My initial enthusiasm for blogging on the subject of adherence policy “carrots and sticks” faded the more I contemplated the disputes that would arise by suggesting “sticks,” so mostly I’ll – pardon the pun – “stick” to “carrots.”
In recent weeks these blog pages have been filled with ways to support patients: reviewing insights about human behavior, the young, the old, reminder systems, games and team care. In fact, this series could have continued all month and we’d not have exhausted the ways in which patients are supported, encouraged and cajoled to be adherent.
Yes, we’ve dispensed plenty of sugar to make the medicine go down, but we’ve not proposed any “sticks” in the event it does not. Let’s face it; we’re not ready for the outrage in the public policy world if we seriously suggested that patients somehow should be held accountable.
In the private sector, some accountability-style policies exist (though not to my knowledge regarding medicines). For example, one major company warns employees that if they have an automobile accident requiring hospitalization and committed a moving violation or failed to wear a seat belt, they’ll be responsible for paying an additional $1,000 deductible. It’s a policy that requests responsible behavior in return for a benefit. I don’t sense that we’re ready for that same kind of “tough love” talk with patients. Not yet.
I liked Joyce Cramer’s notion of the “patient as willing partner” and wonder if we, as patients, sit at one side of the partnership table, what does “the other side” offer us?
In fact, it offers us a lot in the way of benefits, opportunities and “carrots” regarding our medication needs.
- Availability. More medications are available today than ever before, brought to us by public funding and policies that underwrite the cost of basic biomedical research, science education and advanced graduate training. Public policies also provide intellectual property protection to those who successfully innovate to produce new medicine solutions and then – after a time – allow that intellectual property to be used by others to produce cheaper, generic copies of those once-innovative products.
- Assurances. Medications are studied, reviewed and regulated virtually continuously, by regulatory agencies and major health care systems to assure safety, effectiveness and appropriate use. We can report side effects and are encouraged to do so. Those data are monitored and used to further improve pharmaceutical care.
- Accessibility. Medications are more accessible than ever. There is a pharmacy – on average – at every square mile in the US, each one staffed by experts in the use of medications and the management of complex combinations of multiple products for those of us with multiple chronic conditions. These experts can generally tell “in a heart beat” if the side effect we suspect is the medication or the way we’re taking it. For those locations where the “on average” does not apply, mail order pharmacies fill the gap.
- Affordability. Medications are more affordable than ever. The range of generic and therapeutic substitution options allow clinicians and patients to consider the cost of medicines and to pick affordable choices for the vast majority of conditions treated today. Public and private sector coverage for medicines has never been better and every company has a patient assistance program for those who do not have coverage or cannot otherwise afford the medications.
- Alternatives. In this chronic disease epidemic era a large share of the medications we take are intended to treat conditions that could have been prevented. Public policies have invested in understanding the drivers of preventable illness and educating us on everything from nutrition and exercise to stress management and back-injury prevention. Surely not everyone, but many people can practice the alternatives if they choose.
- Accountability. Those who develop, manufacture, prescribe and dispense medications are held accountable for their mistakes. A company that misrepresents the safety, efficacy or indications for their product is subject to legal sanctions and litigation. Clinicians who inappropriately prescribe or pharmacists who inappropriately dispense are subjected to similar consequences. Preventable errors in hospitals are reported and related care is not reimbursed.
Each of these is important and as patients we’d want nothing less. Can we legitimately ask for more? In some cases, yes.
Those with multiple or serious chronic conditions requiring some of the newest biotechnology solutions face great financial burdens. They can legitimately ask for relief. The same is true for people who suffer from cancer and some rare diseases with very expensive therapies. Then, there are those with currently incurable conditions; they can legitimately ask – if not for a cure – then at least for a treatment.
In return for what we have been given, can something be asked of us as patients? I’d like to think so, but I know of none that would gain traction in today’s debates. Are we ready to suggest that the non-adherent hypertensive patient be charged more for heart attack or stroke care? I don’t think so.
Until we are, we may as well ramp up the “carrots,” so many of which have appeared in these pages, stop the handwringing about the cost of non-adherence and haul out our collective checkbooks.
