Stephen Kimmel, MD, noticed a trend in his cardiology clinic: Patients who use anticoagulants, such as warfarin, seemed to have difficulty taking their medication consistently and correctly.
“Each time that happens, it costs $50 for an office visit,” explains Kimmel, a professor at the University of Pennsylvania. “If their anticoagulant goes out of whack, it costs $100 to $150 every time that happens.”
As Kimmel watched this happen on a regular basis, he started searching for ways to help these patients improve compliance. He tried reminder clocks that buzz when it’s time to take a pill, actual phone calls from the clinic, and support groups. But nothing has proven to be as effective as the power of the dollar.
A Small Price to Pay
These days, Kimmel’s research focuses on financial incentives. “Maybe what we need to do is come up with simpler solutions that can work without time and training—something that could be cost-effective,” Kimmel says. “It has to be something that’s doable.”
While some programs hand patients money up front or offer lower co-pays for prescription medications, Kimmel uses a lottery system. Each day, patients have a chance to win a small amount of money ($90) if they can prove they have faithfully taken their pills. (They use a computerized pillbox that keeps track.)
“Hopefully, through the fun of being involved in the daily process, we are helping them change their long-term behavior,” Kimmel says. “The goal of our program is to give people something that will help them help themselves through positive incentives.”
Kimmel, who is conducting an ongoing study for the NIH, says he has preliminary data that show these financial incentives do, in fact, work. He chose patients who take anticoagulants for his study because they must be very consistent and precise about the way they take their medication, and there is a lot at stake if they don’t follow through—namely, blood clots and strokes.
“It’s a complex problem, and it’s hard to solve,” he says. “Pretty much anything is on the table.”
Insurance companies, such as Aetna, are collaborating with researchers like Kimmel because they feel these kinds of financial incentives might be a great solution to rising health care costs. Kimmel argues it’s much more cost-effective to give away $90 in a lottery than it is to spend more than $100,000 to hospitalize a patient who has had a stroke due to a medication error.
Changing Behavior
Research shows that financial incentive programs are a cost-effective measure. One study estimated that for every dollar spent on incentives, the per-patient savings could be $7 for those with diabetes, $4 for those with high blood pressure, and $5 for those with high cholesterol.
Several articles in the Journal of Medical Ethics, however, raise questions about whether financial incentives could mislead patients or even be construed as coercion. Furthermore, some ask whether it is fair to pay noncompliant patients to take their medications, while those who take their medications as directed get no reward for their “good behavior” (other than, of course, presumably improved health). Others wonder if patients would go so far as to start faking noncompliance just to qualify for an incentive.
But Aetna executive Ed Pezalla, MD, MPH, says he feels incentives are a valuable tool to help patients develop more consistent habits and, as a result, enjoy better health.
Poor compliance is an issue not just for cardiology patients, but for people with many different chronic diseases. Anyone with a chronic condition, from epilepsy to mental illness, would be a good candidate for financial incentives, experts say.
Noncompliance adds up to $177 billion a year in extra health care costs, according to the National Council on Patient Information and Education. Studies show one-quarter of all prescriptions written by a clinician are never filled, and patients with chronic diseases like diabetes only take their medication properly half the time.
“As the nation looks for ways to reduce [health care] spending, we need to improve patient compliance,” said Troyen Brennan, MD, executive vice president of CVS Caremark, in a statement.
Like Aetna, CVS Caremark has also partnered with researchers from such institutions as Brigham and Women’s Hospital, Carnegie Mellon University, and Dartmouth College to find ways to improve medication compliance. Financial incentives are one of the options they are exploring.
“This research will help us understand the reasons why patients do not take their medications as prescribed. We will use this information to develop effective, evidence-based approaches to improve prescription adherence,” said William Shrank, MD, of Brigham and Women’s Hospital, in a statement. “We hope this research will help us create strategies to promote wellness in our patients.”