Just half of those given a prescription to prevent heart disease actually adhere to refilling their medications, researchers find in the Journal of American Medicine. That lack of compliance, they estimate, results in 113,00 deaths annually.

That is from Sarah Kliff, here is more.


If we cannot get people to take drugs, a seemingly simple and largely pain-free task for most, imagine how hard it is to get people to exercise and alter their diets for the sake of their health. Many conditions, including cardiovascular disease, can be addressed largely, if not entirely, without medication. What this shows us is that there is basically no hope for these more involved interventions. Even if they work better than drugs (and they do, for the most part), people are not interested. Not that anyone with eyes needed to be told this.

Yes a lot of people are lazy, but the article also mentioned factors such as cost, side effects and difficulty understanding instructions. .

"Most medical research is rubbish" is a better approximation to the truth than most medical research.

My theory is that a lot of them can't afford the medication.

But that could be rational if the out-of-pocket costs is worse than the disease. From the study linked to the linked study: "We did not find sufficient evidence that patients fully understand the potential consequences of CRN on their health. To the contrary, the limited evidence suggested that perceptions of low health risk may predict CRN. It remains to be determined why so many patients apparently believe that skipping doses to reduce costs will not compromise the effectiveness of their treatment." This quote doesn't even begin to quantify the rational basis for skipping treatments to save money -- it simply assumes that they are irrational (in essence).

If you don't think skipping some doses (or all of them) will help, then it isn't surprising that you will pocket the uninsured cost. And you may be right!

Publix Supermarkets in the Southeast offers lisinopril (ACE inhibitor) for free, Walmart charges $4 for a monthly supply of this drug and thiazide drugs, my insurance has a copay of $2 for a monthly supply of both drugs so I don't think cost is that big a factor. Side effects may be a bigger factor as it takes a while to get "adjusted" to these drugs. But in many cases they do have an almost immediate impact on lowering blood pressure so why people dont follow through is a mystery to me.

Does Publix provide free doctor visits and lab tests? My visits which my primary care guy wants me to have every three-four months are billed at $400-500 each, and then under the preferred provider agreement, the insurer knows down to about $250 each, which I am then required to pay the $500 because it does not exceed the $5000 deductible when they begin paying 80%. The cost of this coverage increased annually an average of 10% before ACA passed, and slower since, so I'm now paying $850 a month. Good think I was not only continuously covered for the past 35 years AND didn't have a preX when I had to switch to an individual policy at twice the group rate that I know from my COBRA payments for 100% coverage after $20 copays....

The loudest voices say that most medical treatment and spending is unnecessary and the way to eliminate this unneeded and harmful care is to force individuals to pay for it out of pocket, and only cover the very expensive medical treatment for the most serious medical problems. For example, if you suffer adverse consequences from a drug, the thousands of dollars in doctor or ER visits are paid out of pocket to prevent patients from wasting money on useless medical spending. The cheapest solution to bad side effects from a medication is to stop taking it.

And the patient is the person most able to decide on what medicare care is good and bad, according to the loudest voices and economic theorists, and thus the patient is forced to pay for all medical costs associated with prevention, and the side effects from prevention, to make sure he doesn't promote wasteful and harmful medical spending.

If you were working and only making $30,000 a year and had to have a car to get to work, and had to have housing and good clothes to work, and also repay student loan debt, but no employer health benefits, how much would you pay out of pocket to get the prescriptions you are statistically best off taking. $1000 for a doctor visit once a year? $2000 twice a year? Take off a day to go wait at a subsidized clinic where they bill based on means? Go to the ER and not pay the bill? Or just not go see a doc.

I don't use my insurer's drug benefit because the copays are higher than the costs at all the chain's thanks to Wal-Mart breaking the drug industry's monopoly hold on drug prices. That was certainly a very positive benefit of Maryland especially going after Wal-Mart on health care, as well as Mass to a lesser degree. Mass charges all employers other than the smallest a penalty, while Maryland targeted only employers with more than a 1000 without health benefits, which hit basically one corporation: Wal-Mart. Wal-Mart scrambled to make a case the free market could make health care costs affordable. Prescription drugs were easy pickings because of economies of scale. And they were acting after the drug patents from the "free markets can solve the problem is drug makers are assured monopoly profit" 80s laws were all expiring.

