Non-compliance, No Pay?

Looks like politics will keep on giving me food for thought to a while.

This week President Obama made his case for the healthcare overhaul in a state close by (he was in NC) and I wish I could have made the trip to ask some questions. For the most part I am ALL for a major overhaul. I also admit I have my own biases having grown up in a country with universal healthcare until the age of 15 when we moved to the United States. I am well aware of the benefits and pitfalls. I am also well aware that President Obama is not trying to turn this country into a socialized medicine system as many people fear, but is simply trying to have another option in order to expand coverage throughout this country.

One interesting statement during his talk caught mine and my sister’s ears (we are both physicians). There was a statement referring to Medicare not being used to pay for care when patients are re-admitted to the hospital for the same reason within a particular span of time. It was likened to a car that is fixed at the mechanic’s, only to be taken back a week later with the same problem.

Here is where we became incensed.

No, not quite the same as that car, Mr. President. It is more like this: you DRIVE your car over a motor cross and bang it up, then take it to the mechanic’s to have it fixed, then go BACK to the motor cross and bang it up again… Not quite the same thing. I am an endocrinologist; my sister is an infectious disease specialist. Yes, the treatments within both of these fields are by no means perfect. But they are often based on good outcomes data and are hugely reliant on patient compliance, similar to all other non-surgical specialties. The methods used by my surgical colleagues can be compared to that original story of car and the mechanic, but specialties where the intervention is recommended by the doctor and actually PERFORMED by the patient is more like the second example.

You all know what I mean. The revolving door of non-compliance is enough to have you tear your hair out on a standard outpatient clinic day when more than half your patients are either not taking the medications prescribed, or not taking them correctly (sometimes on purpose.) Gracious, if I were paid only when my patients with diabetes took their medications all the time and then were perfectly healthy, I would NEVER get paid.

I am sure this aspect of the current healthcare plan will be revised, so I am not worried about that. However it did make me think about how we measure our success with our patients, and who is to blame when the treatment course does not go according to ideal plan. Again, the surgical specialties are omitted from this discussion because for the most part those physicians essentially enforce the change needed. We cannot do that in any field of internal medicine where only non-surgical interventions are the mainstay.

I do feel a sense of failure when my patients return with out of control hemoglobin A1C level, LDLs through the roof, or having had a serious event like a stroke since their prior visit. I comb through their prior visits to see what I could have done better. The funny thing is that I always find that I tried, and tried hard. We all do this: we educate, we try to instill a healthy sense of fear and personal responsibility without preaching or becoming paternalistic. Sometimes we get annoyed, sometimes we despair, but we do try. Some patients end up feeling like your personal “project”, like the boyfriend in high school you thought you could “change” or the wayward friend you felt you could “save.” In the end though, just like with any adult, it comes down to the patient himself/herself doing the actual work involved in medication compliance (assuming we are doctors have done our jobs I guiding and recommending the best appropriate treatment).

So I agree it is a partnership with both sides holding a big piece of the responsibility pie. As long as I do my part, compliance will continue to be the biggest hurdle I encounter in my practice of medicine. Not sure how to get through this besides plugging away as I do every time. Suggestions are always welcome. Suggestions? Suggestions out there? Anywhere?

Let’s hold off on docking anyone’s pay until we hear all of these suggestions…