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Derek Lowe The 2002 Model

Dbl%20new%20portrait%20B%26W.png After 10 years of blogging. . .

Derek Lowe, an Arkansan by birth, got his BA from Hendrix College and his PhD in organic chemistry from Duke before spending time in Germany on a Humboldt Fellowship on his post-doc. He's worked for several major pharmaceutical companies since 1989 on drug discovery projects against schizophrenia, Alzheimer's, diabetes, osteoporosis and other diseases. To contact Derek email him directly: Twitter: Dereklowe

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June 15, 2010

Paying People to Take Their Medications

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Posted by Derek

Now here's an idea to think about: improving patient compliance for their prescriptions by paying them to stay on track. The article goes into some of the benefits and potential risks - for example, some people will deliberately act like noncompliers in order to get on the pay system.

But in general, lack of compliance in taking prescribed drugs is a pretty big problem. And fixing it takes more than exhortations or appeals to one's better nature:

“We’ve made our best efforts to say, ‘If you didn’t take your beta blocker or asthma medicine, you have a greater chance of ending up with a heart attack or dead or hospitalized,’ ” said Dr. Lonny Reisman, Aetna’s chief medical officer. “It’s going to take more. It’s going to take incentives.”

I'm just glad that the insurance companies are taking the lead on this one. I can imagine the press a drug company would get for suggesting it.

Comments (30) + TrackBacks (0) | Category: Business and Markets


1. ex-Pfizerite on June 15, 2010 11:52 AM writes...

There is or was a program in the third world called DOTs where a nurse would observe the taking of anti-tuberculosis medicine to help prevent the occurrence of drug resistant strains. I think that in some countries the patients were paid a small fee after taking the dose of medicine.

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2. Bob in FWB, FL on June 15, 2010 11:58 AM writes...

I kinda would think not ending up dead or hospitalized would be enough of an incentive, but obviously it isn't. And I think it's interesting that we can't get folks to take medicines for very real and potentially fatal issues, but folks will fall all over themselves, and risk some seriously funky side effects, to take medications for equally real but far less threatening conditions.

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3. Sili on June 15, 2010 12:29 PM writes...

A problem is farming as well, unfortunately.

I minority, I think, but some do hoard away antibiotics instead of finishing the course in order to avoid having to call out a vet another time. Fucktards.

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4. mirro on June 15, 2010 12:55 PM writes...

I wonder if this also works on the long term, and if there is a possibility to cheat.

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5. Annette on June 15, 2010 1:05 PM writes...

Kind of embarrassing that adults have to be bribed to take medications.

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6. Carovnik on June 15, 2010 2:08 PM writes...

Paying for medicine that has society-wide effects (like antibiotics) yes.

I have some friends that work as doctors and they usualy say that the price incentive is the key for compliance. If you would have to pay for you medicine you would comply with the treatment protocol. But how to balance that with the fact that not everybody has the means to pay for medicine is an another point.

IMHO, paying people to take something that helps them as individuals is maybe smart but in no possible way moral (or fair to people that do take care of their illness).

Maybe the answer is to deny repeated non-compliers their medicine for free for a fixed period of time?

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7. RKN on June 15, 2010 2:53 PM writes...

We'll need another arm in phase trials if this goes thru - drug, placebo, drug with pecuniary incentive. Could be that the last group does significantly better than the first.

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8. VictorS on June 15, 2010 7:13 PM writes...

I wonder how the results were affected by experimental design. I read yesterday that they'd used recording pill bottles that noted whether they'd been opened that day. That alone could boost compliance, exclusive of incentives, if people can readily determine whether or not they've taken their medications.

As for Annette's comment: I'm sure lots of people will feel that way. Should we design health policy around the way we wish people might behave, or the way that they do, in fact, behave? It looks like the latter option is also cheaper and more effective overall.

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9. hn on June 15, 2010 7:56 PM writes...

If I was paid, I'd definitely exercise more and eat better.

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10. Anonymous on June 15, 2010 8:13 PM writes...

