Health Care Thoughts: Non-Compliant Patients
Health Care Thoughts: Non-Compliant Patients
Ask physicians and nurses about their biggest clinical problems and non-compliant patients will likely be near the top of the list.
And why should we care? Because non-compliant patients are huge cost drivers.
Ezekiel Emanuel (MD, PhD, NIH) estimates that one-third of U.S. health care costs are driven by diabetes, and we know a lot about controlling diabetes, but it is very dependent on the patient being compliant with diet and medications. We don’t do so well on this.
Is there something about Americans that make us less compliant than we should be? Is our consumer culture a bad place to promote health? Is there not enough information? Are we stressed into non-compliance?
Whatever the reason, it is very costly for all of us.
Tom aka Rusty Rustbelt
A healthy diet costs more.
A healthy diet costs more.
A healthy diet costs more.
“one-third of U.S. health care costs are driven by diabetes”
I’d be absolutely astonished if that were true. Might be one of those numbers worth tracking down and confirming. Diabetes costs 6% of US GDP? Seriously doubt it although love to see how the number is derived.
Let’s put it another way. US health care spending is, ish, 18% of GDP. French is 12%. His statement is that diabetes alone explains this difference.*
I really don’t think that’s likely.
I’d believe (although similarly want proof) that last 6 months of life care costs 6% of GDP, but diabetes really does seem like a stretch.
OK, so if US health care spending is 18% of GDP, one third of that is 6%. US GDP is around $14 trillion, 6% of that is $840 billion. There are, according to CDC, 19 million diagnosed, 7 million undiagnosed. These numbers give us the annual cost of treating someone diagnosed as being $46,000. Or of all, $32,000.
Erm, for most diabetics, treatment is a couple of visits to the nurse each year, a blood sugar tester and some strips. Even for insulin dependent (a much, much, smaller group) costs aren’t that high: insulin is cheap after all.
As I say, love to see where those numbers come from.
*OK, sure, France has diabetes too, but it’s not something that the numbers about the French system even mention.
Many can’t afford the meds, can’t afford prescribed medical aids, can’t afford devices, can’t afford testing supplies or can’t afford orthopedic, custom made shoes. Believe it or not, a lot of people can’t afford to not go to work when a physician tells them to stay off their feet. “Compliance” is medical industry code word that translates to “poor people and working class people insist on saving a few of their pennies for rent, food, and heat instead of handing all of the money over to us!”
The author whines, “[non-compliance] is very costly for us.” Is it as costly for your papered ass is it is for the poor schmuck for whom geting the bottom half of his leg chopped off means he won’t be able to keep his job of standing at the liquor store cash register anymore. It’s costing him everything? Will your marginally higher insurance payment or tiny increase in withholding taxes really cost you everything? Really?
Try pulling your head out of your asshole and having a look around you at real life in America some day.
Tim Worstall: “I’d believe (although similarly want proof) that last 6 months of life care costs 6% of GDP, but diabetes really does seem like a stretch.”
It does, doesn’t it?
And I am skeptical of that last 6 mos. claim, as well. I can believe it if you select all cases where people died within the next 6 months, but that biases the statistics. It will include, for instance, cases of possibly heroic efforts to save the lives of victims of violence and accidents that failed, while ignoring the cases where the victims survived and lived for decades. I also wonder if experimental treatments are included in those statistics. The cost of research is a separate issue from end of life care.
Not really.
The numbers came from the mouth of Ezekial Emanuel at a 2009 conference.
E.E. is widely regarded as one of the top expert in the country.
Keep in mind uncontrolled diabetes exaccerbates and interacts any number of conditions — cardiac, stroke, neoropathy, gangrene, etc.etc.
Ah jerkoff, I have spent much of my adult life trying to improve health care in this country, especially for the elderly.
Some people cannot afford everything they need, granted. Smearing the entire medical “industry” with your bitching tells me you are not contributing much to improving anything.
By the way, very financially comfortable people are non-compliant too, and then some of them expect Medicare to cover all the damages.
As far as the costs of the last six months, I don’t think much of the 6% of GDP either.
I do know those costs are a substantial part of Medicare costs, but estimates vary.
