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Thursday, December 15, 2016

Shouldn't Patients Be More Responsible for Their Outcomes?

The move to value-based medicine, which includes measurements of patient outcomes, generates heated debate on the subject of patient adherence.

Now that the Medicare Access and CHIP Reauthorization Act (MACRA) will tie doctors' reimbursement to quality metrics, including reports on patient outcomes, a growing number of doctors are angry about being held accountable for behavior that is beyond their control.

Others see it as the physician's job to improve outcomes, pointing to changes in communication style and advances in mobile apps and electronic communication that can make monitoring patient progress easier.

A recent Medscape article examined this issue, noting best practices for handling and preventing patient nonadherence. Recommendations included providing patients with reminders, ranging from phone calls to emails and texts; simplifying dosing by reducing the number of times a patient has to take a drug, and, if possible, decreasing the number of drugs they have to take; making patients an active part of treatment by soliciting their input (for example, on reactions to medications); showing patients the importance of investing in—and taking—medications (as many would rather spend their money elsewhere); and improving patient confidence in managing chronic symptoms.

One physician advises taking a worst-case approach, assuming that patients won't comply, then building trust and setting up mechanisms for feedback. He also advocates preparing patients for side effects with an "If it stings, it's working" approach.

Responses from readers were strong and numerous, with most arguing that physicians cannot, and should not, be held responsible for what their patients choose to do or not do. Additional criticism was aimed at insurance companies, government agencies, and drug companies. But the most pointed criticism was aimed at medical leadership for failing to speak up for the profession, and to respond more forcefully to plans to evaluate physicians' performance on the basis of patient outcomes. Here's a sampling:

"Patients have free will, and some will choose to make the wrong decisions," one family physician wrote. "I have my own three children to mother. I will educate my patients, but I will not parent them."

"It seems to me that this is about controlling doctors' practices and incomes," a rheumatologist believed. "Is this about HMOs trying to profit on doctors' backs?"

"The only way to successfully practice is to go back to being doctors, charging what we consider a fair reimbursement for our services, and not blindly being minority partners in the government/insurance complex," a vascular surgeon opined.

"How is it my fault if my patient who has heart failure decides not to take his meds and eats pizza and hamburgers every day, or if my patient with five stents doesn't want to take statins and Plavix and continues to smoke?" a cardiologist wanted to know. "Are they now expecting me to check in with him every day? They certainly are not paying me to do so. In fact, they are paying me less and less."


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