Paying physicians for medication adherence

by George Van Antwerp

Should you pay physicians for medication adherence?

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
  • Poor adherence limits the effectiveness of the healthcare system
  • Interventions do impact adherence
  • There are lots of reasons for non-adherence
  • Medication adherence leads to lower healthcare costs

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.  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 don’t see prescription adherence as a big issue that they can or should influence.   Is that true?  Would “incentives” change that?

George Van Antwerp is the general manager of the pharmacy practice at Silverlink Communications who blogs at
Enabling Healthy Decisions.

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  • Melanie Rodrigues

    Adherence is an all too important situation with so many prescriptions being written, filled and who knows if they are swallowed? There are millions of pills, capsules and liquids that are wasted each year. Who better than to aid in this than your pharmacist? There are many of us who are trained AND willing to work with our patients to understand why adherence is such an issue on a daily basis. Do physicians have the time or could this be another way to foster a positive interprofessional relationship with another trained healthcare provider?

    • http://Www.georgevanantwerp.com George

      Melanie – I completely agree. Pharmacists are critical to adherence. BUT, I think some of the root cause is understanding the Rx to begin with from the MD and having the MD reinforce adherence in the follow-up visit.

      We have huge issues with primary adherence and many patients don’t realize they are non-adherent.

  • http://robinsonfamilymedicine.com Stacey Robinson, MD

    The pharmaceutical industry would love a pay for adherence program, wouldn’t they? That sure would add to their “bottom line”. I have an idea… how about paying doctors for getting patients off medications?

    • http://Www.georgevanantwerp.com George

      I agree. How about paying everyone for outcomes?

      But, if they are on the medications, let’s not waste them by having patients only take them for a short period of time.

  • soloFP

    I spot check patients on PPIs, BP meds, T2DM meds, and other potential chronic meds through local pharmacies and mail order companies. It takes extra unpaid time throughout the day. I have noticed that patients are more likely to adhere to the $4 and $10 generic meds than the ones with $60 monthly copays.

    • http://Www.georgevanantwerp.com George

      There is lots of research to support that observation both from Shrank (Harvard) and others. The issue is helping MDs understand relative copays which generally isn’t true although it could improve with electronic prescribing.

  • Wayne Ruth, M.D.

    Yes, we need to be responsible for something else.

    It is not enough that we evaluate the patient, make assessments about the proper therapy, navigate the insurance company formulary to see if we can actually make our own decision, write/send the prescription, and then educate the patient about the treatment rationale. Now we need to be the nanny that has to remind them to actually take the medication! And they’re going to pay us for it! (probably by reducing our reimbursement for the visit in an equal or greater amount)

    Maybe it is time to start looking at another line of work or finding a way to retire. This one is starting to look a little silly. How much additional responsibility can they heap on us as they reduce our income?

  • http://drsamgirgis.com Dr Sam Girgis

    “In general, I think most people believe that physicians don’t see prescription adherence as a big issue …”

    I have to respectfully disagree with this statement. Physicians see medication non-compliance as a very big problem. In the long run, it is the cause of increased morbidity and mortality. More proximally, it is the cause of unnecessary emergency room visits, and avoidable hospitalizations. As for using medication non-compliance as a metric for physician pay for performance, it would be an unfair way to evaluate physician performance. There are already enough metrics that will be used in the uncoming CMS pay for performance initiative involving HCAPS.

    Dr Sam Girgis
    http://drsamgirgis.com

  • Marc Gorayeb, MD

    It’s a bit more nefarious than nanny-statism. Look at the author’s connections. Who do you think pays for his services? I don’t think it’s the government. However, this could be an early attempt by the company to insinuate itself into the Obamacare bureaucracy.

    • http://Www.georgevanantwerp.com George

      I do work with a lot of pharmacies and PBMs. That shouldn’t exclude me from trying to figure out how to help patients stay adherent.

      I don’t think you should pay anyone for adherence, but it’s happening today. I appreciate all the dialogue.

  • http://www.drjoe.net.au Dr Joe

    Absolutely not. This would make doctors seen as even more in the pocket of the pharmaceutical industry. Our role is to advise patients not to be their parent. I do not see adherence as a big issue.

  • http://Www.georgevanantwerp.com George

    Sam and Wayne –

    I appreciate the comments. I agree it would be unfair as a metric and emphasize with increasing workload and lower pay.

    I’ve also been surprised by several surveys that show a lack of responsibility for understanding adherence. I always use the example of a patient on statins showing high cholesterol and being moved to a new drug or stronger dose when really the issue is simply taking the pills.

    None of us can make sure the patient takes the pill but the entire care team can influence it.