The have diabetes in France too timwortsal (although one third sounds high to me too).
My mom, who is the sweetest person you could ever meet, says that many of her patients are just “not qualified” to have diabetes, since they are not able to be compliant diabetes patients.
The Emanuel claim has a practical application. It isn’t just an excuse. It suggests that money could be saved (and by the way lives saved) by health coaches — people who go to patients and help them (OK and nag them no denying that). The key point is that one doesn’t have to be a nurse to do this. I read on the web somewhere about efforts along those lines which saved hospitals lots of money (by helping people stay healthy).
back to my mom. Her patients are given pill boxes. The instructions are “on monday take the pills in the little container labeled Monday, on Tuesday …”. This makes a difference compared to giving bottles with pills and written instructions which is better than giving a prescription and hoping it is filled.
The patients in question are people without health insurance who are HIV positive (that’s what my mom does).
Mom is a saint no doubt.
Hmmmm Tim:
“Twenty-five percent of the U.S. community population were reported to have one or more of five major chronic conditions:
Mood disorders.Diabetes. Heart disease.Asthma.Hypertension.
“Especially important is the increase in the number of people treated for conditions clinically linked to obesity. From 1987 to 2002, the proportion of the population treated increased 64 percent for diabetes (accounting for 80 percent of the increase in costs) and increased 500 percent for hyperlipidemia (accounting for almost 90 percent of the increase in costs).”
http://www.ahrq.gov/research/ria19/expendria.htm#diff1 “The High Concentration of US Healthcare Expenditures; June 2006
Granted this is an old report; but, it states diabetes is one of the fastest growing conditions. I would venture to say the numerics are true at the US is truly a bunch of fat butts.
rusty:
Rich people can afford to make a choice; poor people can not make a choice s the “money” is not there. The healthcare industry is pretty muh about selling services and not the selling of outcomes
“Health insurers would pay only piddling amounts to cover the cost of a diabetic patient seeing a podiatrist, for example, though such care is essential to reducing the risk of amputation. And insurers would pay even less same time, as word of the center’s excellence in diabetic care spread, patient volume increased by 20 percent a month. Soonthe center was running a large deficit, and Beth Israel administrators felt compelled to shut it down. “
It is not about you . . .
Why do you put indutry in sneer quotes? How can you possibly not look at American style, greed-driven, profit-at-the-cost-of-lives medical practice as anything but an industrial undertaking?
Thanks for admitting you’re in on the scam system. What’s that Upton Sinclair quote that’s being repeated all over the place this weekend? Something like, it’s nearly impossible to get a guy to see something that’s palinly obvious to everyone else when his paycheck depends on him not seeing it.
Only a moron–or a health industry profiteer–could convince himself that the greatest expense driver in American “health” care (see that’s what sneer quotes are for) is patient non-compliance.
According to the Dartmouth report a number of physicians have patients come in every month or so to check the blood pressure, when a cuff monitor costs less than 1 visit. (Yes it would need a cheap computer to hook up to a phone, but that does not cost a lot). So you ask folks to put the cuff on, move their arm to the right position (the monitor beeps when this is the case), take the bp, and it is sent in. The software at the physicians office, recieves the results and when some set alarm criteria are met tells the physician. All this at a cost of less than 2 office visits. (It also avoids the white coat effect, I take it for 30 days before my appointments, and give the physician the list). I suspect that for other areas similar systems could be set up. Of course in addition if we moved to physicians assistants or nurse practitioners as the primary care person, handing off cases outside their range of expertise to the physician it makes sense. IMHO we have upskilled the medical profession drastically in the last 50 years and as a result they have to charge more because instead of 5 years post college its now 8 to 9.
My mother was diabetic, Type II, controlled by diet. It would astonish me if the costs of her treatment were over £1,000 a year. Be surprised if they were over $500 to be honest.
Perhaps 4 visits a year with the diabetes nurse (what you would call a nurse practitioner) plus testing strips pretty much.
If diabetes isn’t treated, then, yes, OK, I can see how costs could soar (ulcers, gangrene, amputations, blindness, kidney failure etc etc) but even though I know that the US system isn’t all that good at preventive medicine of this kind I still don’t quite buy 6% of the country’s entire GDP.
