On first blush, I find the notion of paying people to take their medication disconcerting, almost patronizing.  However, given the correlation between prescription use and reductions in overall medical costs, as seen in the Medical Care article, it makes sense to look at every possible way to incentivize compliance.  The New York Times article presents different patient models with the common benefit of providing small to moderate financial performance incentives.  Mid-point in the article it digresses to discuss paying doctor’s to get their patients to take their medications – resulting in a financial incentive of between 3% - 5% of the physician practice’s base income, not insufficient by any means.  This latter point, I did find confusing to the point of the article.

I have two thoughts.  First, the New York Times article states that one-fourth of patients don't fill their prescriptions which, obviously, results in their inability to take their medications.  Of course, it’s a leap to assume that people don't fill prescriptions solely because they are non-compliant.  I would suspect that it has more to do with financial barriers (e.g., cost of co-pays and deductibles, lack of prescription coverage).  Second, it doesn't appear that these examples of paying patients have enough longevity.  I would be interested to see if long-term financial incentives continues to result in patience medication compliance.

All of the above are great ideas, however it adds more bureaucracy to the equation, and who is going to pay for that?  Individual doctors, insurance companies, hospitals? PCPs are already overworked, who is going to be respnsible for information from specialists.  Nope this is not a good idea.

While we ponder on monetary incentives to promote medication adherence, do we have the technology in place to track medicatuion adherence. Thisis a classic case that reinforces the need to have a true National Health Information Network. While similar initiative across the pond (in U.K) have run into cust overruns, at the end of the day had the PCP been on the same network and had the looked at a unified medication record via an integrated network the oversight of potential side effects would not have happened.

Weaving medication adherence into larger wellness tracking might be another way to look at this issue. Instead of cash incentives, non-cash incentives like a points system wherein the patient accumulates a certain number of 'wellness miles' and adherence gives an accelerator effect to these, which could overtime be used to defray co-pays/ pay for preventative screening among others.

Studies that never appear in print

Cleveland Clinic pathologist giving a talk in Indiana - He noted a pilot study done by a female cardiologist on amyloid heart, with a 4 - 6 month prognosis. Intervention - thalidomide. Results - 14 - 17 month survival. But the cardiologist and her office departed. The study was replicated by 4 or 5 offices - no difference shown. Problem - the patients in the non-dedicated offices did not get the same nursing and counseling to get them through the considerable side effects of this "chemotherapy"   His diagnosis - patients were essentially left to their own devices and did not stay with the therapy.

Studies confirm poor results in high side effect meds in disadvantaged populations. A good source is pediatric cancer therapy where over 85% of patients are studied.

Those of us in health care, particularly young and on few medications and not on the complex regimens of today, fail to comprehend this.

Took me three years to learn how to take Lactaid right and what I could do to make it work, and the kinds of foods and situations where it would not work.

Also one of the biggest factors involves confidence in the provider and in the medication. When patients have low confidency in providers and low confidence in medicine (specific or generic), there are huge problems with adherence.

Most puzzling case - major diabetic patient with early renal and other side effects essentially not taking medication at all (even without a co-pay or barriers) - eventually he had to have an aortic aneurism repaired. For a year he had no sign of diabetes at all although eventually "relapsing"    Still wonder what possibly resulted in this major change (Immune, change in healing process?)    I have had patients in the early phase of treatment get a honeymoon, but not the late phase people.

Also Medicaid is already doing lotteries. The co-pay and barriers to medications resulted in certain patients with medication failures. In the case of a man with previous duodenal ulcer, the result was near death and over $50,000 cost and lost productivity costs, etc.     This lottery cost the hospital, the physicians, the patient, Medicaid, and all of us. Few studies demonstrate the overall consequences of co-pays for medications, reducing from 7 to 3 prescriptions, barriers to certain drugs, etc.  But primary care folks see the consequences, take the time to explain to bureaucrats that duodenal ulcer may not be on their list, but is a lifelong indication, etc.

Bob Bowman

As a provider for safety net clinic patients I would not recommend paying patients to take medication. I agree with many of you about the need for the patient to understand the purpose and effect of medications. Also I do believe that having the pharmacist actively involved in patient care helps. I do wonder if the patient would be more compliant if the provider knew through technology (escrpts or an emr) if the patient actually refills medications and when.  We do have a pharmacy as part of our clinic and patients are required to get medications only through our pharmacy. We know if the medications are properly refilled and we call the patients on it if they are not refilling in a timely manner.  Also the pharmacist spends time designing labels for the patient who cannot read.  I have not seen any research on the Ready Fill programs that many retail pharmacies are not offering, but it appears that the program must increase compliance because it takes one step out of the patient reordering process