What about paying people to not take medication? For example, when you are healthy you build credits that can be applied to pay for healthcare/drugs later in life. This would provide an incentive to be healthy and could reduce the burden on the healthcare system. Don't ask me who will pay for it, I am not that brilliant.

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11. Jose on June 16, 2010 12:28 AM writes...

DOTS (directly observable treatments) is still going strong under several names, around the globe,and in many developed countries as well. Carrot schemes are generally discouraged, but the stick (incarceration, as in S Africa) is pretty common due the the potential spread of MDR and XDR strains.

The societal public health aspect of TB makes it a little different from paying John Q Public to take his Plavix, however.

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12. cliffintokyo on June 16, 2010 2:52 AM writes...

#10 Like millions of other people, I am a dedicated discount-card checkout-points collector-fiend; I really LIKE your idea!

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13. cliffintokyo on June 16, 2010 2:59 AM writes...

#9 "HON?"
More exercise? Nah! If you were paid, you could afford to drive to the deli!

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14. Anonymous on June 16, 2010 3:22 AM writes...

I find this ridiculous. If some people would prefer not to take their medications, why should we pay for them to take it? And they are talking about economic benefits? Seriously? Should we also pay money to people who would like to commit suicide but would be willing to live if given money for it? Sure, it could have economic benefits (they keep paying tax), but that isn't what matters here.

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15. Evorich on June 16, 2010 5:00 AM writes...

Anonymous - because the effect of the extra illness they create costs their insurance companies, and subsequently us in our premiums, more than if they'd just taken the drugs! It's not complicated! (And suicide is not at all a good analogy, unless you were to suggest that life insurance companies should start paying that incentive!)

In a similar vain, the UK NHS is planning on paying people to give up smoking.

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16. dani147624 on June 16, 2010 5:26 AM writes...

(Just so that we don't confuse who is who, I will write from this name from now on. I'm the author of comment #14, but not #10)
I think this shouldn't be an economic question. The priniciple behind it is what I don't like. People shouldn't be paid to do things such as taking medicine, or give up smoking, no matter how much benefits would it have.
If we start paying for people to stop smoking, what comes next? Should we also pay so that they eat healthy food? Or for dressing up in warm clothes when they go outside?
I live in Hungary, and hope these things will never be introduced here.

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17. John on June 16, 2010 7:01 AM writes...

Maybe we should formulate everything as raspberry-flavored chewable tablets. I like those littel baby aspirins!

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18. torrilin on June 16, 2010 7:04 AM writes...

I kinda would think not ending up dead or hospitalized would be enough of an incentive, but obviously it isn't.

For the typical patient, that isn't the situation. At all.

On a lot of drugs, a doctor will just prescribe. For them, it's fast and easy, and doesn't take much thought. So you take the scrip to a pharmacy and... it's an every 6 hours pill that must be taken with food, but not milk. And you've got another that's every 4 hours, and must be taken on an empty stomach. And your inhalers will have some other schedule. And you're only 8, so that means you have to go to the school nurse for every dose, and you need a note from your teacher for it, every trip.

Not so surprising that kids tend to be very noncompliant. And that's assuming the drug is dosed right, and the kid isn't throwing up an overdose every day an hour after lunch. And that the mom remembers to send in snacks, so the with food medication gets taken correctly. And assuming the kid doesn't have to argue with the teacher every day to get the damn nurse's pass.

For adults, a complex medication schedule like that might last a few weeks. But it ends up sufficiently difficult that at least one or two doses are going to get missed habitually. And then their doc scolds them. And they're annoyed, because they're busy people, and it's a complex schedule and it doesn't fit with anything.

For most people with a chronic illness, that's a simple schedule too!

Generally, a pay incentive won't make much difference. The dose schedule needs to be something the patient can maintain. Period.

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19. Ltw on June 16, 2010 8:41 AM writes...

Posting as a consumer rather than a chemist, maybe you could design withdrawal effects from all drugs to encourage compliance? Suddenly running out of anti-depressants (SNRI in my case) is *really* unpleasant. Not something you do twice.

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20. Ltw on June 16, 2010 8:48 AM writes...

