It’s hard to imagine something scarier than a heart attack: crushing pain, combined with the realization that the organ you rely on to beat every second of every day is in trouble. Suddenly, you are mortal.
Many patients who experience a heart attack consider it a wake-up call, and a reason to take better care of themselves: “Maybe I should walk more and lose a few pounds.” Certainly, for heart-attack victims who are prescribed a medicine to drastically reduce the chances of another heart attack, there is a strong motivation to take it.
But here’s the surprising part: often they don’t. In the year after a heart attack, only about 40% of patients take medications as prescribed (1).
Nudging people toward making good choices
In the past few years, there has been great interest in efforts to improve compliance with recommended healthcare guidelines through value-based insurance (VBI) designs (2). These strategies assign lower pricing to treatments deemed to be beneficial from a cost or outcomes perspective. It is a coordinated system of price nudges toward particular choices of treatment.
The value-based movement evolved partly in response to disappointingly low adherence to beneficial treatments, and partly in response to concerns that consumer-directed plans (where consumers pay directly for many services from their own accounts) might discourage patients from seeking necessary care. This is the logic: If we remove the financial barrier, more people will refill their important prescriptions and stay up-to-date on recommended screenings and exams. So, let’s make “good” options less expensive—or maybe even free.
So, does ‘free’ make a difference? Not really.
Results released this month from a large study found that when a group of patients was offered free heart medication, only 4-6% more of them took it compared to the people who were charged $50 per month for the same medication (3). Even more discouraging, the overall rate of adherence was under 50%. In their discussion, the authors focused mostly on the benefit for those few additional pill-takers, but the real news was expressed by one author: “My God, we gave these people the medicines for free, and only half took it” (4). It’s hard not to share his surprise. The economic “law of demand” tells us that as costs get lower, consumption goes up.
The more we look at this situation, the more complicated it becomes . While there is certainly evidence that cost influences a person’s likelihood of refilling medications, price is only one of many factors. For starters, we cannot look at any one treatment in isolation from other health issues. A study earlier this year showed that the typical heart-disease patient will fill 11.4 medications from six different drug classes every 90 days (1)! More striking, in the same time frame, 10% of patients will fill 12 or more unique medications, from 11 or more different drug classes, written by four or more prescribers, and fill them at two or more pharmacies, requiring 11 or more visits to a pharmacy. Not surprisingly, the more complex the regimen, the less likely people are to adhere to it.
In the context of managing handfuls of different medicines at different times from different doctors and pharmacies, it’s easier to understand why so many people fall short of doing what we ‘want’ them to do. It’s not a single conscious choice between taking a pill or not; it is ongoing management of a complex array of daily and weekly activities.
Going farther than free
After discovering that providing medications at no cost did not make a large difference in adherence, the researchers announced their next approach (5). No, it does not involve better communication or coordination among medical providers, and it does not suggest better-educating patients about the medications and treatments being prescribed. Instead, they intend to make the medications cost even LESS than free, by paying people to take their medications, calling it “value-based 2.0.” They propose to calculate the economic value of lower costs that result from adherence and give it back to patients as an incentive.
While going even further down the path of incentives is a natural extension of value-based insurance, one has to wonder: if “free” is not powerful enough to change behavior, is ‘more free’ where we need to go? Further, should we really be picking specific treatments that we will reward rather than supporting a greater involvement in one’s care?
What if a patient doesn’t take this particular medicine, but instead he loses weight, starts a walking program, and avoids a heart attack that way? Will he not get paid? What if a patient stays healthy in the first place and never needs the medication at all? Will he never have the opportunity to earn incentives because he is never at risk for needing to take medications? What if that specific medication cannot be combined with another treatment a patient is taking for another illness? Will he be ineligible for incentives despite doing the right thing to avoid a dangerous drug combination? What if the patient doesn’t really need that drug anymore, but likes getting the incentive? And the question I hope public policy folks are asking: is it a good idea to pay people to take prescription drugs?
How can a value-based system decide the right financial incentive in every circumstance? The truth: it can’t. Believing that we can preferentially price specific treatments to nudge people toward “good” choices appears to be less effective than hoped. Trying to do it decision by decision is impossible.
Directional goals rather than tactical manipulation
Creating financial incentives for specific treatment choices, one by one, is a little like giving a preschooler a quarter for eating her peas. She is likely to eat her peas while you are watching in order to get the quarter. But does it promote what you really want: for her to gain an appreciation for all healthy food instead of candy, not eat peas for the sake of quarters.
If cost isn’t the barrier, what keeps 60% of heart-attack survivors from taking life-saving medications? Is it the complexity of combined treatments, disbelief about the value of such treatments, or could it be transportation barriers getting to the pharmacy? Does the medication cause side-effects that are worse than fear of another event? We really don’t know; but it isn’t likely to be a simple reason.
Are we putting as much energy into helping patients become active managers of their health as we are into pushing them toward specific choices that may or may not make the most sense for them?
Aligning incentives does not mean creating a series of small bribes in hopes of correcting perceived medical misbehaviors. It means designing an entire system where people own their own choices and benefit from better health and prudent spending, both because they save money and improve quality of life. What we need is a coherent dialog with individual patients to understand their concerns and support their efforts to achieve individual goals.
Why this matters: An interest in encouraging the “right” behaviors has led to narrowly-focused incentives for specific treatments. The recent discovery that offering free medication does not improve patient adherence substantially should make us rethink such piecemeal approaches and consider a broader context.
1. Choudhry NK, Fischer MA, Avorn J, et al: The Implications of Therapeutic Complexity on Adherence to Cardiovascular Medications. Arch Intern Med 2011;171:814-22.
2. Chernew ME, Rosen AB, Fendrick AM: Value-based insurance design. Health Aff (Millwood) 2007;26:w195-203.(accessed November 28, 2011).
3. Choudhry NK, Avorn J, Glynn RJ, et al: Full Coverage for Preventive Medications after Myocardial Infarction. N Engl J Med 2011;(accessed November 28, 2011).
4. Marchione, M. Patients not taking heart meds — even if they’re free. The Arizona Republic, Nov 15, 2011; (accessed Nov 28, 2011).
5. Wendling, P. Free Meds Boost Post-MI Outcomes, Rx Adherence. Family Practice News Digital Network, Nov 15, 2011; (accessed Nov 28, 2011).