In seven years of working on CDC grants focusing on improved care of metabolic diseases like diabetes and high cholesterol, I’ve come to think that two broad factors determine the success or failure of chronic disease management. First, doctors must overcome clinical inertia, the phenomenon in which the doctor and the patient follow the easier path in the encounter and generally leave things as they are rather than stop, start, or adjust therapy when indicated. As many as 85% of visits for high blood pressure are affected by clinical inertia, meaning that medications are not adjusted when the patient’s blood pressure, symptoms, or labs indicate that they should be.
Second, patients who are prescribed therapy must adhere to it. Only about a third of patients two years removed from a diagnosis of heart disease are still taking their cholesterol medications, for example, and only about two-thirds of patients with hypertension take their blood pressure medications on any given day.
One of the most significant predictors of medication adherence is cost. High-deductible plans, the old Medicare “donut hole,” high copays, and expensive branded medications have all been linked to lower adherence rates. One potential solution to this problem is good coaching by the physician and better choice of drugs at the bedside, driven by the physician’s intimate knowledge of medication costs. But do doctors really have a grasp on medication costs? A recent study (paywall) suggests, to no one’s surprise, that they do not.
Investigators sent a survey to 900 outpatient physicians (300 each of primary care, gastroenterology, and rheumatology). A mix of 374 responded. The survey contained a hypothetical vignette in which a patient was prescribed a new drug that cost $1000/month without insurance. A summary of the fictional patient’s private insurance information was provided, including her deductible, coinsurance rate, copay, and out-of-pocket maximum. Doctors were asked to estimate the drug’s out-of-pocket cost at four time points in a theoretical year as the patient’s cost-sharing changed due to other medical expenses.
Overall, 52% of physicians could accurately estimate costs before her deductible was met, 62% accurately used coinsurance information, 61% accurately used copay information, and 57% accurately estimated costs once she met her out-of-pocket maximum. (This performance actually exceeded my expectations. Prior to my exit from daily clinical medicine and entree into the benefits game, I think I would have failed most of these tests.) But only 21% of respondents answered all four questions correctly. The docs’ ability to estimate out-of-pocket costs was not associated with their specialty, attitudes toward cost conversations, or other clinic characteristics.
We need to acknowledge that this is a feature of the system, not a bug. Doctors are not trained to be HR professionals. They’re forced into the role. To quote Malcolm Gladwell:
I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we've made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.
Many people in the health care industry want the system to stay complex and opaque. That’s why large groups like the AMA and AHA are fighting some of the rules that have come about in the past couple of years. But I hope that your instincts match mine. We have myriad reasons to simplify insurance coverage, but I’ll start with two:
First, by reducing cost and administrative burden, we can make patients more likely to adhere to helpful therapy.
Second, if we can make the system more efficient by eliminating administrative complexity, we can leave doctors, nurses, pharmacists, allied health professionals, mental health professionals, dieticians, and others the brain power to do the work they were trained to do.
We hope you have a happy holiday season!
As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.