Bigger carrots and painful sticks to improve medication adherence

As you’ve probably read by now in the New England Journal of Medicine (Full Coverage for Preventive Medications after Myocardial Infarction), so-called value based insurance design, which waives co-pays for maintenance drugs, resulted in only a modest improvement in medication adherence and failed to significantly improve the primary outcome of the first major cardiovascular event or revascularization.

Despite the waived co-pays and study leadership by big machers from Aetna, Harvard, CVS Caremark and the Brigham, medication adherence was still under 50 percent, an improvement of just 4 to 6 percentage points over patients who were faced with co-pays. The researchers’ conclusions are as follows:

Despite the improvements in adherence that we observed, overall adherence remained low… Therefore, interventions to address other contributors to nonadherence (e.g., knowledge, attitudes, the complexity of prescribed regimens, and difficulties that patients have in accessing their medications) will be necessary to adequately address this problem.

I see things a little differently.

Perhaps the trouble is that rewards for nonadherence under value based insurance design are too low and punishment is entirely absent.  Consider the following alternative study design:

  • Pay those who are fully adherent $5000. If that sounds high, keep in mind that these patients incurred about $70,000 in costs on average during the follow-up period
  • For those who aren’t adherent, provide counseling and warnings, and a reassessment of whether their therapy is optimal. If they still aren’t adherent, then cancel their insurance

Of course the second bullet point sounds terrible. But if we’re serious about controlling costs shouldn’t we at least contemplate punitive measures?

November 15, 2011

3 thoughts on “Bigger carrots and painful sticks to improve medication adherence”

  1. Jerry Reeve’s organization has been part of a program with a self-insured employer. It took them a few years/tries with “carrots” but ultimately “sticks” were what made the difference and finally stopped the exploding costs. The program was a “3 strikes and you’re out” model. Their big cost issues were obesity and substance abuse.

    The annual health check-up led to a plan for the year and the individual was assigned a health coach to help them stick to the plan. They needed to adhere to the program reporting on progress, etc. Of the 700 employees who participated, 18% got strike one, 3% got strike two and only one person got strike three. If you got strike three, you went to a health plan that had the employee picking up a big chunk of their health costs.

    I think we’d all like to think carrots are enough but evidence suggests that sticks are necessary.

  2. behavioral econ 101 (not yet a liberal arts prerequisite)covers loss aversion and its outsize leverage on people’s behavior (perceived risk of/fear of loss outweighs like-size opportunity for reward as a behavior driver), so yea, bring the stix.

    I think DW’s bullet-two stick is MAD, however (as in the old-timey cold war nuke ‘strategy’), and much prefer Mr. Chase’s/Jerry Reeves’ weapon.

    No objection whatever to DW’s assertion that higher rewards may help, tho what little evidence is kicking around suggests that response to rewards diminishes as the reward value escalates (perhaps a corollary to the behavioral econ observations on carrots/sticks)

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