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Knowing he'd be keenly interested, I called Bob to tell him about Dr. Stephen Bolles' article on the FICO Medication Adherence Score. He granted me permission to quote: "Michael, at age 86, I am staggered by this news and, quite possibly, for the first time in my life, am speechless!" Bob and I both know that this is clearly an economic attempt to more fairly attribute the costs of consumer misbehavior and, in so doing, improve payer margins. Will it work as intended? No. Why? Because it is unfairly based on probability models - not on an individual's personal behavior pattern. While I share Stephen's concern for privacy, and totally agree with him that some medication non-compliance occurs for very valid reasons, I have a different perspective (bias). This FICO model is merely a creative expression of an industry wanting to reduce costs by punishing bad behavior. As auto insurance premiums are "red-lined" by zip code, the theft frequency of the particular model, and the overall credit score of the insurance applicant, it appears that the FICO model will "red-line" individuals based upon correlating third party (ie, demographic data) with dispensing history for selected base populations, stripped of personal identifiers.
If it plays out this way, future lawsuits based on unfair, and possibly discriminating pricing practices will most certainly occur. Lawyers, start your engines! But, for me, the real story here is much bigger. This is another creative example of using economic carrots and sticks to alter consumer behavior. Life insurance companies have adjusted premiums to known actuarial risks for decades (think: smoker vs non-smoker rates). This is simply a well-intentioned, but deeply flawed effort to punish consumer misbehavior that wastes billions of health care dollars. It is simply one more symptom of economic pain caused by consumers (that also happens to kill > 125,000 of them each year). The American Heart Association describes cardiovascular medication non-adherence as "the number one problem in treating illness today"(3). Even in Portugal, this economic dimension of this problem is well documented (4). Indeed, another strategy recently deployed to address problems with antihypertensive medication non-adherence is one in which the insurance company mandates a periodic intervention with a RPh for certain chronic medication prescriptions. Folks who comply have a significantly lower co-pay on the prescription than those who do not comply. Economic carrots and sticks. The days of (as I like to say) the "fishes and loaves" are gone. This is "hardball." Recently, a colleague challenged me on the arguments I made in the 1990s regarding the economic non-sustainability of our disease-care system. "An economic trainwreck!", I declared back then! After all, he argued, we're still spending, more and more. I reminded my dear friend that we've simply raised the credit limit, just like Congress just did. The bills are growing. The day of reckoning will come. It's simple math. Finite resources, increasing consumption + consumer misbehavior = crisis. And, when that happens, we may all be forced to take our medicines under the watchful eye of some medication dispensing robot built by Bob.
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2. Stephen Bolles responds to Levin Michael, a good morning to you. Thanks for your note and very nuanced take on the FICO medication scoring issue. I appreciate the emphasis on the very real problem of individuals who need medication and don't take them as needed or cannot afford what is prescribed. That problem, as you articulately point out, still is in search of an effective strategy, as those behaviors contribute to poor outcomes. It is a very real tragedy in many respects that does not need to happen.
My primary concern about health data is not about privacy, but about transparency, informed management and ownership decisions, and the value of the data itself. These data have become monetized, and the value of that monetization is not accruing in consumers' favor. People are, essentially, making money on our behaviors without our participation and license. That's a fundamental paradigm difference than what the current system uses. But the current paradigm, in my view, is deeply flawed, and our lack of active participation in these transactions contributes to poor societal health and wellness outcomes. My second concern, which I probably did not articulate fully enough in my notes to John, is that the complexity of the decision-making context for these 'non compliant' individuals is simply not being captured. The system is engineered, essentially, to avoid capturing it. That's another paradigmatic flaw.
