If there’s one thing I’ve learned from working as a doctor, it is that “what the doctor ordered” is not always what the patient gets. Sure, I’ve encountered the usual obstacles—like pharmacy “benefit” (ha!) managers whose restrictive formularies don’t cover the medications ordered by their physicians—but I’ve also been amazed by the number of patients who don’t take medications as prescribed. In psychiatry, the reasons are numerous: patients may take their SSRI “only when I feel depressed,” they double their dose of a benzodiazepine “because I like the way it makes me feel,” they stop taking two or three of their six medications out of sheer confusion, or they take a medication for entirely different purposes than those for which it was originally prescribed. (If I had a nickel for every patient who takes Seroquel “to help me sleep,” I’d be a very rich man.)
In the interest of full disclosure, this is not limited to my patients. Even in my own life, I found it hard to take my antidepressant daily (it really wasn’t doing anything for me, and I was involved in other forms of treatment and lifestyle change that made a much bigger difference). And after a tooth infection last summer, it was a real challenge to take my penicillin three times a day. I should know better. Didn’t I learn about this in med school??
This phenomenon used to be called “noncompliance,” a term which has been replaced by the more agreeable term, “nonadherence.” It’s rampant. It is estimated to cost the US health care system hundreds of billions of dollars annually. But how serious is it to human health? The medical community—with the full support of Big Pharma, mind you—wants you to believe that it is very serious indeed. In fact, as the New York Times reported last week, we now have a way to calculate a “risk score” for patients who are likely to skip their medications. Developed by the FICO company, the “Medication Adherence Score” can predict “which patients are at highest risk for skipping or incorrectly using” their medications.
FICO? Where have you heard of them before? Yes, that’s right, they’re the company who developed the credit score: that three-digit number which determines whether you’re worthy of getting a credit card, a car loan, or a home mortgage. And now they’re using their
clout and influence actuarial skills to tell whether you’re likely to take your meds correctly.
To be sure, some medications are important to take regularly, such as antiretrovirals for HIV, anticoagulants, antiarrhythmics, etc, because of the risk of severe consequences after missed doses. As a doctor, I entered this profession to improve lives—and oftentimes medications are the best way for my patients to thrive. [Ugh, I just can't use that word anymore… Kaiser Permanente has ruined it for me.]
But let’s consider psychiatry, shall we? Is a patient going to suffer by skipping Prozac or Neurontin for a few days? Or giving them up altogether to see an acupuncturist instead? That’s debatable.
Anyway, FICO describes their score as a way to identify patients who would “benefit from follow-up phone calls, letters, and emails to encourage proper use of medication.” But you can see where this is going, can’t you? It’s not too much of a stretch to see the score being used to set insurance premiums and access (or lack thereof) to name-brand medications. Hospitals and clinics might also use it to determine which patients to accept and which to avoid.
Independently (and coincidentally?), the National Consumers League inaugurated a program last month called “Script Your Future,” which asks patients to make “pledges” to do things in the future (like “walk my daughter down the aisle” or “always be there for my best friend”) that require—or so it is implied—adherence to their life-saving medications. Not surprisingly, funds for the campaign come from a coalition including “health professional groups, chronic disease groups, health insurance plans, pharmaceutical companies, [and] business organizations.” In other words: people who want you to take drugs.
The take-home message to
consumers patients, of course, is that your doctors, drug companies, and insurers care deeply about you and truly believe that adherence to your medication regimen is the key to experiencing the joy of seeing your children graduate from college or retiring to that villa in the Bahamas. Smile, take our drugs, and be happy. (And don’t ask questions!)
If a patient doesn’t want to take a drug, that’s the patient’s choice—which, ultimately, must always be respected (even if ends up shortening that patient’s life). At the same time, it’s the doctor’s responsibility to educate the patient, figure out the reasons for this “nonadherence,” identify the potential dangers, and help the patient find suitable alternatives. Perhaps there’s a language barrier, a philosophical opposition to drugs, a lack of understanding of the risks and benefits, or an unspoken cultural resistance to Western allopathic medicine. Each of these has its merits, and needs to be discussed with the patient.
Certainly, if there are no alternatives available, and a patient still insists on ignoring an appropriate and justifiable medical recommendation, we as a society have to address how to hold patients accountable, so as not to incur greater costs to society down the road (I’m reminded here of Anne Fadiman’s excellent book The Spirit Catches You And You Fall Down). At the same time, though, we might compensate for those increased costs by not overprescribing, overtreating, overpathologizing, and then launching campaigns to make patients complicit in (and responsible for!) these decisions.
Giving patients a “score” to determine whether they’re going to take their meds is the antithesis of good medicine. Good medicine requires discussion, interaction, understanding, and respect. Penalizing patients for not following doctors’ orders creates an adversarial relationship that we can do without.