Note that Wal-Mart, CVS, Target, Walgreens, etc plus the drug manufacturers all make a profit off $4 for 30 or 60 pills by having humans actually counting the 30 or 60 pills. If anyone was losing money on the labor, a 20 cent bottle with the same cost as a 10 cent bottle would win the market by allowing the manufacturer to prefill bottles sealed without a cap, and then the drug would be dispensed by adding a label and the right cap.

But Wal-Mart has been completely unable to overcome the doctors chokehold on the most basic primary care. All but one of the medical doctors in Congress are Republicans opposed to ACA, but all favor protecting doctors from lawsuits and any price controls, but not one calls for allowing nurses to take over many things only doctors are allowed to do as a way of expanding access and lowering costs.


If your Doc is charging $400 - $500 you need to find a new one...

And next time you go offer to pay with a check/credit card or cash and not use insurance - you will be amazed at the discount you can get for paying your own way.

Two factors that I think a good study would find are more likely to lead to non-compliance are...
1. Life style changing side effects - loss of sex drive is common with many heart/BP meds and others.
2. Lack of symptoms - at some point after taking the meds for a while the patient "feels fine" - their is a belief among many folks that you take medicines when you are sick - once your are well you can and should stop. I have not seen this later point researched - but I would guess for many it is hard to understand why continuing meds is important once I feel better - especially if #1 is present.

The medicine has already been prescribed, I'd assume the doctor has already been visited.

You have to define "can’t afford the medication". People who can afford stuff often say that they cannot. They have other priorities.

Yes. The ones who are admitted for uncontrolled diabetes due to med noncompliance often have the latest smartphones on hand. In the end, how much can we really do when a person's priorities are different from our own? How much free will do we allot them to abuse the health care system?

An ICU stay for DKA is not inexpensive, mind you. It can probably run to more than the individual can earn in his lifetime. How do we balance an individual's worth to society in allocating scarce resources?

And they CAN afford cable TV and their flat screen tvs?

C'mon folks, the linked article is full of speculation and guesses - surely we can do better in identifying the reasons behind "non-complianmce".

I frankly expect better quality control from MR.

Here’s a quick thought experiment:

1. Low-income patients are less likely to currently have insurance
2. Low-income patients are less likely to follow medical orders (pharmaceutical or otherwise) even controlling for insurance enrollment status
3. Most physicians currently have very little extra capacity
4. Under ACA, physicians will be penalized for patients not following orders either directly or indirectly (think Accountable Care Organizations)

If most low-income patients become enrolled in Medicaid or Medicaid-like programs, how do they become attractive from a business standpoint for physicians? Instead of physicians discriminating on the basis of insurance status, they will discriminate on the basis of likeliness to follow orders. If my assumptions are correct, these two groups may have a large amount of overlap.

Another, and potentially better, way to think about a post-ACA world (fully implemented) from a physician’s standpoint is: What type of patients will have good outcomes that are not reliant on following post-discharge orders? I think the likely answer is young to middle aged people with no comorbidities and middle to high SES status. Either way, I think my argument still holds that there will still be a strong bias for treating the population that is currently insured in private plans post-ACA.

Well, these doctors can aggressively seek legislation allowing nurses to handle 80% of primary care under the supervision of the primary care doctor within the medical home.

Dentists are mostly Mds, and they work with two dental techs who do 80%-90% of the primary dental care (30 minute exam and cleaning requires less than 5 minutes of the dentist's time).

But while dentists make heavy use of division of labor, they too, maintain a chokehold on care. They won't go into rural or poor areas for lack of profit, but they won't allow nurses who have drug privs and dental training to do the exam, X-ray, and cleaning plus fillings even under remote supervision. Electronic X-rays are cheaper than chemical, so sending X-rays to a dentist 200 miles away is not a big deal, and close-up photos could be provided as well, and even video links, so fillings could be closely supervised by a dentist.

