IMBUNATATIREA COMPLIANTEI

From Medscape Business of Medicine

Best Ways to Deal With Noncompliant Patients

Mark Crane, BA

Introduction

Once you've figured out what's ailing your patient, the real challenge is convincing him or her to follow your advice. Only half of all chronically ill patients take medicines as directed, and many don't even bother to get the prescription filled, according to a 2003 World Health Organization study.

Beyond that, many patients refuse to make recommended lifestyle changes that can improve their health.

Noncompliance is dangerous for the patient and frustrating for the physician. As more insurers and Centers for Medicare & Medicaid Services (CMS) promote pay-for-performance programs, physicians will potentially be scored and reimbursed on the basis of patient outcomes -- meaning that noncompliant patients could drag down doctors' scores.

Patient refusal to follow a treatment regimen also affects the nation's healthcare system. "The cost of patient noncompliance is easily in the tens of billions of dollars a year in needless complications and hospitalizations," says David B. Nash, MD, MBA, an Internist and Chairman of the Department of Health Policy at Jefferson Medical College in Philadelphia, Pennsylvania. "If we could improve compliance, we'd be well on our way to fixing the healthcare system regardless of what reforms are ultimately passed."

Up to 11% of hospital admissions, 40% of nursing home admissions, and about 125,000 deaths a year are due to noncompliance with prescribed medication regimens, according to the American Pharmacists Association. As former US Surgeon General C. Everett Koop once lamented, "Drugs don't work in patients who don't take them."

Economic Woes Increase Noncompliance

Today's tough economy has created new reasons why more patients are noncompliant. Patients don't take medications if they can't afford them. Many patients who have lost their jobs and health insurance are forgoing prescription drugs or office visits.

"People who have lost jobs are putting off preventive care and canceling routine visits," says Rick Kellerman, Chair of the Department of Family and Community Medicine at Kansas University School of Medicine in Wichita, Kansas, and past president of the American Academy of Family Physicians (AAFP). "That creates long-term potential for conditions to develop into more serious illnesses."

On the basis of widespread money problems, physicians should take the time to ask about a patient's financial circumstances that can affect compliance.

"Patients are often reluctant to tell physicians that they've lost a job and can't afford medicine," says Kellerman. "Perhaps it should be part of a standard history to inquire about whether they might have trouble filling prescriptions or returning for follow-up care."

It's especially important to counsel patients about dosage when money is tight because some patients split pills to make them last longer. Physicians can also provide free samples, substitute generics whenever appropriate, and refer patients to pharmaceutical company or government assistance programs.

 

Physicians face 2 chief noncompliance challenges: patients who can't comply due to financial reasons, and those who don't want to make the effort to lose weight, test their blood sugar, or say no to harmful lifestyle choices.

For doctors, it's vitally important to take time to tell patients why the treatment is necessary.

"As many as 1 in 5 patients don't fill the original prescription because the doctor didn't convince them that they really needed it," says Kellerman. "It takes time to sit down with the patient and make sure they have all the information they need, but currently, the reimbursement system and shortage of primary care doctors doesn't make that easy."

"There are multiple reasons for noncompliance," adds Donald J. Palmisano, MD, JD, a vascular surgeon/attorney in Metairie, Louisiana, and former president of the American Medical Association (AMA). "Patients may not understand what you told them. I typically ask the patient to repeat back to me what it is he's supposed to do. It's important to explain that if the patient doesn't take the medicine, he's at increased risk for stroke or some other illness.

"If I suspect the patient is unclear, we give written instructions and may follow up with phone calls. It's important to know if the patient is able to read. I've been amazed over my career at how many patients cannot," says Dr. Palmisano.

Patients need to know what the drug is and how it works in terms that are understandable to them. How and when should they take the drug? For how long? What side effects can be expected? What are the consequences of stopping the medication? If doctors can answer these questions, it's far more likely that your patients will follow your advice.

Depending on your practice workflow, it may be useful for a medical assistant or nurse to discuss the prescription with the patient. He or she can stress the importance of the prescription and make sure the patient understands what is expected.

 

Technology Can Help Promote Patient Compliance

Type the words "patient compliance" into Google and you'll get 3.7 million hits, mostly from vendors eager to sell you programs to encourage patient compliance. Some of them can be helpful.

The solutions take the form of patient education, reminders, and ongoing monitoring, including call centers, email reminder programs, computer programs, high-tech packaging, and other tools to remind patients of dosages and refills.

As electronic health records and e-prescribing grow, these technologies help physicians and health plans determine whether patients are taking their medications. Horizon Blue Cross Blue Shield of New Jersey, for example, is working with Merck & Co., Inc. to send text messages to physicians, informing them of patients not filling their prescriptions. Another program, supported by Pfizer Inc., provides automatic voice mail reminders to patients, replacing mailed notices.

