Should Patients Be Paid for Medical Compliance

A June 13th article in The New York Times discussed a pilot program in Philadelphia where patients on anti-clotting medications such as Coumadin can win a small sum of money if they take their medication. Insurers and government agencies are also looking at innovative ways to create an incentive for patients to follow their doctor's orders. According to Pam Belluck in The New York Times article, at least one-third to one half of all patients do not take medication as prescribed and one quarter never even fill the prescription. Think of that!

As a physician I find that degree of non-compliance stunning. As all parties look desperately for ways to cut down on the enormous costs of health care in the U.S., it is not surprising that paying patients to stay healthy has become an option. By encouraging patients to stay healthy, it may be possible to avoid emergency room visits, eliminate surgeries or other expensive interventions, cut down or avoid hospitalizations and maybe eliminate some of the unnecessary trips to the doctor. Some insurers are paying for membership in health clubs and gyms. Can paying for healthy food choices be far behind?

While any program that succeeds where others fail, especially in the fraught area of soaring health care costs, should be applauded, there are possible unintended consequences for this novel approach of offering carrots to wayward patients. The "big brotherish" overtones of this program makes me wonder where we lost the concept of individual responsibility. For those patients who are mentally handicapped or those who are incapacitated by poverty or illness, any outreach and support makes sense. But do we really want to assume such a proactive stance when it comes to the majority of our citizens? We now have nurses going to homes, giving weekly telephone outreach, and transporting patients with chronic medical problems to doctor visits. Again, for those patients who are unable to access the medical system, this makes sense. But as with any program with good intentions, the risk of creating a passivity and childlike dependency is real. All these outreach efforts have enormous administrative costs.