Lyle, I like your proposal! I estimate a similar consolidation of visits solution:” Of course in addition if we moved to physicians assistants or nurse practitioners as the primary care person, handing off cases outside their range of expertise to the physician it makes sense.” For those compliant patients with their chronic conditions controlled, consolidating of visits to one physician could significantly drop physician care costs.
In my own case it would drop ~60%. In Lyle’s technology driven example it could drop another ~20% and still allow for one Dr visit per year. Lyle’s proposal also consolidates Lab Tests, and it makes one DR responsible for all the prescriptions, further lowering risk of medicine interactions saving even further. My back of the envelope estimate are a real 5-10% savings are possible.
BTW, there are a couple of positive side effects. This solution adds value to medical students to enter the General/Nurse Practitioners fields as they get the preponderance of visits and healthcare dollars. Our GP and Dr shortages could be lessened in months with this proposal. Due to reduced volume it further disincentivises Drs. from denying medicare/medicaid patients.
Finally, since this article was about non-compliant patients, using Lyle’s technology-based solution on the blood sugar meters would incentivise those non-compliant patients, and at the very least identify them when they do not report results.
Another thought about this article, if diabetes is the cause then the cause of diabetes should also be addressed. Since most understand it to be diet and life style, adding resources to prevention becomes a tremendous cost saving.
Simpler solutions were available other than the abortion that became Obamacare. But, that thought comes from a conservative who deeply believes more Government is not the automatic answer, regardless of the problem.
Note that as genome research continues more and more findings are being made of differences in metabolism between people. Some are saying that the issue is at least 50% and possibly more genetics. If you think about it in an evolutionary perspective, the problem is that we (and all animals) evolved in an environment of food scaricity. One never knew when the next famine might arrive. Now in a very short time (3 to 4 generations) we have placed ourselves into an environment where we did not evolve. The fact that dogs, cats and horses have the same problem with obesity as humans, suggest a deeper issue. Left to their own devices some dogs, cats, and horses would get very fat (see stories on fat cats and dogs …). Perhaps in 20 years if research continues then pills will exist to counteract the way some peoples metabolism works. I believe I heard from my niece who is a vet that some reptiles also show the obesity problem.
So sometimes we need to look accross species and if we see a similar problem then look for an underlying common cause. (Big point we are more animals than we like to think)
For all the angst over Ryan’s plan which makes the individual more responsible, estimating the results with a “no change” baseline is OK for estimating potential changes, but they clearly do not consider what Lyle’s and my extension to it are capable of doing to lower the out year estimates.
WaPo http://www.washingtonpost.com/opinions/why-we-must-end-medicare-as-we-know-it/2011/06/05/AGs7AmJH_story.html has an opinion piece that starts with: “Almost everyone agrees that America’s health-care system has the incentives all wrong. Under the fee-for-service system, doctors and hospitals get paid for doing more, even if added tests, operations and procedures have little chance of improving patients’ health….”
Lyle’s proposal adds incentives to patients, including compliance, and Drs to change the way we are currently seeking and delivering treatment. Those incentives have many far reaching improvements to costs and deliver of treatment compared to today. Those are clearly not factored into the CBO and other comparisons.
CoRev,
It is all about merikan’s character.
Merikans with no character ought to suffer.
Yes, thanks STR.
Have a nice day. Simply do not patronize the system. Perhaps a witch doctor.
There is penty of preventive medicine available to many (not all) Americans, but that does not keep people out of Krispy Kreme or McDonalds.
Also, after a certain age control is quite difficult no matter how disciplined the patient.
Mrs. R. is a bit grouchy this morning, she injured her shoulder this weekend trying to reposition a non-compliant patient with multiple problems who is 5’2″ and 275 pounds. The patient regularly receives deliveries of junk food from her family, which of course negates all of the care planning and professional dietary advice.
The same evening a patient threw a temper tantrum, pulled out a feeding tube (supplemental nuitrition) and sprayed her with goop. Then a patient with some dementia and a bad attitude took a swing at her. And then a patient with a long history of alcohol problems was taken to a bar by a family member on the way home from some lab tests (uncontrolled diabetic).
I see retirement coming soon, which will be a shame for the patients.
