.wvdhhr.org/bms/oAdministration/bms_admin_WV_SPA06-02_20060503.pdf.)
Members Agreement (Page 1)
Members Agreement: Members Rights (Page 2)
-
West Virginia Plan
Benefits Package – Children
Benefits Package – Adult
Footnotes
- Idaho and Kentucky have submitted plans with similar philosophies. [back]
- On the other hand, it would be a dandy plan if all the patients were Spock clones operating on pure logic or if the patients had at least enough sense never to be sick. Or, better yet, if there were no patients at all. [back]
Related Posts:
AMA Passes New Policy On Adherence To Treatment Plans
Perhaps you should sit down before reading this — and it probably wouldn’t be a bad idea to grab your socks, lest they be knocked off by this revolutionary news.
Ready? OK
Last week, the American Medical Association’s officially recognized the importance of patient adherence to a prescribed course of treatment program to achieving effective and efficient health care.
“For any health or wellness program to succeed, we must find ways to help patients follow through on treatment plans,” said AMA President-elect Ronald M. Davis, M.D. “The best health outcomes occur when the physician and patient work together toward a common goal.”
The AMA also plans to develop a list of resources to enhance adherence.
I applaud the recognition although it seems belated and a tad superfluous.
There is, however, no truth to the rumor that the AMA will also officially recognize the importance of oxygen to human respiration.
Related Posts:
