AlignMap

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

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

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

HealthPrize Technologies – Motivating Treatment Adherence With Incentives

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

From the HealthPrize Technologies site:

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

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

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

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

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

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

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

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

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

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

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

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

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↩

From Nov. 3, 2008 American Medical News - By Doug Trapp

American Medical News Critiques West Virginia Medicaid Incentive Program

The graphic above is the heading for an American Medical News¹  story about the West Virginia Medicaid patient incentive plan.  The basics of the West Virginia plan and my perspective on it was discussed in this blog two years ago at West Virginia Medicaid Compliance Contracts – The Plan, The NEJM Perspective, & The Rest Of The Story.

See if you can guess AMA’s perspective from the clues in the headline:

When incentives lack appeal:
Medicaid reform meets confusion, skepticism

That’s right – in formal terms, this means  “Incentives used in the West Virginia Medicaid reform plan to encourage certain behaviors in patients lack appeal, thus causing confusion and skepticism.”

In less formal terms, it means “The West Virginia Medicaid reform plan stinks.”

Now, try the subheading:

West Virginia is one of the first states to offer inducements
for patients who pledge to follow physicians’ orders,
but most of those eligible aren’t taking the bait.

Let me suggest that the key words are “… most of those eligible aren’t taking the bait,” a figure of speech that leads me to suspect that it required the totality of the author’s self-discipline to forgo his impulse to add “Thank God” at the end. After all, I’ve never read a story in which good things happened to anyone who does “take the bait.”

At the risk of provoking the AMA to reconsider its position, I agree with their point that the bureaucratic implementation of the incentive plan is – hmmmm, let’s call it suboptimal. In fact, I am probably more critical of the plan’s structure than is the AMA. More about this a little later.

The Criticisms

The  article’s  basic argument is presented in the excerpts that follow:²

The program, which began almost a year ago in most parts of the state, is a novel attempt to use incentives to boost enrollees’ personal responsibility and ownership over their health care. Eligible enrollees who agree to a wellness plan, follow other physician directions, and show up on time for medical appointments can receive free additional benefits, such as help with quitting smoking and membership in Weight Watchers. Those who don’t take the option are relegated to a basic plan with somewhat fewer benefits than their existing plan.

Enrollment in the enhanced plan so far has been low. About one-third of West Virginia’s Medicaid beneficiaries — who numbered 392,000 in 2007 — are eligible for Mountain Health Choices based on their relative good health. But only about 15,500, or 12%, of those eligible had signed up as of Sept. 30, according to state counts. Another 3% had begun the enrollment process.

Why hasn’t the program been more popular?

Some patients simply might not know about or understand the program. Others might not read well enough to grasp the details. But even for those who want to pick the enhanced option, it’s not always simple.

For starters, Medicaid enrollees are instructed to call their primary care physician. “Many don’t have a primary care provider,” said Renate Pore, president of the patient advocacy group West Virginians for Affordable Health Care. “They don’t know who they’re supposed to call.”

Some eligible enrollees might not see a need for extra benefits, said Sarah Chouinard, MD, medical director of Primary Care Systems Inc., a health center in Clay, W.Va. For example, a 30-year-old woman with seasonal allergies might think she just needs her allergy prescription and annual Pap smear, not a wellness plan and extra hospital coverage.

The requirement that patients commit to regular office visits could pose a barrier for those with limited transportation options, said Rodney Fink, DO, director of clinical service for Access Health, a group of six health centers in southern West Virginia, including the Beckley facility where Dr. Bennett works.

Some observers say the state needs to do a better job of selling beneficiaries on the extra benefits. Dr. Fink said doctors also need to do a better job of focusing their patients’ attention on it.

… The Deficit Reduction Act of 2005 gives states authority to offer varying benefit levels to Medicaid enrollees. A few states, including Idaho and Kentucky, responded by offering incentives to beneficiaries who adopt healthier behaviors. Other states, such as Florida and Wisconsin, set up similar programs under waivers from the Centers for Medicare & Medicaid Services. The Deficit Reduction Act of 2005 lets states offer varying benefit levels to Medicaid enrollees.