Most primary care offices with more than 3 or 4 docs have moved or are moving to PAs and FNPs. Specialists and surgeons are using PAs for many duties as well.
Mrs. R is a Saint.
My Ex is a nurse, I never lost respect for her profession and her practice of it, despite our other failings…………………………………..
rusty
D’uh puts his argument in a way you find offensive. Get over that and try to understand what he is saying.
I believe I saved my life by being non compliant. I am aware that this would not always be the case. A person has to make choices and use their own judgement. Following Doctor’s orders is not ALWAYS the right thing, and arrogance among doctors is no small health-care risk itself.
Waldmann
I believe you have the answer. Too many people with big jobs and big egos think that “non compliance” is the fault of ignorant lazy customers. It never occurs to them that there are better ways to get compliance than just blaming the victim… er patient.
CoRev
glad to be able to say i agree with you here.
but let me spoil it all by saying that “barefoot physicians” could solve a lot of the high cost of medical care, and they would probably be a lot better at knowing how to get “compliance.’
I agree with you about Obamacare also. It is tragic the dems can’t think of anything better than getting “the rich” to pay for the corporate “your money or your life’ way of doing health care.
of course it’s hard for them to think with the Repugs yelling all the time about taxes and big government.
lyle
i think you are right as to phylogenetic origins. still, you’d think we could learn to control our behavior without taking a pill for it.
oops
the barefoot physicians would require some government involvement… just as a counter to the medical industrial complex.
we need to get beyond sound-bite thinking.
CoRev
making the patient-consumer more responsible is a dishonest dodge. ordinary people are not capable of judging health care options. and most ordinary people aren’t capable of being responsible in any meaningful sense of the term.
i know what Buff will make of this statement. but look around you.
people need leadership. the American tragedy is that currently there is no honest leadership.
rusty
so much for making the patients more responsible. i would of course be in favor of letting them die alongside the road, but it’s so damn hard to tell the bad uns from the good uns.
talk to Mrs R about how she uses her body to shift a heavy weight. no need to get hurt.
Non-compliance concerning pre-diabetes and diabetes is usually about things most of us can control. The diabetes in the media is part of the end of a process that is often years in the making. With the resulting impact on the body it is a horrible way to die over time.
Non-compliance in treating diabetes is about pretty basic ideas and should not be confused with non-compliance about other medical procedures and such. Treating the resulting complications is a huge expense…treating the diabetes is pretty basic early on. But requires patience and consistency/
Shifting a patient is different from shifting a weight…depending on hook ups, the reasons shifting is necessary…and staffing patterns are such that oft times the needed manpower is simply not avaiable.
I find doctors often are horrible at ‘compliance’ meetings. Really bad, and five minutes tops is not enough. Cooperation tends to work better.
Actually it sounds like there is a nearby solution. Let cuban trained physicians practice in the us as Physicians Assistants. They know how to get by on less material than us physicians, and can take care of routine issues. Its like the issue of what happens if you get knocked out, say by a bicycle accident without a helmet. In the good old days (1950s) the dr, said keep an eye on him and bring him in if he gets sleepy. Today its a visit to the emergency room and a large bill. Is proceeding against the 1% or less case in all cases the most cost effective solution? or perhaps more watchful waiting but people are too busy for that, but have plenty of time to wait in the emergency room.
http://tpmdc.talkingpointsmemo.com/2011/06/democrats-break-down-impact-of-gop-medicare-plan-district-by-district.php
Well, to return to the nitty gritty of politics, take a look at the information provided through the link above. If your Congressperson wants to know how much hs/hr Congressional district will lose in support from Medicare/Medicaid as a result of the Ryan approach, Waxman has kindly provided the numbers.
I have said here before that cuts in benefits create decreases in the money floating around in the domestic economy. Once it’s gone, it ain’t gonna come back. So, want to know how much ordinary people around you are going to have to come up with if Ryan has his way? Then, take a look…but I warn you, it ain’t pretty, honey. NancyO
coberly,
I’m all for leadership. I’m all for bringing the horse to water. What I’m against is forcing the horse to drink. Most ordinary people ARE capable of being responsible. Most ordinary people manage to get up every day, get dressed,, get the kids out the door to school and get to work on time. I am not willing to give up my freedoms to cater to a small percent of incompetants.
