Saturday, August 24, 2013

Out of Sight, Out of Mind
And when he is out of sight, quickly also is he out of mind.
Thomas a Kempis (1380-1471)
When it comes to medication adherence, what we’re doing isn’t cutting it. Though as individuals we may feel ill-equipped to transform patients into “pill people,” as a community we face an opportunity to develop better ways of caring for people even when they’re out of our sight.
Lisa Rosenbaum, MD, and Willima Shank,  “Taking Our Medicine – Improving Adherence in the Accountability Era, “ New England Journal of Medicine, August 22, 2013

“We’re all in this together” is a familiar Obamacare theme.  If  physicians, nurses, hospitals, pharmacists,  and other health care community members together would collectively  provide “coordinated” care,  outcomes would improve.   
·         By shifting physician reimbursement from fee-for-service to collective capitated payment to patient outcomes. 

·         By penalizing hospitals financially when they are readmitted because of non-adherence  to treatment plans or life-style misbehavior.

·         By  not caring for patients “out of sight and out of mind “ by not  controlling and tracking patient behavior outside the physician’s office and outside of the hospital. 

·         By improving patient adherence to good health principles through “Patient-Centered Medical Homes” (PCMHs), Accountable Care Organizations” (ACOs), and Bundling Bills (BBs) holding providers accountable for total costs and outcomes.

It’s as simple as the ABCs or the  PCMHs,   the ACOs, or the BBs,  or the IPAB (Independent Payment Advisory Board), who would enforce it all.
Or is it?   Americans are a notoriously independent people.   They think they know what’s good for their health, even if health professionals do not endorse it.    An estimated 1/3 to to ½  of patients do not follow prescribed medication regimens. This non-adheremce  may cost the US $100 billion to $290 billion annually.    You can decrease these costs  and non-adherence  problems by prescribing generics,  by tracking use at pharmacies, by recommending weekly pill boxes to minimize forgetfulness, or by home visits to monitor compliance.  
 On top of these factors is the general distrust of government policies that interfere and intervene into patients' daily lives.    There are practical and deeply psychological issues involved when you start tinkering with a culture that treasures independence and personal choice to live as one pleases. 
Besides, how  can you or do you predict what patients will do, once they leave your sight and who enter their own mindsets?   How  do you go about penalizing physicians  for patient misbehavior and non-compliance once the patient is out of sight. This is beyond the realm of new payment mechanisms or predictive algorithms.  This is about transforming a culture.

Tweet:  Controlling patients' misbehavior and non-compliance with  treatment plans is difficult once the patient is “out of sight and out of mind.”


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