Patients who don't listen to their doctor – whether it's a choice or for reasons out of their control – put their health in jeopardy and create enormous costs for the health care system.
A patient in his 50s who won’t take prescribed blood thinners and ends up having a stroke. He’s disabled now and can no longer work to provide for his family.
A diabetic patient who watched his own mother go blind from the disease but refused to change his diet and get regular check-ups. He’s now on dialysis and has lost almost all his sight.
A woman on oxygen for lung disease who kept smoking because she simply didn’t want to quit. Her condition is rapidly declining and she’s facing imminent death.
Patients like these are known in health care as “noncompliant” because they can’t or won’t follow medical advice to help manage their conditions. They often don’t take their medications as prescribed. They don’t follow recommended eating and exercise guidelines. They don’t get tests ordered by their doctor or return for follow-up visits. It’s a widespread problem with devastating effects on patient health and medical costs:
When these patients seek care, they are often sicker and require more intense and expensive treatment. Research shows patients who do not take medications as prescribed by their doctors cost the U.S. health care system about $290 billion in avoidable medical spending every year. Besides those costs – about 13 percent of total health care spending – there’s also $1.5 billion annually in lost patient earnings and $50 billion in lost productivity.
They give you a blank look and say ‘can’t you just give me a pill?’
To say all of this is frustrating is putting it mildly, says Dr. John Meigs, a family physician in Centreville, Alabama, a rural town of about 3,000 people. He also served as president of the 130,000-member American Academy of Family Physicians.
“Chronic diseases have consequences,” Meigs says. “You go to the doctor to mitigate those consequences, but it’s a two-way street. I can’t make you do something. I give advice and suggestions, but you’ve got to be the person responsible for doing it. I am not going to call you every morning to remind you to take your medicine. I won’t slap your hand in a restaurant if I see you order a double hot fudge sundae for dessert. I can tell you not to do those things, but it’s up to you to listen.”
Meigs is quick to point out there are different kinds of noncompliant patients. The first are the willful noncompliant – the patients who can but won’t do what the doctor tells them to do (the ones he sees eating that double hot fudge sundae). Sometimes these patients are willing to take medication, but most of the time they aren’t willing to make lifestyle changes such as losing weight, quitting smoking or getting some exercise.
“I wonder sometimes why they even come to see me. I write a prescription, we talk about a game plan to get them on the path to success and then they come back in a year and we talk about it all over again because they didn’t do anything I said,” he says. “Or they come in and I talk to them about changing their diet and losing 10 pounds and their blood pressure would probably come down on its own. But they give you a blank look and say ‘can’t you just give me a pill?’”
Other patients, though, can’t comply because of factors outside their control. They may lack health insurance or not be able to afford their co-pay. They may not have transportation to get a test or see their doctor, or they may not be able to miss the time at work. They may not have understood the doctor’s instructions because of a language or education barrier. In some cases, the patient suffers from a mental illness that impairs their judgement and the ability to care for themselves. And sometimes it’s a combination of these things and many other possible reasons.
Meigs sees this every day in his community, where the average per capita income is about $25,000 and the median household income is about $42,000. About 15 percent of the population lives below the poverty line. About half of his patient population is covered by Medicare.
“From food scarcity to environmental factors, there are countless barriers to health and wellness that our patients face every day,” he says. “Being in a rural area adds another layer of complexity on top of the significant role social determinants of health play in affecting patient health outcomes.”
Meigs says some of his patients must routinely make tough choices about how to spend their money, and medical care often has to wait behind food, shelter and other necessities. “With my Medicare or low-income patients, you can write a prescription that costs $300 a month, but guess what? They aren’t going to get it,” he says. “Even if it’s a $60 co-pay, it’s a struggle.”
He says it’s incumbent on him, as a family physician, to help patients address whatever is keeping them from being healthy. Once he identifies the problem, his office staff helps if they are able, or they connect the patient to a social service agency that can.
“We have to treat that patient in the context of their community, their family, their local resources,” Meigs says. “It takes a village.”
Short of monitoring patients around the clock, what can physicians do to help ensure patients heed their advice after leaving the exam room? Dr. Cynthia Villacis, a primary care doctor in suburban Cincinnati, says the solution begins with conversations in that exam room. She has worked with patient populations ranging from the inner city to rural and suburban areas, and she currently divides her time between her primary care practice and as an addiction medicine specialist. In all those areas, she says doctor-patient communication is key.
“You have to take noncompliance a step further and find out why the patient isn’t doing what you asked them to do,” she says. “If you are just lecturing the patient about doing something and not finding out what’s going on, you’re not doing your job.”
If a patient admits not taking a medication, for example, she will ask why they stopped. If it was because of side effects, she will try to find another medication that may not cause those problems. If they keep forgetting, she will suggest ways to remember.
“I love pill boxes with the days of the week. They help out a ton,” she says. “People’s chance of taking medications are much, much higher if they have a pill box. A lot of patients put alarms on their phone for medications or for a follow-up visit. But I don’t make any assumptions. I ask if they have a phone, and if they do, I ask them to put an alarm in there.”
In one case, Villacis had a patient who needed to monitor her blood pressure at home. She was willing to do it but was overwhelmed by all the different devices, so she didn’t get one. Villacis found one and ordered it for her, then showed her how to use it at her next office visit.
“She needed somebody to take the time to do the extra stuff with her,” Villacis says.
Some patients are simply not going to comply with everything their doctor asks. This is especially true of patients who make decisions based solely on how he or she feels. For example, a diabetic patient who eats a sweet dessert and doesn’t immediately feel any different may not see the value in regulating blood sugar. Or someone takes blood pressure medicine for a month or two, then decides they must be “cured” by now and stops.
“That’s the challenge with any chronic disease, especially when you don’t see the immediate feedback,” Villacis says. “So if you have diabetes and you eat a brownie, you might feel more tired or you might not. But you don’t immediately feel bad. If someone with diabetes got crushing chest pain every time they ate a brownie, they’d figure out not to eat it.”