Friday, July 09, 2010

Paying People To Take Their Medicine

For Forgetful, Cash Helps the Medicine Go Down, New York Times, June 13 2010

I think this is a great idea, for some people and some medications. From my experience with low income people, those who take anti-psychotic drugs and some people on insulin or warfarin are good candidates, as are addicts. But for incentive programs to be effective, and not turn into laughing stocks, as I gleaned from the comments, it would be a good idea to involve case workers or other impartial advocates.

It looks like, from this excerpt, doctors may not always be impartial advocates. Or there is something more to this than meets the eye:
"Aetna has begun paying doctors bonuses for prescribing medication likely to prevent problems: beta blockers to prevent heart attacks, statins for diabetes sufferers. Currently, 93,000 doctors are in Aetna’s “pay for performance” program; bonuses average three percent to five percent of a practice’s base income."
What do you get when you pay docs to prescribe meds? You get docs prescribing meds. Does that seem odd to you? Paying docs to prescribe meds? Isn't that their job?

Statins for prevention are controversial1. I think statin makers would like to see docs prescribing them though. I would sure hope, if I dug a little, that I did not find statin makers, or any other drug maker, in any way sponsoring Aetna's program.

So when you go to the doctor, know that in the back of her mind she may be thinking how much more money she'll make by writing a prescription instead of a referrel for a dietitian, a disease education class, or a fitness center (all of which insurance companies should rightfully cover since lifestyle intervention has been shown to be more effective than drug intervention2).

1 Statins And All-Cause Mortality In High-Risk Primary Prevention, Archives of Internal Medicine (an AMA journal), June 28 2010. Which concluded:
"This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up."
2 One example: Reduction In The Incidence Of Type 2 Diabetes With Lifestyle Intervention Or Metformin, New England Journal of Medicine, 2002. Which concluded:
"Lifestyle intervention was more effective than metformin."

1 comment:

Doc D said...

I assume some of the comments to NYT asked what you do if patients use the cash to buy cigarettes.

In any case, I've been following the statin research, and like most other issues, the evidence is muddy and could turn into dueling studies until we get to the bottom of it all.

Note that this Archives effort only looked at simvastatin-equivalents and studied only "high" risk patients. We can expect the rejoinder to come from those aspects, IMO.