But West Virginia took the concept one step further by limiting benefits for Medicaid recipients who do not promise to follow a wellness plan and listen to doctors’ orders. The state is now on the line to prove the tactic will work.

The ultimate goal of Mountain Health Choices is to forge relationships between patients and physicians that lead to healthier lifestyles and better preventive care, said Shannon Landrum, spokeswoman for the West Virginia Bureau for Medical Services in Charleston. …

Parents must agree to pick a medical home for their child, bring the child on time for a minimum number of office visits, and ensure that immunizations are up to date and prescriptions are followed. The agreement is similar for adults, with the addition of required screenings, such as colonoscopies, glucose levels and mammograms.

Some points of contention

The West Virginia program is more controversial than other states’ because it automatically bounces nonparticipating beneficiaries — possibly without their knowledge — into the basic plan. Once there they encounter more restrictions than in traditional Medicaid, such as caps on prescriptions and mental health services.

For example, children in the basic plan are limited to four prescriptions per month, even though a child with asthma and attention deficit disorder could easily hit that limit, said Fernando Indacochea, MD, president of the West Virginia Chapter of the American Academy of Pediatrics. Landrum, however, said a state review of data from three pilot counties prior to implementation showed that children on Medicaid average fewer than one prescription a month.

And while individual mental health therapy is covered under the basic plan, crisis intervention is not, said Bob Hansen, executive director of Prestera Center, a mental health and addictions treatment agency in Huntington.

Georgetown University’s Center for Children and Families on Aug. 9 issued a paper criticizing the state for automatically limiting kids’ benefits via the basic plan. If the program aims to encourage healthy behaviors among Medicaid enrollees, said Joan Alker, the deputy executive director of the center, “I don’t think there’s any evidence that they’re achieving that.”

West Virginia already has learned some lessons that could be applied by other states considering incentives for patient compliance.

Dr. Fink said programs such as Mountain Health Choices won’t work unless staff at clinics and health centers proactively advise patients about their health care options. He added that physicians should form a second line of support and also gauge their patients’ awareness.

Landrum said it can be difficult to engage Medicaid enrollees as they gain or lose program eligibility. About 40% of Medicaid beneficiaries in West Virginia don’t renew their benefits from one year to the next. States that want to change Medicaid from a program that simply pays claims into one that promotes health improvement and wellness need to be patient and look for ways to measure success in the long term, Landrum said.
Hope for the future

To improve physician awareness, the state could notify doctors of their Medicaid patients’ deadlines for choosing a new plan, said Violet Burdette, CEO of Northern Greenbriar Health Clinic in Williamsburg. Eligible beneficiaries receive a Mountain Health Choices enrollment packet 60 days before their Medicaid benefits are changed. They have 90 days to respond.

Burdette also said enrollees might be more engaged if they had to choose either the basic or enhanced plan instead of being channeled into the less generous plan by default. Landrum said only two Medicaid beneficiaries have actively declined the enhanced plan.

Work of enrolling can fall on physicians

Some physicians are excited about West Virginia’s pilot program that offers incentives for Medicaid patients to stick with a wellness plan, even though it does cause extra work for doctors.

Sarah Chouinard, MD, medical director of a health center in Clay, about an hour from Charleston, said her facility has convinced more than a few patients to take advantage of the enhanced benefits in Mountain Health Choices. The clinic, which is in one of the three pilot counties for the program, treats about 7,200 patients, a third of whom are enrolled in Medicaid.

Dr. Chouinard said explaining the initiative to patients requires additional staff time but coordinates well with the medical home model the center offers.

Terrence Reidy, MD, was less enthusiastic. He practices at a community health center in Martinsburg, in the eastern part of West Virginia.

A state Medicaid representative visited his facility about a year ago to explain the role the center would play in promoting the expanded plan. “It seemed like our office was then expected to be the ones to get the patients to sign up,” Dr. Reidy said. The internist hasn’t been contacted by state officials since then, he said in late September.

