Bribing patients to follow doctors' ordersby Tom Crann, Minnesota Public Radio,
Dr. Jon Hallberg, Minnesota Public Radio
St. Paul, Minn. — If you've filled a prescription lately, you've probably noticed the little yellow stickers telling you to "take all this medication" or "take as directed." But do you follow those directions?
Some patients are getting an incentive to do so. A recent New York Times article points to programs around the country that provide cash incentives or gift cards to get patients to take their medications as prescribed.
MPR medical analyst Dr. Jon Hallberg joined All Things Considered's Tom Crann on Tuesday to discuss the trend of bribing patients to follow doctor's orders.
Tom Crann: How common is it that you have patients who don't take their medicine?
Dr. Jon Hallberg: I'm afraid it's way more common than we would like to believe. I knew we were going to be having this conversation, so I've been paying attention in the clinic the last few days. And it really surprises me how many people are [not taking their medication]. They don't even have a problem telling me that their not taking the medication. Usually, in years past, it was like they were sort of embarrassed about it.
Hallberg: Yes. You'd sort of wonder, "Boy, your blood pressure's terrible. How can that be when you're on four medications?" But now it's like it's harder to pay for it. They don't like the side effects. They don't want to take it, and they're pretty open about that.
Crann: So what should patients do if they have valid concerns about their medications, such as, "It's not working? I feel better," or, "I don't like the side effects."
Hallberg: Well, so many of our medications today are once daily medications. And they can be taken at different times of the day. And so I often will work with a patient [and say], "Rather than taking it first thing in the morning, take it before you go to bed at night. You'll be sleeping while maybe it's having some of the major side effects." Sometimes it's just a matter of getting used to it and being on it for two to three to four weeks, and then it's really not an issue.
But a lot of times, I will turn to my pharmacy colleagues and ask them for some advice. I think the bottom line is that there are ways around this. You can switch from one pill to a different kind of pill that does similar things. There are really ways around this that are much preferable than just stopping the medicine.
Crann: Medical incentives, getting people to do what they need to do, even with a cash prize if necessary, is this idea new?
Hallberg: Not really. The minute I saw this headline, I was thinking back [on it]. I think for years now there are some of my patients who come in, and they will get a Target gift card if they show up. And I sign a form saying that their child came in for a well child visit. So this is not a new concept. I would say it's been going on for at least a decade on some level.
Even at the University of Minnesota, we get incentivized to fill out a wellness form online. Many times you can be registered for a drawing. So that's not new. The fact of actually offering cash if you take your medications as directed, that's new.
Crann: And what is getting in the way of people taking medicines that are good for them?
Hallberg: I think many times it's almost a philosophical issue. If you and I have pain and we take a pain medication and it works--.
Crann: You get relief.
Hallberg: Yes, and there's the incentive. If you have a migraine headache, you can't breathe, you have pain, you're sick, you take an antibiotic. Those are fairly simple.
I think the trouble is that when people have high blood pressure, high cholesterol, diabetes, any number of conditions that require daily, constant taking of medication, that gets much trickier because you don't feel the difference. And it really gets tricky when you've got someone with a condition like schizophrenia where they feel better because of the medication and then they stop taking the medication.
Crann: Because they feel better.
Hallberg: Exactly. It's a vicious cycle.
Crann: So really, when it comes down to it, are financial incentives actually what is necessary here? Or are there other ways to do this?
Hallberg: Well I certainly think that there are many people who feel that that is the case, that we've tried everything we can. We try and partner and do motivational interviewing and explain things and try and tell people, "If you take this, you will not have this bad outcome." And that hasn't been working. So we've got to try something else.
But I think that, as person who lives and breathes the world of primary care, I think having a medical home, having a good relationship with a provider, still trumps the carrot of dangling something like ten dollars in front of the person.
Crann: Because we're really talking about ten, twenty, fifty dollars here at most.
Hallberg: Yes, these aren't huge dollars.
Crann: So basically, having a good relationship with your primary provider is really what it boils down to?