When I read of the fights on these policies, whatever objections raised initially by doctors are valid, but when the dental techs or nurses offer solutions to the objections, the doctors only object louder and stronger, without offering any alternative, and absolutely no solutions.

Doctors control health care delivery, and they have only driven up costs. If doctors were committed to providing universal access to everyone, and had been committed to that in 1960 which was long after it was clear universal access was a national priority, then Medicare/Medicaid would never have been needed. The shape of Medicare/Medicaid - fee-for-service - was dictated by doctors.

I know of no doctor who argues the solution to health care costs, like the solution to food cost, is to deny it to the poor so they die or become even less productive to society. Instead, they argue that health care is available to everyone, even the poor childless adult, because they will get life critical care if they can get to an ER. Then they blame the poor patient for failing to somehow get a prescription for generics that only doctors can provide so they can take the drugs regularly, no matter how inaccessible doctors make themselves.

I'm on statins. I went off once, just being tired of them, but went back on with the theory that yes, doctors are domain experts. The reaction I get most from my friends, mostly outdoor types with a few vegans etc., is that I shouldn't trust doctors and I should just stop. (I'm 50's, 6' and 145, bp 116/65, so I do get the idea that my "need" for them is statistical rather than personal.)

No-one is a domain expert on the effect of taking statins for decades.

You got a typo here. Is that number 11,300 or 113,000?

Maybe 113,00 is using the European decimal point separator.

Here's something worse. I knew a fellow who received a heart transplant. His doctor was really impressed when he took all his meds after the procedure. Most patients don't, the doctor said.

I agree that this is quite impressive. I am amazed at the [rare] patient whom I admit who remembers all the names and dosages of his meds.

No worries. Some clever entrepreneur in the market for coercion is already working on it: take away their insurance if they don't comply. Hire an army of armed bureaucrats to gently or not-so-gently nudge 'em. Let 'em die, factor their shorter time as a savior of other programs in the market for coercion, like ....medicare? The academic tax-eaters will clamor to take their money to research how to save them from themselves. The possibilities are endless in the cesspool that is the market for coercion.

Actually, there is marketing research being conducted on how to increase drug compliance rates.

Think: about how to create habits and what cues to prompt compliance with routines.

Here is a book you might want to read: The Power of Habit by Duhigg; look in appendix for the research.

On the other hand, they could simply look to Africa where compliance rates for the poor and illiterate with HIV are higher than for the wealthy and college educated in the US.

I find that surprising and would be interested to take a look, if you recall the reference. I'm guessing you're talking about free HIV drugs?

It's the problem even with free. With the type of health care being delivered shifting to address chronic illnesses (that we manage, not cure), we've run up to patient resistance to therapy. This is largely due to a discounting factor, imho. People are poor judges of the long-term effects of something that at the moment, seems quite benign.

They say, "I feel fine. Why should I care about my blood pressure?"

What's the good response to that? I could use academic literature to try to convince them, but really how can I align their incentives with what I know to be the optimal therapy?

Richard - do you REALLY "know" the optimal therapy - I seem to recall reading some research on hypertension that found 5 different therapies for the same patient who visited 8 different Doctors...

And is the definition of high blood pressure ageed upon - is it based on solid scientific research or is 120 an arbitrary number that could be 130 or 140. And is it 90 or 80 or 70 on the other end?

As I understand it, it works by not actually giving the patient the drugs and expecting them to take 'em. There's a traveling nurse that visits every patient every day and gives them that day's dose.

"Just half of those given a prescription to prevent heart disease actually adhere to refilling their medications" SO what does that imply for the neoclassical assumption of rational behavior? Does it disprove the assumption or are we to infer that whatever people do, even it kills them, is rational behavior? Or will the neoclassicals argue with Friedman that unrealistic assumptions don't matter?


I would argue that it is perfectly rational to stop taking meds when one feels "better" - either because sympoms are no longer present or nasty side effects go away when i stop taking meds.

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