The center treats about 2,400 Medicaid patients, two-thirds of whom are children. Only about 2% of patients have opted for the enhanced benefits. “It really has not changed our practice a bit,” Dr. Reidy said. Still, consulting even a few patients about their choices of Medicaid benefits and crafting wellness plans adds another unpaid job to his already tight schedule.

One job West Virginia physicians will not have is that of enforcer. The state will review claims records to track patient compliance with the enhanced benefits agreement.

The West Virginia Medicaid Plan As An Example Of Misalignment

If I were a hot-shot psychiatrist – and, as it turns out, I am – I would diagnose a severe case of ambivalence on the part of the creators of the West Virginia Medicaid Incentive Plan.

On one hand there are significant rewards offered to reinforce those desired patient behaviors in the form of a greatly enhanced set of benefits.

On the other hand, it’s as though the administrators fear that the incentives will prove too popular so bureaucratic hurdles (e.g., the requirement that the patient designate a primary provider and take the initiative to sign up for the program)  were created to minimize the number of patients taking advantage of the more extensive, more expensive plan.

I do not believe, however, that the increased expectations placed on the physicians as an uncompensated, de facto administrative assistant and compliance monitor is part of that ambivalence. Nope, I believe that assigning uncompensated tasks, necessary for the functioning of the plan, to physicians and ther offices is merely one more instance of habitual legislative laziness.

Otherwise, one is face with explaining why a the plan’s administrators, who apparently believe in the power of incentives, would create a program that rewards patients but not only fails to reward the clinicians for reaching the same end-points but penalizes them by requiring them to perform work without pay.

Enough of the preliminaries – my contention is that the problems in the design of the West Virginia Medicaid Incentive Plan can best be characterized as a lack of alignment.³

There are so-called pay-for-performance schemes that reward or penalize clinicians, for example, based on the extent to which they follow treatment protocols or on the percentage of their  patients that follow specific pateint protocols, such as designated disease screenings (e.g., mammography or colonoscopy) or participation in disease management programs. There are programs like the West Virginia Medicaid plan that reward or penalize patients for specified healthcare behaviors.  I know of no programs that coordinate both clinician and patient reinforcement systems.⁴

In fact, many programs seem to follow the West Virginia model by offering to reward one group (patients in West Virginia’s case) and simultaneously punishing the other (assigning time-consuming administrative tasks to clinicians without compensation). In these situations, the issue is not a lack of alignment but misalignment.

Further, we’ve only addressed aligning two healthcare stakeholders, the clinician and the patient. In many cases, for example, a patient’s outcome depends primarily on the dedication and efforts of a non-professional caregiver such as a spouse, family member, or friend.  Yet, I find no programs that provide even token rewards for this group beyond generic support groups. Other stakeholders, such as community organizations with healthcare programs, likewise must be taken into account.

And third party payers, bless their hearts, have to be in alignment with other stakeholders if ongoing healthcare efforts are to be have a chance.

And – steel yourselves – on a macro level, pharmaceutical companies and medical equipment manufacturers have to be transformed from miracle workers/sources of all evil (choose one) into participants who gain and lose in unison with other stakeholders.

OK, I only said it was easy to understand the benefits of alignment, not that it was easy to design or implement a well aligned program .

1. American Medical News is a newspaper produced by the AMA for physicians.↩
2. While I have included a large portion of the text and have tried to keep the sense of the original article intact, there is always a risk of distorting the author’s intent. Consequently, I urge viewers to read the entire piece available here: American Medical News↩
3. I use “alignment,” In the context of healthcare, to indicate the condition of the patient, the clinician, and other stakeholders sharing mutual aspirations and grasping the complementary nature of their roles such that each individual or entity involved can support the treatment decision made, even if is not the first choice of a each stakeholder.↩
4. I have purposively chosen the “I know of no programs that … ” sentence format because I continue to believe that healthcare providers and patients benefiting in concert is such an obviously beneficial idea that someone somewhere must have tried it; I just haven’t run across it yet. ↩

New Articles Echo Previous Posts

Two articles have appeared in the lay press in the past 24 hours that focus on topics recently addressed in this blog.