For me, all this underscores my concerns that the consumer--as much as many hate that term--does not occupy a position in the data economy where transactions are taking place that use them, but do not engage them. So I do not disagree with anything you wrote; on the contrary, I see your viewpoint as a necessary vector for a more holistic appreciation of the problem. Warm regards! I hope our paths cross again. Stephen Bolles, DC 3. Levin responds to Bolles' Good morning to you, Stephen, and thank you for your thoughtful response. Point One : You raise an important point concerning data privacy, which, my friend, has become historical artifact, sad to say. Monetizing consumer behavior data is the very foundation for advertising. While one could argue that the monetizing of aggregated data (such as this FICO medication score) is simply an unpleasant marketplace reality, I find myself flaming at targeted digital behavioral advertising which targets the specific consumer in real-time, monetizes his physical whereabouts, and sends a message to his cell-phone telling him to buy a discounted smoothie from Jamba Juice as he strolls past it's front window at the mall. That is an egregious invasion of personal privacy, facilitated through cell phone/satellite technology. Grrrrr. Ever wonder why those pop-up banner ads seem relevant to you when you visit a website? It's because they are. And folks are making tons of money on targeted behavioral adversting. Just ask Google.
I'll offer one example I dealt with many years ago. The SIG for a Rx medication was 2 tabs QID. Eight tabs/day, right? It is urinary tract antibacterial. Use 8 tabs, it works great. Use less than 7 and it typically fails. The New Prescription Audits (NPAs) for the pharmacies in my zip codes had an average Rx of 5.5 tablets/day. My job was to educate the docs to get them to prescribe correctly to optimize clinical outcomes. Now, you and I both know that the folks from IMS who sell the monetized data in the form of NPAs to the drug industry profit handsomely from that data product. And you and I both know that the prescribing doctors were generally unaware that their aggregated prescription activity was being monetized. Is this example a bad thing? I'd argue that improving the public health by changing ineffective, costly prescribing habits is a good thing. And in what year was I involved in this example of dataset monetization? 1974. Point Two : I agree with you. Capturing only the "what is" and not the "why is it" is a paradigmatic flaw. It prevents us from understanding the "why" behind the "what" of consumer behavior. For me, that's a lost opportunity cost. For businessmen, one could argue "who cares about the why, just change the what, right now!" Capitalism in full bloom. Point Three : Thanks for sharing your real-world experience with the term "non-compliance" at United. Reductionist models are expedient, but, as you point out, imprecise models which unfairly impact consumers (just as this FICO product promises to do!). I salute your efforts at United to challenge the models and, perhaps more importantly, promote transparency and consumer protections. Had our regulators enforced such transparency requirements in the mortgage lending space, we'd not be in the horrific economic mess we are now in. It's tough being Sisyphus! I deeply enjoy this thoughtful dialog and again, thank you for your engagement and consumer activism. Keep fighting the good fight! Michael PS: This "dataset ownership" discussion brings to mind The Little Prince. (I'm going from memory which, at my age, sometimes fails - so please bear with me.) Upon his visit to the planet inhabited by the accountant, he was puzzled why the accountant kept count of all the stars. The accountant told the Prince that by counting the stars, he owns them. The Prince thought this very odd. How can one own all the stars? In our discussion, do the folks who own all the data own all the people? :) References from Levin's initial response (1) Wetheimer, Albert and Santella, T. "Medication Compliance Research: Still So Far to Go" Jrnl App Research in Clinical and Exp Therapeutics http://jrnlappliedresearch.com/articles/Vol3Iss3/Wertheimer.htm (2) Jorgenson, KM "Robert C. Bogash: Gadgeteer and hospital pharmacist extraordinaire" Am. J. Health Syst Pharm 2010, Jan 15; 67(2):154-7 (3) http://www.onemedplace.com/blog/archives/4926 (4) Morgado, et al "Predictors of uncontrolled hypertension and antihypertensive medication non-adherence" J Cardiovascular Dis Res. 2010 Oct-Dec; 1(4): 192-202
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Comment: While I suspect that there may be subject matter in here for author Dan Brown, I was not sure whether this dialogue was proper Integrator fare. I do think it is good for those of us caught in the touch-feel zone of actual human interaction that defines much of the integrative practice space to be reminded of the very different contexts and problem sets that make up much of the US healthcare system.
Ultimately, given the hard numbers Levin offers for deaths and harm from non-compliance, wouldn't it be nice to begin to separate out where non-compliance is health giving? This is truly patient-centered outcomes. Perhaps the new Patient Centered Outcomes Research Institute can start grappling with these kinds of meaty questions. I wonder if some of the resistance to asking such questions is because we are truly talking, in these patient choices, or in integrative efforts to limit or end undesired pharma, about alternative medicine.
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