“Life is tough, its tougher if you stupid.” I also beleive Darwin had something to say about this also.
What’s really funny is your worried about this and not the mass de-institutionalization of the really insane during the 70s that has continued since then. Start there.
Islam will change
STR,
Mrs R is a saint. My mom (RN) worked the ER and I always respected the litteral crap she had to put up with. I still remember coming home from college my sophmore year and walking into a ER that had just had a shootout -in the ER (gang-bangers followed the wounded to finish the fight). Wasn’t the first dead body I had seen but the first group of them…
She always told me the stories that raised the hair on the back of my neck were the tame ones…
Islam will change
NO,
It would be nice if Obama and the Dems can get a budget together. Their latest was rejected 97-0 by the Senate.
Yet we are still harping on Ryan’s already dead plan. May I ask why? And where is the President and the Dems?
Islam will change
buff
i agree with you. no horses are forced to drink on my farm.
hell, i can’t even get my kids to drink.
ordinary people are capable of ordinary responsibility. medical care is not an ordinary responsibility. and “finding a job” is not something that “ordinary” people can do if they have not happened to have the “in demand” talents and a decent education. so we have 10% acknowledged unemployment and my guess is three times that people who can’t find a job because they don’t know how, not because they are too lazy and need tough love.
as for mass deinstitutionalization, until i learn otherwise i’ll say that the crazy man who sleeps in the bushes by the river is less of a human disaster than “one flew over the cuckoo’s nest.”
Rdan
I agree with you about this and the non compliant diabetes patients. However as a person who has hurt his back more than once, I will insist that you can prevent injuring yourself unless you are actually thrown from a horse. And the exercises you need to do are of course neglected by non compliant back patients.
Buff, There is a very vulgar expression about how right you are about the Dems. I haven’t got a clue about what the Senate D’s and the President are gonna do. The Dems work for the same guys the R’s work for. Kinda takes away the old New Deal zeal. All I can say to this President is, If you don’t want to be responsible for a mess, don’t get in there and comprimise away everything BEFORE you even begin! Oh, here’s a clue about the expression–starts with No and ends with Sherlock. NancyO
So when a diabetic ignores the rules he/she knows from extensive counseling and education, it is the physician’s fault? Society?
Mrs. R is well trained and has worked for decades without a major injury, but sometimes urgent trumps safe.
Got to go shopping with Mrs. R today (eyes rolling) and she regaled me with her recent adventures (names changed to protect whatever).
Mrs. R: Doris, you should skip dessert. You blood sugar reading is way too high.
Doris: I want a piece of pie.
Mrs. R. Doris, your blood sugar is 440, the doctor has ordered 10 units of fast acting insulin, you should really skip dessert.
Doris: I need a piece of pie.
Mrs. R: By rights, you should be in a coma. You blood sugar is very high. Can I get you some sugar free candy?
Doris: I love pie.
Mrs. R: mumble, mumble, mumble, bleep. bleep (not in front of the patient)
With administration of both fast acting and slow acting insulin Doris had her pie and did not go into a coma.
Rusty
i understand. sometimes just lack of attention trumps safe. but i was also making the point that people who have had a back injury are often non compliant when it comes to doing the exercises that would help them prevent having another one.
Rusty
I know people like that. I used to know people who said they knew how to teach people like that to control their behavior. Mrs R is a saint, but her behavior modification technique.. in your example.. is , ah, unsophisticated.
yep, I know. why don’t they just do what they are supposed to do.
coberly:
Try getting the information to make a cost decision on treatment wen you are ill. You can’t .
str,
Its the diabetic’s fault – no one else. Following a physician’s directions are ordinary responsibilities. If you actually can’t do that (as oppossed to too lazy to do it) you shouldn’t be given the keys to a car.
I’m not in coberly’s league where the vast majority of our fellow citizens are too stupid to tie their own shoes without having the ‘wise elders’ tell them when and how.
Islam will change
coberly,
They should. Doris is basically attempting to commit suicide by pie. Given the fact pattern str laid out that is the only conclusion. Many ways to kill yourself and this Doris seems to have decided to do ‘death by sugar’. Has the benefit is that you can deny trying to commit suicide.
