Tuesday, November 10, 2009

A Bodyguard of Life

Harvard’s Dr. Will Shrank recently tipped us off to an important study of medication usage--that is, who takes his or her prescribed medication, and who doesn’t. This study comes out of the burgeoning field of pharmacoepidemiology and pharmacoeconomics--18 syllables of tongue-twisting, to be sure.

But the subject, polysyllabic as it might be, is no laughing matter, because it’s a matter not only of life and death, but also of economic health. Sponsored by
CVS Caremark,
the study seeks to address a puzzling phenomenon:

Non-adherence to essential chronic medications has been widely recognized as a major public health problem, according to prior research cited in numerous medical journals. One quarter of original prescriptions for essential medications are never filled, and patients with important chronic diseases such as diabetes and coronary artery disease adhere to their medication only about half of the time. Non-adherence to essential medications is a frequent cause of preventable hospitalizations and patient illness, with costs to the U.S. health care system estimated at over $200 billion annually. A better understanding of the predictors of non-adherence and strategies to improve medication use has the potential to meaningfully impact the public health.

Such findings--one quarter of prescriptions never filled, patients failing to keep their regimen half the time, at a cost to America of $200 billion--pose a serious challenge to many prevailing orthodoxies in the policy world. For free-marketers, the challenge is obvious: What is to be done when people exercise their freedom in perverse ways, by not taking needed medication? How valuable is “empowerment” when people can’t handle their power? A libertarian purist might dispute these non-med-taking findings, or shrug them off as a cost of freedom, but, either way, we all pay when people get sick. We pay for Medicare and Medicaid and other government programs, and we also pay in terms of lost economic output and productivity.

So the challenge is to figure out how to help people make better use of their own volitional power--how to get them to take their meds. The Obama administration and top Democrats would say, of course, that they have the answer, that Obamacare provides for such assistance through more efforts at developing holistic care. But here’s the rub: Not everyone trusts the government. In fact, not too many people.

So what to do? The answer is to improve on the various hybrid systems--which go by many names, including managed care, integrated care, and medical home--that encourage people to do the right thing. It’s a tricky field, because it takes us right into the murky realms of psychology, sociology, and behavioral psychology, where “unintended consequences” sometimes seem to be the norm.

And to realize, further, that the information age can be our greatest ally, if we think through how to make it work. Google, for example, has created an online flu shot finder.

Another encouraging straw in the wind was seen on ABC News Tuesday night; it seems that "World News" ran a story in Juneon a certain DNA-specific lung cancer treatment. One man, suffering from terminal lung cancer, saw the story, got ahold of the treatment, and is now cured. Which is to say, it's hard/impossible to know what message will click with what patient. So the answer is probably to try all possible messages, in hopes that one message or another clicks. (And on "World News" last night, we saw ads for Aricept, Vesical, and Medicare--a further reminder that medical information gets out to people in all different ways.)

Here at Serious Medicine Strategy, we have nothing but praise and admiration for those--including Shrank & CVS Caremark, ABC, and Google--who are working through pieces of this overall puzzle. And while we are inclined to wish that there’s an iPhone app to solve every problem--and they're getting there, as the iPhone becomes more and more tricorder like--I realize that life is not anywhere near that simple. New technology is surely a big part of the solution, but tech must be integrated into a larger system--that’s where the strategy aspect comes into play.

That’s why, here at SMS, we have invoked, here and here, the work of Carl von Clausewitz, the 19th century thinker who systematized thinking in the field of military strategy. We need the same for medical strategy in the 21st century. How do we create a system whereby all elements of our society and culture are harmonized and mobilized to achieve agreed-upon goals? There hasn't been much harmonization and mobilization in recent decades, which is why we've had a hard time getting things done.

And as often argued here at SMS, when we are confronted by a serious problem, we should do more, not less. We should push harder for a solution. We should power through.

So we might ask: What could we do to strengthen the incentive system for people to “get with the program,” without tumbling into coercion? As we were thinking about these questions, we Googled the phrase “bodyguard of lies” and got 106,000 hits.

