June 17, 2010 
Adherence is the big focus these days. It’s an issue where everyone is aligned – payer, pharmacy, PBM, pharma, patient, MD. And, there are certainly lots of savings to be gained both hard dollars (less ER visits) and soft dollars (less absenteeism).
BUT, COME ON…
There are lots of issues around adherence. Getting people to fill the script after they leave the doctor’s office. Making the script affordable. Getting them to take the medication. Remembering to take it over time. Dealing with side effects. Dealing with differences in cultures, conditions, health literacy, etc.
Now, people are paying you or giving you a chance to “win” money every day just for taking your medication (see NYT article). So, in my mind, this eliminates the issues of affordability (i.e., you already have the drug) and side effects (i.e., you’re not going to take something that has a meaningful side effect just for money). So, why do I have to pay you. Does the dentist pay you to brush your teeth? Of course not. Does your auto insurance company pay you not to speed? Does your life insurance company pay you to not drive drunk? NO…In all these cases you either pay more money if you do this or your service gets discounted if you don’t.
If you have a chronic illness, can afford the medication, and have no meaningful reason to not take it, you should be doing your best to take the medication. Otherwise, you’re driving up the costs of healthcare for you and your friends and your kids. You do have some social responsibility to try and get better OR you should pay more for your healthcare. We all have a choice (see the 1,000 pound woman).
Won’t paying people just create a long-term “dependency” where I only want to take my pills when I’m getting paid? Probably…we certainly used to see that incentives at the call center drove up success rates, but once they went away the success fell below the baseline.
Will this create an incentive simply to open the pillbox to get paid even without taking the medication? No one is there making sure it goes down my throat so I’m sure some people will game the system. (A sentiment shared by John Mack at the Pharma Marketing Blog.)
For the people that are adherent, will you just be wasting money? Yes…and why should my neighbor get paid for forgetting…I’m going to want the same thing.
Don’t get me wrong. I’m a fan of incentives, but reward me for the right things otherwise we end up with situations like Enron. Incent me for managing my BMI, my A1c value, my blood pressure. I can take medication, work out, or diet to achieve those.
Give me tools and information. Help me to understand my drug. Help me to afford my drug (e.g., value based insurance design or patient assistance programs). Educate me on my condition. Have a talking pillbox or medication bottle. Call me to remind me to refill. Sign me up for auto-refill.
I just can’t get on board with this latest twist. I guess the proof is in the pudding so we’ll see if it makes a difference. I’d love to be proven wrong here and see us throw money at people and change the healthcare cost curve.
Enabling Healthy Decisions 
I agree with you, this is a wrong approach. While carrots are necessary, we have to use sticks too.
And like it or not, some form of financial penalty for being obese is unavoidable. It may not come in 3-4 years, but it is coming.
So if your doctor determines that you have medical conditions resulting from obesity, and you fail to lose target weight, you will pay higher premium / tax. This is to ensure that health plans and gov’t don’t arbitrarily use weight/BMI as a gauge to unfairly penalize people, because you can still be somewhat overweight and be perfectly healthy.
Unfortunately, it is becoming more and more socially acceptable to be overweight. In fact, we cater and try to profit from them. That’s the country we live in today.
Adherence is important, but it is a low-hanging cherry with dubious payoff. We need to shift our focus immediately to that huge, delicious, juicy coconut hanging 100 ft off the ground. It will be a tough climb. But the payoff will be huge.
The way I look at it, that coconut will fall eventually by itself. But it will fall on our head and cripple us in the process. So we can wait and wait and push out luck, or we can start climbing the tree now.