    George

  • http://fertilityfile.com IVF-MD

    If somebody gets happy whenever something happens (in this case, patients taking their meds) they should fell free to reward the doctors, the patients or whomever — they can reward them all they want as long as they’re doing it with their OWN MONEY.

    It’s unethical to be talking about doing things with OTHER PEOPLE’s money unless those other people give expressed consent. If we all adhered to this primary ethical principle, a lot of problems would solve themselves or at least be a lot better than the way they are now. :)

  • jenga

    Should we pay teachers on whether or not their students do their homework?

  • Sebastien Piret

    Great to see such posts opening up to broader views. This is indeed a big issue. Although money does influence outcomes in a way, I’m not sure that money should be considered as a mean to these objectives. Patients should value their health no matter what. Otherwise, this will surely lead to compliance “side effects”. Besides, there will unfortunately always be people who can’t afford ANY kind of medication (even generics). And technically, although I’ve never been one, Doctors are paid to treat or cure patients, not to make them adherent. So I believe that it’s a question of giving the right information, at the right time, and the right way to patients. This is very time-consuming, especially to Doctors who are very busy anyway, so the right tools need to be designed in order to facilitate those settings. Pharma companies, Doctors, IT specialists including social media & mobile experts could join forces to increase relevance towards patients while staying efficient in the process. I know that sounds like a blurry dream, but a lot of such dreams have finally come true. The question are: what will happen and when will it happen?

  • pcp

    Why not fine patients if they’re non-adherent?

    • NEMO

      Because the patient ALWAYS has autonomy, that’s why!

    • Diora

      Because a patient has a right to refuse medication.

      • pcp

        Exactly. So don’t make my income dependent on your autonomous behaviour.

    • http://Www.georgevanantwerp.com George

      But should patients pay more for healthcare if they smoke or do other things that lead to worse outcomes and higher costs? That seems to be likely.

      • NEMO

        More for Insurance? Sure, if the insurance company feels their lifestyle or behaviors are going to increase their risk.

        For healthcare? No, treatment should not cost more, it is the treatment and there should be no value judgement or additional monetary punisment meted out to get treated.

  • Fam Med Doc

    I’m ok w getting paid for patient adherence & better medical outcomes overall IF AND ONLY IF patients are 1) fined by their insurance company for obesity (BMI OVER 30) & 2) fined for non-participation in treatment (not seeing the doctor on a regular basis; not taking meds as prescribed).

    • NEMO

      You’ve lost your soul as a doctor the day you forget you are an advocate for your patient and part of your duty is to respect their autonomy!

      • doctorjay

        I don’t think anyone’s disagreeing that part of a physician’s duty is respecting patient autonomy – what we’re saying is that we shouldn’t be penalized for patients choosing to exercise that autonomy. Linking payment to adherence creates an irreconciliable conflict of interest on the part of the physician. Only a scheme where both patient and physician BOTH have a financial incentive for adherence would resolve such a conflict.

        • NEMO

          BINGO!

          That’s exactly why physicians should NOT be paid for patient medication compliance!

  • Angela Caffaratti, MD

    I just today had a patient admit to stopping her bisphosphonate because of a lawyer commercial. It is hard to be heard through so much noise.

    • Diora

      Does she have an osteoporosis or was she taking it for prevention? What is her risk for getting a fracture in the next 10 years?

      It is her body, and it is her right to evaluate whether of not the reduction in the risk of fracture is more important to her than elimination of a tiny risk but of a very serious condition.

    • Leo Holm MD

      Check out the NNT. A lot of people should stop their bisphosphonate.

  • Kristin

    I think the big issue here is that we don’t have a good system in place for measuring adherence. Smart phones or smart pill bottles are the obvious next step–something that removes the element of reporting bias (“Sure I took my pills! Every day! Just like you said! Except I skip them whenever I feel like it…”) from the process.

    Some work in research psychology is being done on adherence–the work I’ve seen is with reference to aging populations with mild cognitive impairment. There’s some work looking at whether participants who get “smart” pill bottles that record when they were opened and give reminders have better adherence than participants with typical pill bottles; however, one major limitation of that work is that the pills in question are dummies, and the participants know it, so they don’t have much in the way of motivation.

    Incentives only have a shot in hell of working if the things they’re dependent on are measured accurately. Otherwise, you’re looking at making a lot of doctors very angry, or giving doctors powerful incentives to develop inaccurate, bias-prone methods of adherence measurement. Having incorrect adherence data isn’t going to do any patients any favors.

    Assuming that patient health, and not selling more pills regardless of whether people are taking them or flushing them down the toilet, is what you care about. If our nation’s food industry is any indication, the pharmaceutical industry doesn’t need us to consume our meds at all–just be shamed or coerced into buying more of them.