Those words, “bodyguard of lies,” are attributed to Winston Churchill, who supposedly told Stalin in 1943, “Truth is so precious that she should always be attended by a bodyguard of lies.” The phrase became the title of a 1975 best-seller by Anthony Cave Brown, Bodyguard of Lies: The Extraordinary True Story Behind D-Day.

But here’s something interesting. We Googled “bodyguard of life” and got just six hits.

Now what does that tell us? It tells us that we have put more focus on one kind of bodyguard than the other kind. I am glad that we cloaked D-Day, for example, in a bodyguard of lies, thus taking the Nazis by surprise. And we must never lose the capacity to cloak our military operations in stealth. But if we know a lot about cloaking our miliary actions, it would appear that we are not as far along when it comes to cloaking our medical actions in a positive way--reinforcing good-health behavior.

We have much work to do. Fortunately, some of that important work is being done by Will Shrank and the phighting pharmacoepidemiologists and pharmacoeconomists up in Massachusetts.

Bodyguards of life. It would be cool if there were a best-selling book by that title, trumpeting some enormous health success, on a par with D-Day.


  1. "How to get them to take their Meds?"
    You don't. The only recourse is to shoot them ;)
    Seriously, I, at 67 yrs. take 6 different Meds daily plus 4 different Vitamins.
    Get CVS to e-mail the doctor i.e.; that Peter's prescription hasn't been refilled in 2 months. Is he dead or screwing around with his Meds? Anyway, we are canceling his prescription refills until you write us new script for him:)

    This may help!?
    Any other ideas out there?

  2. This kind of "We are losing billions of our dollars because people are not following the doctor's orders, so we can justify spending billions of dollars monitoring and controlling people (and punishing them for disobeying)." thinking is one of the many things that comes out of the idea that the government should run our medical system and our lives. As soon as they are paying the bills that means that they own us. I would rather go back to the good old days when what you paid was your business, whether you took your drugs was your own business, and if you didn't come out very well then it was your own damn fault.

    By the way, has it ever occurred to anyone that the fact that most people aren't paying their own medical bills is part of the reason that people don't value the drugs that they are given for free? Someone who just paid $250 for some pills will almost certainly take them, don't you think?

  3. Brian has some very good points.

  4. Mental Health in America is a segment of medicinal care that probably bonds with this article in a very big way. When discharged from a clinic and as a stand alone living with their family or alone in a studio apartment it is virtually impossible to know how a patient experiencing what we now know as brain disease is improvising with their medicine or maybe throwing it away. Of course in almost every case we can monitor the situation after the fact when symptoms return in a few days or when the patient becomes a ping-ponger going back to his home away from home. Needless to say this cost the tax payers a fortune and in some cases a clear danger to the patient and/or society.Two reasons a man will be adverse to medication is that virtually all anti psychotic drugs have sexual side effects. Most times this unpleasant feature can be easily overcome with one of the ED drugs.It gets more complicated, however when ego elements cause particularly younger patients to take the attitude that some other force is creating a perceived "artificial" maleness. In Bipolar cases, patients love the power trip of manic episodes where in fact they are known to be more creative and self assured and sometimes more successful on a temporary basis before the disease with out medicine becomes uncontrollable. Particularly and because there are 50,000,000 Americans who are directly or through a relative have ties to our mental health systems, monitoring medication must be conducted in a more innovative and cohesive manner because if you add it up "the screw ups"
    are costing this country a wheelbarrow full of doubloons and at any rate, the whole mental health system would implode under the initial Congressional bill.

  5. If we do the simple, needed health-care reform ... change tax treatment to uncouple health insurance from employers and make the consumer the decision-maker... it's likely that new forms of contractual relationships will develop that address this problem.

    It's very possible ... perhaps probable ... that doctors and groups will offer low-cost umbrella agreements where for, say $1 a day per person, certain basic health care needs are provided for on an ongoing basis. This system will then be linked with insurance for truly catastropic care (its original purpose). Trusted doctors would again become natural gatekeepers for care and would have the time and motivation to look after their patients, including their compliance.

    Give the free market the opportunity, and it will find the solutions.