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Friday Feb 27, 2015

The Folly of Judging Physicians Based on Patients' Foibles

Physicians write nearly 4 billion prescriptions(www.nejm.org) each year in the United States, yet roughly half the patients who come to us for help fail to take their medications as directed. Among older patients, the proportion could be as high as 75 percent(www.talkaboutrx.org).

Patients often suffer the consequences when they don't take their medications as directed, but so, too, do physicians when reimbursement is tied to outcomes and community metrics. This can create an adversarial relationship between a prescriber and a "noncompliant" patient, which is antithetical to the kind of relationship family physicians want to have with their patients.

I recently attended a presentation about minimally disruptive medicine(www.wsj.com), which means simply health care that is designed to meet the goals of the patient while also considering the capacity of the patient to meet those goals.

This overall concept gets at the issue of noncompliance and whether we should even use that term. Noncompliant conjures up an image of a patient who disregards our advice because he or she doesn't value it, but the truth is that any number of factors can prevent a person from adhering to a prescribed regimen, including insurance coverage, out-of-pocket costs, health literacy, cognitive issues, social problems, transportation and more.

The speaker gave the example of a 55-year-old man who had several chronic conditions, including diabetes, high cholesterol, hypertension and obesity. Due to his multiple conditions, his physician advised him to exercise, but the man had a blue-collar job that caused him back pain. That pain rendered him largely sedentary at home, which exacerbated his chronic conditions.

In addition to his physical health concerns, the man's chemically dependent daughter had moved into his home along with her children to escape an abusive relationship. And on top of everything else, the man was suffering from depression.

The patient said he was simply overwhelmed, was unable to exercise and had little time to make the office visits his physician recommended to keep his conditions in check.

We've all had patients like this. They are aware of their health problems and would like to address them but feel unable to do so. Some are merely treading water. That leaves the physician with the unenviable choice of "firing" patients or continuing to try to help them under the very real threat of financial penalties.

Payers would like patients to fit neatly into a single mold but the reality is that patients need an individualized plan that fits their needs. Progress in addressing chronic conditions -- even if it's just baby steps -- should be valued rather than discounted, and physicians should not be penalized for being unable to force a patient with multiple chronic conditions to make miraculous improvements in the face of a litany of obstacles.

I had a patient whose hemoglobin A1c was 14. We were able to bring that number down to 10, which is a significant improvement. But from a payer's perspective, it wasn't good enough because my community metric is 8.

Using these types of quality measures across the board has unintended consequences, and physicians are being punished unfairly for failing to live up to these expectations. Drawing a line in the sand and saying, "Meet this number," fails to recognize the value of the work primary care physicians are doing to reduce the burden of illness and costs to the health care system if a patient happens to land slightly outside an ideal target area.

Being sick is emotionally, physically and financially hard on patients. We need to look at how we can partner with patients and individualize their therapies so they can make progress toward health goals that make sense for them -- not just for us and certainly not for payers.

Lynne Lillie, M.D., is a member of the AAFP Board of Directors.

Posted at 04:11PM Feb 27, 2015 by Lynne Lillie, M.D.

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