Patient "Skin in the Game" Has Its Limits: The Assymetry of Patient Cost-Sharing Incentives

The Disease Management Care Blog always thought that the upsides and downsides of patient "skin in the game" was "symmetrical."  Writing in the Oct 24 issue of JAMA, Kevin Volpp and colleagues point out that that may not be true and that patient economic incentives may not necessarily work as intended when it comes to Choosing Wisely. 

Rather, economic incentives can be asymmetrical.

In other words, it's commonly thought that if increasing patient out-of-pocket cost for a drug (for e.g., an unproven brand-name drug) or unnecessary health care service (for e.g., antibiotics for uncomplicated sinusitis) decreases utilization in a population by a certain amount, it should stand to reason that decreasing the cost (for e.g., for a cholesterol drug) by the same amount would correspondingly increase utilization (for e.g., among heart attack patients). 
 
According to Dr. Volpp and colleagues, it doesn't work out that way.  Research has shown that increasing out-of-pocket costs can readily prompt patients to defer testing or treatment.  However, the converse is less true: decreasing out of pocket costs has limited impact on incenting patients to embrace testing or treatment.

Reasons include:

1) persons are generally more sensitive to financial losses than to gains (especially when those gains are intangible savings).

2) when it comes to drugs, a decreased or absent co-pays every 30 or 90 days has little impact on the daily decision to take a pill

3) increases in cost dissuade patients that already want a service or medication; decreases target a different population of patients who are not engaged and are already paying nothing.

Implications for the population health management industry and the patient centered medical home: coaching patients to take their medications or to pursue needed testing may require significantly different approaches depending on out-of-pocket co-pay arrangement.   Patients are more likely to view cost sharing as a barrier, while those with little cost-sharing may benefit from additional incentives.

What Population Health and Care Management Needs to Know About Getting People to Take Their Pills

Suspecting that the poorly controlled [insert name of chronic condition here] is the result of not taking the medication as prescribed, the doctor says: "Remember to take the [insert name of pharmaceutical here]!"

After silently concluding that the benefit of the medicine is less than the cost, hassles, side effects and long-term risks, the patient thinks "Like hell!"

That scenario has probably been played out thousands of times today in clinics across the United States.  According to Zachary Marcum and colleagues writing in the May 22 JAMA, that's costing $100 billion a year. 

Doctors like the Disease Management Care Blog have responded to "medication nonadherence" with entreaties to take the pills as prescribed. When docs take the time to address the issue with patients, research shows it can make a positive difference.

Marcum et al believe physicians can do better if they understand the six types of behaviors that lead to medicines going unused:

1. Insufficient understanding of the link to health and well-being

2. A decision that the benefit is exceeded by the costs.

3. Complexity of the medication management overwhelms the patient

4. Inattention (or what the authors describe as low vigilance)

5. Irrational or conflicting beliefs about medicine

6. Perceived lack of efficacy

What does the population health management service provider community need to know about this?

1. There are a variety of screening surveys that can be used to identify each of the patterns above; unfortunately for DMCB readers, however, there is no single survey that can do it all. 

2. There is also no single intervention that has been shown to consistently increase medication compliance.  Instead, multiple concurrent supports are needed, including education and behavioral support.  This paper by Ho et al echoes that assessment, pointing out that there is ample evidence that other valuable supports include reducing the number of pills, use of special containers, telemonitoring with interactive voice response, non-physician (nurse or pharmacist) one-on-one involvement and regular clinical follow-up with reminders.  Last but not least this paper in the Annals points out that reducing out of pocket patient costs can also make a difference.

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