Hallberg: I'd like to believe so. I think that it's more complicated than that. I think many of the people that this kind of incentive is targeted toward are those who are falling between the cracks. They have a very serious condition and they don't have a primary care provider. They don't have access to health care, and yet they're expected to take these meds.
They estimate that there might be a hundred billion dollars a year spent in this country on people who aren't taking their meds as directed. It's an enormous problem. So there's no one simple solution for this, obviously.
Crann: Could it be that some of these people maybe aren't taking medication because they don't have good insurance or can't afford it, and then ironically, it's contributing to the spiraling cost of health care?
Hallberg: There's no question that that's part of it. It's one thing to tell somebody that they need to take a medication, but if they don't really have the money for a co-pay. It's all a matter of how we allocate the dollars that we have. And people, if they're told, "You need to take this medication. It's going to cost you this much a month," but the options are food or child care or some other things, it's a very difficult situation.
Crann: What ethical dilemmas does this bring up?
Hallberg: I think one of the biggest concerns is if you incentivize somebody to take their medications and you pay them, what happens when the money runs out? And they've been sort of playing this game, in a way, of willing to do this. Certainly, the article quotes people who are very excited about this. They're almost playing the lottery. They might get ten dollars or a hundred dollars.
Well that plugs them along for a while, but then you pull the money away, now what happens? Are they going to not be compliant? And also, how would you and I feel if we're taking our medications as directed, and we know that people who aren't are actually getting paid to do so? You and I might be tempted to say that, "Actually, I'm not taking my medication."
Crann: "I'm not either, and I could use a ten-dollar gift card."
Hallberg: That's right.
Crann: But if programs like this are actually motivating people to do what's right for them, what's the downside?
Hallberg: I'm not sure that we know what the downside is yet. All of this is sort of hypothetical. I think that if we can prove, and it's going to take some pretty big studies to show that this makes sense, it really does make a difference, you're going to have to look at outcomes and readmission rates to hospitals and all that kind of stuff.
If we're convinced it works, well then I think we'll go with it or some form of this for some kinds of patients that have a hard time complying. But again, what happens when you don't have the incentive? I think we come back to the fact that we have to educate. We have to connect people with clinics and people that they trust because ultimately that's what's sustainable. I don't think that carrots being dangled are really a sustainable way of doing this.
Crann: As I read about this, there are a number of different programs in different places -- one in Pennsylvania that's even almost like a lottery. You take your medicine and you get entered in for a little game of chance. What's in it for insurance companies or providers to do this?
Hallberg: It seems like it's mainly the health insurance companies that are doing it. It's ultimately their money that's being spent when people are hospitalized.
Crann: And what's in it for them to spend even more money here?
Hallberg: Well, it's estimated that something like a hundred billion dollars a year are spent on readmission rates because people are not taking their medications properly. And so imagine if you have asthma and you take an inhaler every day to try to prevent the asthma from flaring up, that really pennies a day probably to prevent that, if you take your medication. But a single ER visit is going to cost thousands of dollars. And so it's a no-brainer that you want to spend a little money upfront to try and incentivize people to take their meds.
Crann: So in the end, they're thinking ten or twenty-five dollars as an incentive beats the hospital bill a few years down the road?
Hallberg: That's exactly right.
Crann: Now that this article and this idea is out there, do you think people are going to come in to the clinic and ask for a little incentive to take their medicine?
Hallberg: I hadn't really thought about that. I have a feeling after you and I have this conversation that we might be hearing some of that.
Crann: Ask your doctor if ten dollars is right for you. Thanks, Jon.
Hallberg: Thank you, Tom.
Dr. Jon Hallberg is a medical analyst for MPR's All Things Considered. He's a physician in family medicine at the University of Minnesota and medical director of the Mill City Clinic in Minneapolis.
(Interview edited by MPR reporter Madeleine Baran)
- All Things Considered, 06/16/2010, 5:50 p.m.
Tom Crann is the host of All Things Considered for MPR News.
Assistant professor in family medicine at the University of Minnesota, and medical director at Mill City Clinic.