Health Literacy

In today’s Chicago Tribune, Literacy can be a matter of life and death By Leslie Goldman examines the crisis caused by the inability of large numbers of patients to understand basic medical instructions, resonating with several AlignMap entries, including Health Literacy , Medication Leaflets, and The Gap Betwixt, Health Literacy: A Clear Problem Without A Clear Solution, and Healthcare Illiteracy Linked To Higher Mortality Among Elderly .

This short piece features intimidating statistics from pertinent studies, such as the following:

Compensatory measures healthcare professionals can make are also discussed.

This article can be found at Literacy can be a matter of life and death

Incentives For Results Rather Than Enrollment

An article By Elizabeth Dunbar in the 24 Sept 2007 Washington Post, Study: Money Can Prod One To Lose Weight adds to themes raised in Monetary Incentives To Decrease Obesity and Another Case Of Cash For Compliance, reporting that

The article focuses on the economic benefits such an incentive plan, which provides no help to participants on how lose weight, would hold for employers:

Details of the study itself and further consideration of its implications can be found at Money Can Prod One to Lose Weight

Show Them The Money

Source: Oregon companies up the ante to encourage employees to make healthy lifestyle choices by Brent Hunsberger. The Oregonian. January 21, 2007

Monetary incentives (and disincentives) are being considered by more and more third party payers. Within the last two weeks alone, for example, two of this blog’s posts, Payment For Medication Compliance: Incentive or Bribe? and Monetary Incentives To Decrease Obesity, have directly addressed this issue. Moreover, cost-sharing, which can be viewed as cash incentives once removed, has accounted for three recent posts.¹

The article featured today notes that workplace health and wellness, some of which have been in operation for many years, have had little effect on obesity and diabetes rates or on health insurance costs. Taking a more aggressive stance, a small number of Oregon employers have joined forces with Regence BlueCross Blue Shield of Oregon to offer cash incentives to persuade workers to eat better, lose weight, exercise regularly and monitor their health.

The program, tested on Regence’s own employees the past two years, gives workers points for exercising, reading health education materials and joining weight- and smoking-cessation programs – points that can be redeemed for gift certificates or other prizes.²

Other employers are offering similar perks on their own. More than 100 mostly salaried employees at Roseburg Forest Products Co. who last year met certain exercise, weight and health-management goals — without smoking — will get, on average, a $419 bonus in their paychecks next month, representing a 10 percent rebate on the cost of the timber company’s annual cost to insure an individual. And some employers, liking what they’ve seen, are expanding incentive programs to include workers’ family members. Portland-based Stimson Lumber Co. recently extended its wellness program, dubbed StimWell, to workers’ spouses, refunding their monthly insurance premiums and offering free “accelerometers” to track the frequency and intensity of their exercise.

But there’s a clinker:

Nonetheless, Regence has been sufficiently impressed by the involvement of its employees to extend the program by offering, for example, healthful food in its cafeteria at heavily discounted rates.

Commentary

It’s noteworthy that the enthusiasm and interest in health improvement shown by Regence’s own employees, which seems a key factor in the company’s decision to vigorously promote the program, may well depend reflect a the impact of the company’s social networks as well as the cash incentive.

In addition, Regence appears to be shifting their programmatic concept from an early focus on a few goals, such as weight loss, to a more extensive system that covers more areas of healthy living and offers more options to those outside the mainstream.

My point? Not only is research necessary to discover if these systems have a positive effect on health and healthcare savings but work is also needed to determine what factors motivate employees to take advantage of these programs.