So str what’s the protocal for dealing with suicide attempts?
Islam will change
NO,
I would actually have a lot more respect (even if I disagreed with the policies) if Obama would actually show some spine and leadership at all. You guys can bitch about Bush Jrs policies all day but at least he had enough spine to fight for them and get them enacted (and with bi-partisan support). And was smart enough to throw in the towel early when it was an obvious loser and move on (SS reform for example).
I’ll admit I don’t agree with the Dems statist tendendancies but Obama is making Carter look good in the leadership division.
If Obama and the Dems want to lead they need to put out a coherent plan and execute. But Obama can’t even get a budget together that can get ANY Dem votes in the Senate. If unemployment starts back up and NATO actually gets into Libya with ground troops even a Palin might have a chance against him in 2012.
You may not like were they lead us, but there is no doubt that LBJ, Reagen, Bush Sr/Jr, Clinton at least led. the world is teetering and Obama is just not there.
Islam will change
Mrs. R has a wing full of patients, plus being on-call on two more wings, so sophistication is hard to accomplish.
Rusty & Buff, for those of us with some age, it is a common understanding that many people die when they decide it’s time. Is it suicide? Perhaps, but it is common to see an elderly and/or very sick person decide to just stop fighting and speed matters. Oregon even has a law to assist it!
My roommate is diabetic, as well as having HCV (hepatitus C) and both of those conditions are completely controlled with medical pot here in california. When he first arrived here from Missouri, he was going blind, his feet were going numb, the whole thing–and 2 weeks after getting his pot card, his blood sugar was normal, his vision improved, and he was well on his way to losing a hundred pounds, without doing anything extraordinary with his diet or anything else. It’s the medical industry’s best-kept secret.
type 2 causes have a lot to do with diet and lifestyle decisions. type 1 is caused by an autoimmune response. our immune sytem attacks the beta cells in our pancreas. please dont forget the 5-10% that have done nothing to bring this onto ourselves.
Thank you for stating this fact. I have a son with type 1 diabetes, diagnosed at age 12. Most people have no clue as to the difference between type 1 and type 2 diabetes. If the healthcare industry in the US remains profit driven, I honestly think my son would be smart to consider moving to another country so his whole future isn’t overshadowed by the threat of spending every dime he ever makes on managing a disease that in no way had anything to do with his ‘non-compliance’.
My Mom was forgetting to take her pills alll the time. I was aclling her twice a day to reminfd her. She ended up triple dosing and ended up in the Er and the hospital for 5 days. I bought her a medq pill box. It is an “All-in_one” electronic dispenser. I set the times (onein the Morn and one at night). When it’s her time the individual box starts flashing and an alrm sounds. It makes forgetting impossible. My Mom has not missed ONE pill sinece Aug. It costs less than 40 dollars but is the greatest thing ever. MEDQPILLBOX.com and check it out
As an RN (soon to be NP) and a mom of a type 1, I’d like to state some facts as to the cost of diabetes. Diabetics, 1 and 2, require on average drs appointments every three months. This will include lab work, at least an hga1c. They are to see an opthalmologist once a year. They are 2-4 times more likely to have a heart attack or stroke. Diabetes is the leading cause of kidney failure, and 60% of nontraumatic amputations are in diabetics. A diabetic’s healthcare cost is twice that of an average person. A type 1 diabetic is on average, going to be hospitalized once a year. Someone said insulin is cheap. Regular insulin and 70/30 are relatively inexpensive, though control with these meds (type 1 and 2) is difficult. These are not recommended for children. Lantus for instance is $85 a bottle and many type 1 and 2 will require up to a bottle a week, not including their fast acting insulin. Picture the working poor 30 year old without insurance paying upwards of $450 a month JUST for meds. Throw in strips ($30-$100s), ketone strips, treatment for lows, etc it adds up. If you want great control and want an insulin pump, try $7000 every 3-4 years with supplies being a couple of hundred a year. Keep in mind even with great control some folks will have complications. Disability, dialysis etc is not cheap. This is not just the US. It is worldwide. Follow it on the WHO website. Thanks.