Electronic alerts have proven helpful and effective in encouraging patients to get screening and treatment for dyslipidemia. A report published in the January 2008 issue of Circulation described a randomized controlled trial in which investigators from The Netherlands found that 65% of patients who received electronic alerts were screened vs 35% of patients who had inquired by themselves.[1]

Numerous new high-tech devices can help patients remember when to take their pills. Some offer subscribers a reminder service via a pager or other wireless device. MedivoxRx Technologies Inc., in Pittsford, New York, has a talking pill vial that reminds blind, visually impaired, and illiterate patients to take their medicines.

The Med-eMonitor System, developed by Rockville, Maryland-based InforMedix, Inc., combines compliance and disease management on the basis of the patient's care plan. The system includes a portable drug storage device that uses chimes to prompt the patient to take the medicine. It also asks patients whether they have taken the meds, monitors their health status by asking other questions, and records the time and date of all interactions.

The system automatically uploads the patients' information to a central database. If there is cause for concern, it triggers an outbound email, page, or cell phone text message sent to the patient's physician.

 

Companies Help With Nurse Coaches and Teaching Aids

Some manufacturers are using nurse coaches to promote compliance, especially with high-cost specialty drugs. For example, McKesson Specialty, a provider of reimbursement, distribution, and clinical services for specialty drugs, runs nurse-coach programs through partnerships with manufacturers and health plans. For drugs that require self-injection, McKesson's nurses teach patients how to inject the drug, conduct monthly phone-ins, and coordinate care.

Some pharmaceutical companies are providing physicians with practicing counseling tools to help patients.

For example, a portable teaching aid from teriparatide (Forteo®), an osteoporosis drug, demonstrates to patients how bone strength and density can improve from treatment. The teaching aid is a 3-dimensional model that replicates before-and-after treatment bone biopsies from the hip of a clinical-trial patient of the drug.

A program for tazarotene (Tazorac®) is designed to encourage teens to regularly apply the acne medicine. Messages are delivered through text messages received on teens' cell phones from a mobile "buddy" who they've selected. The program offers patients a series of incentives and rewards, such as wallpapers and ringtones, the magazine reports.

David Nash comments, "All of the new methods are helpful, but there's no magic bullet and nothing substitutes for the basics: taking the time to explain to the patient why you're prescribing the medication."

 

Should You Dismiss Noncompliant Patients?

At times, you'll encounter patients who complain endlessly about their conditions but stubbornly refuse to follow the recommended treatment.

"We doctors tend to blame, but perhaps I could have done a better job of communicating," says Kellerman. "If I have trouble communicating with a patient, I try to look at myself first. It's rare to discharge a patient unless he's disruptive or abusive to the staff."

Patients who repeatedly break appointments or don't show up for scheduled procedures may be discharged from a practice, however.

"I had a patient scheduled to have his colostomy closed," says Dr. Palmisano. "He never showed up. We had a hard time locating him. We finally did and reschedule, but he didn't show up again. He came to the ER [emergency room] a few nights later, drunk and creating a disturbance, cussing out the staff.

"I told him I couldn't continue to treat him and that it was in his best interest to find another doctor. I gave him a referral to a clinic and told him I'd be available in case of an emergency. It's rare to discharge patients, but sometimes you have to. It gives them a reality check that they cannot keep acting the same way."

Some pay-for-performance programs could lead to unintended consequences, including pressuring physicians to discharge noncompliant patients who might undermine their performance scores.

"I worry about 'cherry picking' and 'lemon dropping' in poorly designed pay-for performance programs," says Kellerman. "If I'm paid based on patient outcomes over which I don't have ultimate control if the patient is noncompliant, I could be penalized financially. That could be an incentive to drop patients who need my help the most."

"Every doctor has an obligation to do the best he can for patients," says Dr. Palmisano. "So doctors may get an extra percent or two of reimbursement if they follow certain guidelines under these programs. We have to remember that patients are individuals, and we can't let managed care or government policies dictate the ethical practice of medicine."

"All physicians can do is make sure patients have the information they need to make a rational decision," says Kellerman. "It's ultimately the patient's choice whether to accept our advice."

 

How to Dismiss a Noncompliant Patient

Discharging a patient should be a last resort only after repeated attempts to find out why the patient is disruptive or won't comply with your advice.

Physicians should personally speak with the patient to ask about any specific complaints, say malpractice risk managers. You may learn that the patient is unhappy with your treatment or office staff. These situations could potentially be corrected.

It's important to end the doctor-patient relationship carefully to avoid getting sued for abandonment or discrimination. Most liability insurers have protocols and sample letters that doctors can use to reduce their risk for a lawsuit when they discharge a patient.

It's wise to warn patients first that they'll be discharged unless their behavior changes. Document any noncompliance in the patient's chart. You should also document that you informed the patient of the specific potential consequences of failing to follow medical advice, says Dr. Palmisano, who also heads Intrepid Resources, a risk management firm in Metairie.

Send a termination letter by certified mail, return receipt requested, and keep the receipt in the patient's file. Give the patient sufficient notice that you will stop treating him or her. A month is usually adequate, but check with your insurer or state medical society for guidance.

Inform the patient that you'll continue to treat him or her until the termination date and for any emergencies that occur up to then. Refer the patient to the local medical society or hospital to obtain a list of physicians. Offer to transfer the patient's records promptly once you receive a written authorization.

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