Could PCPs Be Financially Liable for Patients' Lack of Adherence?

There seems to be an inexorable movement toward greater and greater measurement of outcomes in medicine and tying incentives—for health plans and for individual physicians—to those outcomes. I don’t know how long this trend will last, but I see no sign that it will abate any time soon. The move toward paying for value has serious difficulties, not the least of which is adjusting for the baseline risk of the population being treated (without such risk adjustments, the easiest way to make more money is just to avoid taking care of sick patients). 

Another problem with paying doctors and health plans for the outcomes of care is that the outcomes of care depend on patients’ behaviors—in particular, their adherence behaviors—and not just on what diagnosis is made or what treatments are prescribed. A doctor can make the right diagnosis every time and prescribe the right treatment every time, but if the patient doesn’t take the medication, is that the doctor’s fault? Should the doctor be financially penalized just because the patient didn’t do what the doctor recommended?
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Some doctors might be caring for a population of patients that is inherently less adherent. Holding doctors at fault for that would be bad (as it would discourage doctors from caring for non-adherent patients). But to the extent that doctors can change their patients’ adherence behaviors—and this column has discussed lots of ways to do just that—giving doctors financial incentives to use the available tools to improve their patients’ adherence is entirely reasonable and potentially a very effective means to improve patients’ overall treatment outcomes.

Already, hospitals and health plans are incentivized to improve patients’ outcomes, and, therefore, hospitals and health plans are paying more and more attention to intervening to improve patients’ adherence to their treatments. Doing the same for doctors is not far behind. But who needs such incentives. We all want to see our patients get well. To get them well, we should be doing all we can to encourage their adherence to treatment.

 —Dr. Steven Feldman is a professor of dermatology and public health sciences at Wake Forest Baptist Medical Center in Winston-Salem, NC, where he studies patients’ adherence to treatment. He is also Chief Science Officer of Causa Reseach, an adherence solutions company, founder of www.DrScore.com and author of “Compartments”.