1. Cost-sharing and Adherence To Prescribed Medication, Healthcare Cost-sharing And Medication Compliance, and More On Cost-sharing And Medication Compliance↩
2. For example, employees receive 500 points for enrolling in exercise competitions and 2,000 for completing them. At 10,000 points, workers get a $50 gift certificate through Hallmark Insights to one of 100 retailers of their choosing, including Lowe’s and Target. Company officials say the incentives, so far, have worked. Nearly half of its work force joined some sort of rewards-incentive program, said Denise Johnson, Regence’s human resources director for benefits. It doled out nearly 6,500 gift cards last year (it caps at five the number of gift cards an individual can get in a year). And summer game participation increased from 500 in 2004 to 1,700 in 2006.↩

Using Cash Bonuses and Penalties To Enhance Weight Loss In Obese Employees

Employers penalize obesity
By Daniel Costello
Baltimore Sun. July 29, 2007

This article reports on an increasing number of employers using monetary incentives or disincentives to promote dieting and exercise among overweight employees with the goal of improving the employees’ health and, consequently, lowering medical costs secondary to obesity-related health problems.

Some employers penalize overweight employees if they don’t slim down while others offer fit workers lucrative incentives that may decrease their healthcare premiums by thousands of dollars a year. Examples include

• Clarian Health Partners, an Indiana-based hospital chain, will, beginning in 2009, charge employees up to $30 every two weeks unless they meet weight, cholesterol and blood pressure guidelines the company deems healthy, i.e., employees’ pay will be docked if they fail to meet certain weight ratios, cholesterol, blood pressure or if they smoke.
• UnitedHealthcare, a national insurer, introduced a plan this month that, for a typical family, includes a $5,000 yearly deductible that can be reduced to $1,000 if an employee isn’t obese and doesn’t smoke.
• County workers in Benton County, Ark., were offered, beginning last summer, a similar plan. The $2,500-a-year deductible can be reduced to $500 if a worker meets low height/weight ratios during yearly on-site physicals. Thomas Dunlap, Benton County’s benefits administrator, said the plan had witnessed a nearly 30 percent drop in claims – and led to changes in the workplace. Workers can attend free weight-reduction classes, and there are now regular competitions between departments to see who can lose the most weight. Acknowledging that it could be partially the result of the new deductible, he noted that the county didn’t have to raise its insurance premiums this year and likely won’t next year.

Some criticize this tactic, claiming that the lose-weight-or-pay plans “turn the health care system into a police state.” In addition, implicit in the strategy is the notion that people who are obese and have other health issues and change their situations with reasonable effort.

Lewis Maltby, president of the National Workrights Institute, a Princeton, N.J.-based employees rights group, called the trend

Employers reply that they are only responding to the rise in both health care premiums and the proportion of obese Americans.

In a telling statistical change, sixty-two percent of 135 executives responding to a PricewaterhouseCoopers survey this spring said unhealthy workers such as those who smoke or are obese should pay higher benefit costs, compared with 48 percent who said so in 2005.

Further, in January 2007, the U.S. Department of Labor released final clarifications on the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which ruled that employers can use financial incentives in wellness programs to motivate workers to get healthy. Nonetheless, some lawyers say weight-based compensation plans might run afoul of other employment laws such as the Americans with Disabilities Act.

In recent years, companies have offered cash, merchandise and gift cards to those who lose weight or lower their blood pressure. A few have begun refusing to hire workers who smoke. The new plans are different because employers are demanding that workers participate in health exams and have their weight checked and blood taken to screen for high cholesterol or blood sugar.

Commentary

The use of mandatory monetary penalties and/or bonuses to direct lifestyle changes in the name of better health, especially when “better health” is a proxy for “lower costs,” is intriguing on several levels.

First, of course, is the question of the efficacy and efficiency of such tactics.

The ethical questions already suggested extend beyond the employers-employees contracts. Governmental agencies currently pass laws regulating the use of tobacco, alcohol, and, most recently, high-fat foods. It is hardly inconceivable that medical care provided by the state might someday come at a higher price to those citizens whose habits are deemed unhealthy.

