A buzzword circulating in the health policy world is value-based insurance design. This phrase sounds like something the business world might latch on to. It sounds very businessy–companies in control of maximizing shareholder value.
Two studies were published in Health Affairs dealing with aspects of this approach. They studied the effect of lowering copayments for medications on adherence: i.e. how often patients took the medicines. One study eliminated copayments for generic medications and lowered them for brand-name drugs. It found adherence improved 1.5% to 3.8%, depending on the drug. The other study eliminated copayments for statins and reduced them for clopidogrel (Plavix), and found adherence increased 2.8% for statins and 4% for clopidogrel a year later.
These studies remind us that adherence is a complicated issue and show that lowering co-pays helps very little. The other striking aspect of these articles is that they give no indication that the authors realize that by encouraging their employees to take more medicines and spending money to do so, in most cases they are raising the total cost of healthcare for the company.
Finally, supporters could point out that this experiment resulted in improved quality of care. This reminds us of another reality — higher quality care usually costs more; or to phrase it another way, if you want something better, it will cost you.
As a nurse for 40+ years and now as a patient in my senior years, I can tell you why some people don’t take their medicine. Side effects and dose are way more important than cost. Physician denial of side effects, even when the list of these very symptoms comes with the medications from the pharmacy, and lack of documentation of a patient’s report of side effects is incredibly frustrating to a patient who just wants to feel ‘well’. By the way, that statement in the info from the pharmacy is worthless when it says that “if side effects persist or are bothersome, contact your healthcare provider”, or “may be present as your body adjusts to the medication”. Taking time to discuss how long “persistent” is (after 3 doses? 10 days? 3 weeks? 30 days? 6 months? 2 years?) and explaining how your body has to “adjust to the medication” would be incredibly helpful. After all, the most ordered medications today are for symptomless conditions (hyperlipidemia, hypertension, type II diabetes). It is incredibly difficult to be labeled with a diagnosis and relegated to a lifetime regime of body altering chemicals that make you feel too bad to function or enjoy life, when you felt fine without them.
During the last year I have been prescribed at least 9 medications with side effects so bad that I discontinued them myself after reporting to the physician that I could not tolerate being dizzy, weak, uncoordinated, nearly comatose, unable to swallow, short of breath, unable to sleep, hallucinating, having chest pain and palpitations I had never had before, having large unexplained bruises, intolerance of sunlight, swelling feet face and fingers, having diarrhea, having severe constipation, being unable to urinate, having brown urine, having blue toes and fingers, having muscle cramps, and having brainbusting headaches. I was unable to stand, get myself to the bathroom, or drive to the doctor’s office to complain without omitting the medication for 48 hrs before the appointment. Keep in mind that I felt well when I went to the doctor for a “welcome to Medicare” physical. These were medications for symptomless potential conditions that were “recommended for some one my age”. With each report of side effects to the prescribing doc, all I was offered was another medication to treat the side effects. I was offered a diuretic for swelling from a CCB, a sleeping pill for sleep disturbance from lisinopril, a pain pill for muscle cramps and headaches from a statin, an antihistamine for the cough and nasal congestion that most of them brought on, a pill for diarrhea and one for constipation, an antiarrhythmic for the palpitations that most caused, an emergency call system for the weakness and dizziness, and an ASPIRIN for chest pain. (Actually the aspirin is the only one I continue to take) I’m confident that if I had continued to take all these meds as ordered, I could now be diagnosed with CHF, afib, angina, irritable bowel syndrome, kidney failure, dementia, Parkinson’s disease, and diabetes.
All of the meds were $4 items from Walmart, so cost wasn’t an issue. Quality of life is the issue for me. I actually believe that some of these medications might have been somewhat helpful for me and tolerable at much smaller doses, but until I can find a doctor who works with me to find the smallest effective dose for me, I’ll just be a “non-compliant patient” taking my aspirin and multivitamin. Maybe I’ll only live to be a happy 81 yo instead of a disabled 81 ½ yo.
One doc told me that I had no business asking questions, that at my age I just needed to “do what I was told”. Then he said, “doctors don’t have time to answer questions, you are costing me money every time you come in here”. Needless to say, I am saving both of us some money and haven’t been back there.
I can’t access the original articles. Was the endpoint prescriptions filled or pills ingested (patient reported)?
In the Pitney-Bowes study, all they say is:
Medication Adherence We measured medication
adherence by estimating the number of days
of medication available to each patient or the
“proportion of days covered” in each month between
January 2006 and December 2007.
I assume they used claims data.
In the North Carolina study, they wrote:
Medication Adherence Outcomes We assessed
medication adherence using the medication
possession ratio, calculated as the number
of days over the entire study time period for
which the enrollee had medication. We adjusted
the number of days’ supply in the ratio
to account for medication left from filling previous
prescriptions. The ratio accounted for
medication switching between different therapeutic
classes of drugs—for example, from a
calcium-channel blocker to an angiotensinreceptor
blocker—to avoid overcounting a supply
of a drug that enrollees were no longer
taking.
I again assume this is claims data.