Hopefully no one will take that seriously :) but it's worth noting that some treatments are self-enforcing. The sweet spot is it makes you feel bad but doesn't kill you if you stray - so you can learn from the mistake.

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21. Lu on June 16, 2010 10:54 AM writes...

As for patient compliance, I found that travel-friendly packaging works wonders for me.
Some birth control pills have awesome packaging: a flat little box with blister inside which I can drop in a purse. A blister has days of the week imprinted on foil so I can track my pills.
I wish more medications were packaged like this. Those huge half-empty bottles are so inconvenient...

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22. Vader on June 16, 2010 11:29 AM writes...

Once you've explained to a grown adult what the consequences likely will be for failing to take his medication, you've done all you really should. Any other approach, however well-intentioned, is fraught with the peril of unintended consequences.

I find it interesting that adults who have to pay more of their prescription costs tend to be more serious about taking the prescription. It gets me thinking about what it means to be a grown adult. Perhaps we have so many safety nets in place already that the problem is a shortage of grown adults?

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23. CR on June 16, 2010 12:04 PM writes...

6. Carovnik on June 15, 2010 2:08 PM writes...

"I have some friends that work as doctors..."

Are they doctors, or only work as doctors? Is that like staying at a Holiday Inn vs. being a real doctor? Sorry, couldn't resist.

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24. formerlawyer on June 16, 2010 1:28 PM writes...

to Torillon

It may be as simple as having children hold their head in a particular position. See:

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25. torrilin on June 16, 2010 1:45 PM writes...

I fail to see how a different pill swallowing method changes the kid needing a note from the teacher at least 2-3 times a day and needing an extra snack sent in from home every day.

Teachers regularly blame kids for "not taking their medicine". It's also pretty common for teachers to tell students that they have a policy of no students are allowed notes, for any reason. And it's generally going to get a kid suspended or expelled if they try and keep a stash of their medications on them, so they can take their pills on time.

(don't even *ask* about snacks in class...)

If you want people to comply with a medication schedule, it has to be possible to actually take the drugs.

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26. formerlawyer on June 16, 2010 2:54 PM writes...

Oh, I agree. The media have been replete with examples where kids were arrested for say, Tylenol in the school. Zero tolerance policies in the "War on Drugs" have gone amuck!

Part of this may also be the loss of school nurses due to budget constraints or fear of liability issues. After all if you don't provide a "service" people can't complain! (Until the lawyers get creative - that is)

And yes, I won't talk about snacks in class....

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27. cliffintokyo on June 16, 2010 9:12 PM writes...

#22 Vader
I agree with your first point, which seems to be a sensible statement of the reality, but if your second comment is correct, why is non-compliance an issue in the US - usually claimed to be the country where patients pay the most for their meds?

["I find it interesting that adults who have to pay more of their prescription costs tend to be more serious about taking the prescription."]

#14 also provided a good comment that is complementary to your first point.

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28. Anonymous on June 17, 2010 12:11 PM writes...


My second point was a misreading of Carovnik. I misunderstood him to be saying that he had actually observed that patients paying for their medicine are more likely to take it.

But I don't know that the original link compared compliance across countries with different payment schemes. In other words, I don't know whether compliance is greater here than in, say, England, or not.

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29. Jonadab the Unsightly One on June 21, 2010 5:46 AM writes...

> We'll need another arm in phase trials
> if this goes thru - drug, placebo, drug
> with pecuniary incentive.

Make that four: placebo with no monetary incentive, drug candidate with no monetary incentive, placebo with incentive, drug candidate with incentive.

Any bets on whether the two placebo groups perform differently?

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30. Jonadab the Unsightly One on June 21, 2010 5:57 AM writes...

> the extra illness they create costs [everyone]
> more than if they'd just taken the drugs

I've got an answer for that one: insurance companies could just write it into the contract that if it's been shown that you were non-compliant about taking your prescribed meds, your coverage is reduced. Expensive stuff is no longer covered, because you didn't take your own health seriously.

I'm not sure American society could be talked into this one right now, but it does put the consequences back on the head of each individual for their own actions. (Of course, there's the question of who determines what exactly constitutes non-compliance, which could be a somewhat thorny problem to address.)

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