May 4, 2011 
I’d love to hear some physician perspectives on this. It’s a question that comes up every once in a while.
Let’s start with a few facts:
- Adherence is estimated to be a $290B problem. (NEHI Report)
- Poor adherence limits the effectiveness of the healthcare system. (WHO Report)
- Interventions do impact adherence. (Express Scripts presentation)
- There are lots of reasons for non-adherence. (MAPS)
- Medication adherence leads to lower healthcare costs. (CVS Caremark study)
The question of course is what to do about that. Most of the programs focus on consumer or patient interventions.
- Refill reminders
- Gaps-in-care
- Off-therapy reminders
- Auto-refill programs
- POS consultations by the pharmacist
But, interestingly, I’ve seen a few other studies recently that show that prescription programs targeting physicians can influence behavior (example here). I’ve also heard a few companies talk about paying physicians to keep patients adherent.
There are a few arguments that happen here:
- Should the physician play a role in adherence?
- Does the physician know if a patient is adherent? Should they get this data? From whom?
- If the physician asks the patient, will they tell them to truth or will it simply be a case of “white coat” adherence?
- Should this be a performance metric in a pay-for-performance environment?
- Will PCMHs and ACOs structures change this and make adherence a critical issue for discussion between the patient and physician?
In general, I think most people believe that physicians (as indicated in studies like this one) don’t see prescription adherence as a big issue that they can or should influence. Is that true? Would “incentives” change that?
Of course, the debate isn’t limited to paying physicians as multiple companies are paying consumers to be adherent. Here’s a post from last year from another blogger called “Paying Patients To Take Their Medications Is Stupid” which is similar to one of my posts from last year.
Enabling Healthy Decisions 
I got to share this as a guest post on KevinMD’s blog. It has gotten a lot of comments over there.
http://www.kevinmd.com/blog/2011/05/paying-physicians-medication-adherence.html
Great question! I think that the first reactive answer of most people to this question would be — Isn’t this part of what doctors do or are supposed to do? After all, there isn’t a reimbursement code for “get your patients to take their medication”.
Unfortunately, as Dr John pointed out, “As doctors we always moan about patients being ‘non-compliant’ or now the PC term ‘non-adherent.’ But other than the emerging quality metrics and P4P many doctors don’t really care if their patients don’t take their meds–there are just too many patients, and enough that follow our instructions to keep us going. In a sense, we ‘cut our losses.'” For his entire comment, please see http://wp.me/p1fYJ7-5I
As Steve points out, effective physician communications with their patients is a key; and for those physicians who are not good communicators, perhaps “delegating” this function to a nurse, physician assistant, or third party advocacy group (the latter of which I used with success) is a possible solution.
Patient non-adherence can be linked directly back in many cases to poor physician communication Poor patient adherence is associated with the following patient factors: 1) doesn’t perceive the need for the medicine (or believes that there are other alternatives to try first), 2)doesn’t belief that the prescribed medication will be helpful and 3)isn’t taught how to take their medication,including side effects and when to stop.
It is the physician’s job to address these 3 aspects with the patient as part of prescribing a new medication. Most physicians do not. Failure of physicians to address these issues with patients is linked to intentional non-adherence. The point is that paying physicians alone will not work. Physicians need to be taught how to talk with patients about these types of patient treatment issues. Besides isn’t this something physicians should be doing anyway? Are we going to start paying them to be empathetic next?
Steve Wilkins
http://www.healthecommunications.wordpress.com