Other, more specific issues are present in abundance. Which healthcare habits are fair game for bonuses and penalties? Should those with hereditary disorders be expected to pay more? How about those with a genetic predisposition to obesity? Are those who fall below the weight norms to be penalized? Or those who do not make it to follow-up clinical appointments? Or those who choose to see a priest for healing rather than a physician? Who sets the standards for healthy behavior? If a pregnant worker doesn’t seek adequate pre-natal care but is healthy and bears healthy children, is that family assessed extra costs? If a 32 year old former college athlete turned company VP plays in a semipro football league with its attendant risk of injury, should his behavior be considered unhealthy and efforts made to change it? What if he sky-dives on weekends? How about if his moonlighting job is serving as guinea pig for testing medication?

It’s a tricky new world.

Source:
Mental Illness Drug Payments Call
BBC News. January 1, 2007

Cash Incentives For Treatment Adherence: Pros and Cons

This is an interesting discussion of the practical aspects of compliance management in day-to-day clinical practice.

The issues are basic:

• Noncompliance is a common problem in psychiatric practices; 20-50% of these patients are believed to be non-adherent to prescribed medication
• Paying people with severe mental illnesses to take medication may encourage some to stick to their drug regime
• There are practical and ethical concerns about using cash payments to enhance compliance

Commentary

While the clinical study is interesting, the BBC story is more provocative, and its issues may well be more significant than the research findings in determining if the strategy of financially rewarding patients for adherence is put into practice.

The quote from Marjorie Wallace, of the charity Sane, exemplifies the resistance to this tactic:

Even the chief author of the study, Dr Dirk Claassen, indicated that such measures, if used at all, would be applied to a limited group: “Financial incentives might be a treatment option for a high-risk group of non-adherent patients with whom all other interventions to achieve adherence have failed.”

While the use of loaded terminology such as “bribes” triggers a multitude of negative connotations, especially when the patients bear psychiatric diagnoses, the same basic considerations are the essence of the ethical struggle over any compliance enhancement schemes.

It seems intuitively apparent, for example, that the approval of an authority figure can be as powerful or more powerful than a cash payment. Are the urgings of the doctors as unacceptable as monetary reinforcements? What if the urgings come from friends and family? How about reminders to take medication or a physician’s listing of research indicating the effectiveness of a medications? Is there any difference in promoting compliance with psychiatric medications and adherence to treatment for HIV disorders? If paying patients to take an anti-psychotic unethical, should states rescind laws legally forcing resistant patients to take drugs to treat tuberculosis? For that matter, should the government be allowed to enforce regulations requiring childhood vaccinations or restricting the use of tobacco or serving of certain foods?

Indeed, one school of bioethics maintains that any reinforcement, encouragement, or even commendation of treatment adherence is the equivalent of coercion on the part of the clinician, some holding that even subtleties as seemingly innocuous as a physician’s tone of voice, however benign his or her intent, represent intimidation of the client.

For clinicians such as myself, however, the notion of simply laying out various treatment options, including no treatment at all, in a value-neutral manner without indicating my recommendation is unpalatable and smacks of shirking ones duties.

The precedent that comes to mind is the battle between physicians and the antivivisectionists in the early 20th century.¹

My guess is that most clinicians charged with the care of patients make many decisions every day that involve parsing such ethical dilemmas with the well-being of a human being in the balance. For that reason, if no other, I believe that an automatic dismissal of material inducements, one of the few compliance enhancements strategies shown to routinely be effective, is counter to the best interests of patients and deserves further consideration.

1. E.g., William Osler performed vivisection to study typhoid and tapeworm in pigs and testified against antivivisection legislation in government hearings in the U.S. and England↩

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

Source: 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

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 have a right to decide things about my health care and the health care of my children.

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  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.)  Click on thumbnails below to enlarge to  full size for reading.

Members Agreement - Page 1

Members Agreement - Page 2

West Virginia Plan

Benefits Package – Children

Benefits Package – Adult

Footnotes

1. Idaho and Kentucky have submitted plans with similar philosophies.↩
2. 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 at least had enough sense to never be sick. Or, better yet, if there were no patients at all.↩