    • http://Www.georgevanantwerp.com George

      All the pill bottle tells you is if they open the pill. There are nano-technologies and other things coming that can tell that the pill was taken, but at some point enough is enough. You have to educate the patient and trust that they are empowered to take the medications.

      We need infrastructure to help with cost, literacy, and other barriers.

  • Jenga

    We are paid to treat patients not ram pills down their throats. The benefit that they themselves might get from taking the pills should be the only incentive. I’m an orthopedist and give alot of narcotics for fractures and such. With the refill requests I get, I’m pretty sure my adherence is off the charts. Call me silly, but I don’t think I need to get paid for that.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    I think we should have a tiny implantable device placed in an inconspicuous location, such as the back of one’s head that will continuously monitor and report adherence.
    In Stage 1 we would use it to collect data and inform George so he knows who he needs to be targeted for remedial education. In Stage 2 we would use it for communication with doctors so they can press the issue during routine visits. And in Stage 3 we can improve outcomes by ever so mildly zapping those who don’t adhere to whatever we want them to adhere to.

  • John Kaegi

    Why must every solution to health care problems be to throw money at physicians? Yes, the problem is real — patients skipping meds is at the heart of most of the chronic disease escalation and cost inflation. So, how do we motivate patients to take meds? Not by throwing more money at the doctors. Rather, by changing physician orientation toward wellness. The FFS reimbursement methodology orients practitioners AWAY from taking time to coach for prevention and wellness, to follow-up and hold patients’ hands. Under FFS they can’t afford to take the time to do those things. Under as staff model (salaried practitioners) with strong upside bonuses for improving the health of their patient panels, they would be strongly incented to focus on prevention and wellness.

  • Roger Ulrich

    This is an area that is the bane of many physicians’ existence. I am a family physician and I can’t tell you how many patients I know who are not compliant with medicines that are prescribed. Under the new ACO approach that is in the pipeline, physicians are going to be dinged if their patients don’t meet some governmentally designed wellness parameters. Besides the fact that some of those guidelines are rigid and not evidence based, it is beyond the powers of a physician to ensure that a patient is adherant, not only in taking medicines but regularly showing up for appointments and adopting behavior modifications. I find it strange that one would even considering discussing rewarding or punishing physicians for something that at the end of the day is the decision of the patient and not the physician. We run the risk of physicians only providing cadilac services to select patients without severe problems to avoid the possibility of their income being affected by something which is again outside of their scope or control.

  • Diora

    A couple of things I’d like to mention.
    1. I am not sure how accurate the pharmacy/mail order companies of adherence are. From personal experience with a mail order company: if you are on medication, and the doctor prescribes a different type/dose of the same medication; you send in the new medication, the mail order company adds the new prescription but doesn’t automatically removes the old one. So you get the new pills, but if someone were to check refills the old one would still appear as a non-refill. Additionally, with some medications, if the doctor stopped prescribing it, you have to actively remove it from the list. For example, if a woman and her doctor agree to try to slowly get off HRT in a particular year, the mail order company will have it as a non-refill unless the woman goes and removes this from the list.

    2. It’s our bodies. Today, a lot of drugs are prescribed to otherwise healthy people to reduce risk of certain bad-things-happening and in many cases the ABSOLUTE risk is quite small. I had a doctor who wanted once to prescribe me a statin for my under-1% 10-year risk of a heart attack. I am sorry doctors, but even if my risk had been higher, it’s entirely my choice if I want to trade in a small in absolute numbers risk reduction for a life long drugs with potential side effects. My body, by right. Also, with the guidelines for many “conditions” getting tighter and tighter, there are quite a lot of drugs prescribed with relatively small chance of benefit for an individual. A patient has a right to make an informed decision on those. Of course, ideally, the patient would discuss it with the doctor rather than just not refill, but still, it’s the patient choice.

    One should distinguish the situations of non-compliance that has high consequences e.g. a transplant patient not taking anti-rejection meds and non-compliance with so-called “preventive” drugs that reduce often a small risk of something bad happening.

    In terms of health care costs, not all non-compliance increases the cost. Depending on the NNT, some non-compliance may save money overall.

  • paul

    i instantly translated the title into:
    “witholding physician pay for medication non-adherence”

    • Leo Holm MD

      Any excuse to not pay physicians is a legitimate one. Don’t you know what “quality” is?

  • Christie B

    I absolutely see the risks to this – I think the comments have clearly articulated most of them. But I wish there were less problematic ways to achieve the benefits of such a plan.

    One theoretical upside would be that doctors would have an incentive to actually make sure that they had buy-in and understanding of the treatment plan. How often do physicians prescribe something and a patient never returns so the physician doesn’t get any feedback about why the patient didn’t want to or was unable to be adherent to the prescribed treatment? Suddenly health literacy interventions would move from “nice to have but no time or staff” to being essential.

