The following article from the fall 2014 issue of Changing Business, the research magazine of the Johns Hopkins Carey Business School, describes a research paper in which Assistant Professor Emilia Simeonova shows that innovations to help patients follow medical plans often overlook the role physicians play in the post-prescription process.
You might think no one would notice or care if you skipped a drug dose or failed to fill a prescription. But sicker patients translate into higher expenses, so insurance companies care a great deal. And many are willing to pay big bucks to make sure you take your medicine.
Businesses have been churning out high-tech innovations to help the health care industry encourage patients to stick with their treatment plans. Think weight loss incentives, apps to promote timely insulin injections, and chips implanted into pills that transmit a signal confirming they have been swallowed. Products are even available to help insurers predict how likely you are to take your meds based on factors such as home ownership, job status, and credit card purchases. Insurers could use the information to adjust your rates or to offer incentives that motivate you to follow your doctor’s orders.
Problem is, most incentives assume the patient is solely responsible for following a treatment plan and ignore the potential role of physicians, thus missing an opportunity for more effective ways to keep people healthy, says Johns Hopkins Carey Business School Assistant Professor Emilia Simeonova.
“There is no scientific basis that compliance is entirely due to just the patient,” says Simeonova, who with colleagues Sergei Koulayev of the federal Consumer Financial Protection Bureau and Niels Skipper of Aarhus University in Denmark has written a working paper titled “Can physicians affect patient compliance for medication? Evidence from a large-scale study.”
Why don’t patients always take their pills? Simeonova and her co-authors, figuring the answer would help the incentive designers better pinpoint how to intervene, set out to explore the significance of patient and physician factors when it comes to medication adherence.
U.S. evidence is limited because data are generally available only from pharmacies, hospitals, or insurance companies. So the team turned to Denmark, whose universal health system made possible a data set that includes every adult who took at least one of four common prescription drugs (ACE inhibitors, beta blockers, statins, and oral anti-diabetics), every physician who prescribed them, and each of the 15 million sales of prescription drugs in those four categories in Denmark over a seven-year period. Denmark’s electronic monitoring system enabled the researchers to track individual prescriptions, patients, and physicians, and to correlate adherence rates with age, gender, education level, and other factors.
Labor economists pioneered a statistical method — “large-scale two-way fixed effects estimation”— to tease apart worker and company factors in their studies of the labor market. In a move new to health economics, Simeonova and her colleagues applied the method to their data, analyzing to what extent patients, doctors, and drug types matter in patients’ decisions about taking medicine. What the researchers found is that while patient factors play the largest role, some 30 percent of the patients’ decision-making process is attributable to physician factors. Moreover, the research team discovered that compliance changed over time even when a patient stayed with his or her doctor. This suggests that the patient-doctor relationship evolves like any other and those developments trigger variations in whether patients follow doctors’ orders. It makes a difference, for example, whether a physician explains how a drug will help the patient or how to handle potential side effects.
Simeonova and her colleagues recommend that before policymakers tackle medication-compliance issues and businesses design the next generation of incentives, they need better evidence showing what is really behind patients’ decisions to take or skip medication. The researchers argue that patient incentives alone will not help compliance rates reach their potential, and urge the development of incentives for physicians as well. To address the adherence variations that can occur during the life of a doctor-patient relationship, they say, doctors need inducements to maintain communication with their patients and to track their behavior over time. So electronic medical records and monitoring systems would likely be important tools.
The findings provide important insight into some long-held assumptions, Simeonova adds. In the United States, a strong correlation exists between socioeconomic status and health outcomes, part of which can be traced to differences in compliance rates. Studies indicate that people on the lower end of the socioeconomic scale tend to be less committed to treatment plans. Policymakers therefore often draw the conclusion that people will become healthier only after poverty is eradicated.
“What we’re saying is that another way to address this difference in adherence and patient outcomes is to give physicians the tools and incentives to address it, because it does appear that physicians can do something about this,” Simeonova says. “It’s easier to change physician behavior than to lift an entire population to superior health self-management.”
— Rachel Wallach