  • Sebastien Piret

    Regarding the NNT, patients do not think according to this parameter: they just have an issue they’d like to solve. Compliance is something that gets in the way. NNT is surely useful to Drs but that does not allow them to make a decision to treat a patient or not though. Regulators set the rules and patients set their own values in this frame. Once a “treatment deal” is agreed between the Dr and the patient, then the teamwork as I describe above starts, to my belief.

  • Magpie

    The number one reason in my mind not to incentivize medication compliance by paying physicians is the conflict of interest. I’ve seen it first hand how a doctor will attempt to coerce a patient to medicate as first line treatment rather than take an equally effective course of watchful waiting. I don’t even want to imagine how such an incentive to physicians would work as there is, without payments, great pressure on patients to comply or else.

    Case in point. My newborn wound up in ICU at three months of age with a viral infection. He was placed in ICU after an episode of SVT while febrile, that was reversed with an ice bag to the face. In the 12 hours following his admission to the ICU, during the overnight, he had two more episodes of SVT while febrile, each again reversed with a bag of ice to the face. The next afternoon, a cardiologist came in to talk to me about the situation.

    Without any testing yet done on my son’s heart, he was insistent that my child would need to be on beta-blockers to prevent another SVT. Doc was appalled when I asked what the diagnosis was and what tests we’d be doing to confirm or rule out causes and what other options, instead of a beta blocker, did we have to consider.

    While he agreed to await testing and results before starting the beta blockers (I refused to start them without a clear reason), he implied I was going to be killing my baby by withholding medcation he deperately needed now.

    When all the tests (EKG, ECG, echo, x-ray, etc.) all came back and there were no structural defects, WPWS was ruled out, his rhythm was normal and everything on two 15 lead EKG’s were normal…still doc insisted we needed to start beta blockers! HELLO! You just ruled out 85% of the reasons for SVT and are left with the 15% that never have another episode – a febrile baby, slightly dehydrated with a minor and now resolved electrolyte imbalance due to the fever. Why the hell do I need to give him beta blockers when watchful waiting – that is specifically serial monitoring of his heart rate at feedings for the next three months – is reasonable?

    The doctor didn’t even want to consider this, said it was tooo risky, what if he had another episode? Did I want to be responsible for him dying?

    Ummm, I’m his mother and yeah, I’ll take taht risk because I can easily take heart rate routinely each day at feedings and prefer that to exposing him to serious potential side effects of beta blockers if he might never have another episode!

    I monitored for the next nine months and NOTHING – no SVT’s or any other cardiac problem!

    If that doctor had an incentive payment to push compliance and I refused, then what? Would I have lost my child for doing what the AHA even considers a reasonable first line treatment?

  • PAULMD

    There is a fun game that I made up during all of the hoopla of ACA, ACO, PFP, PHOs and other newly badged word salad that I cannot avoid reading. You may want to try it from the safety of your own home. I will draw a by on it.

    In college some friends of mine would play a game they called, “Bob Newhart”. They would gather all forms of alcohol and watch an episode of The Bob Newhart Show. Whenever Bob’s wife would say her charateristic, “Bob”…they would drink. By the end of the show they were well on their way to making bad decisions.

    Now, everytime I read word salad regarding the new paradigm shift in medicine, I see the word “quality” more than I ever could have imagined and it is near ridiculous in its contexts. See more, do more, spend less and better quality. Quality, Quality, Quality Quality….

    Replace the name “Bob” with “Quality” and get yourself some adult beverages. Another era of bad decisions are sure to follow:)

  • http://www.TheHealthCulture.com Jan Henderson

    Great topic and discussion. There was an interesting article recently in New Scientist called The Bonus Myth: How paying for results can backfire (http://bit.ly/kZrONc) (behind a paywall, unfortunately). It’s commonly assumed that offering a financial reward motivates better performance, but studies show that just isn’t true. “In many circumstances, paying for results can actually make people perform badly, and that the more you pay, the worse they perform.” It comes down to what’s long been known about how intrinsic motivation is much stronger than extrinsic motivation. As Sebastian Piret comments above, it would be preferable if patients would act because they value their health.

    The article cites a number of studies in health care and questions whether financial incentives in the ACA are scientifically sound. Also, I thought this was interesting:
    “An assumption is being made that doctors are substantially influenced by their income, or even primarily attracted to healthcare because of the financial rewards. But if you look at the literature on what actually motivates doctors to become doctors, very little of it is related to financial reward.”

    Of course, there’s a difference between initial motivation and the reality of keeping one’s head above water as a PCP or family medicine practitioner.

  • Angela Caffaratti, MD

    We could just subsidize small local farms instead of corn.