Comp-LIE-ance

Patient compliance is one of those words that’s thrown around pharmacy school/trade magazines like singles at a titty bar.  Its the illusion that you have the ability to make your patients take their medication like they are supposed to.  Yet another concept that looks great on paper/in the magazines but in real life, not so much (gee, sounds like OBRA90?).

Lets look at this from a realistic standpoint.  You have say 500 patients that you fill medication for on a regular basis.  Do you really believe that you can help improve compliance for each and every one?  You don’t even have time to take a lunch, let alone remind the 90 year old Mrs Smith (who’s clock should of ran out a LONG time ago) that she needs to take her water pill?  Why spin your wheels making MORE work for yourself when you can focus on the patients who ARE compliant, who DO care about their medication, and are willing to work WITH the healthcare system vs just wasting money?  Its just a frustrating losing battle – the sooner you realize this the better off you are.

Sure, you can be one of the pharmacist in the APhA magazines who sit and talk with each patient for 45 min about compliance/MTM/unicorns and pixie dust, but after your store goes under (or you get sued into bankruptcy because your bargain basement techs you hired to do the grunt work killed someone) then will you understand that enforcing compliance is a war long lost? Compliance begins with the patient, plain and simple.  They need to choose their level of involvement of their own health and well-being.

Nothing pisses me off more than having a damn intern pharmacist spend 30 min talking to a patient about compliance.  The patient just gets a glazed over look, says “uh huh” a ton and walks out in no better shape EVERY SINGLE TIME.  Patients don’t want to be lectured about their medication, they want to pick up their government-vicodin and go about their day.  PATIENTS DO NOT CARE WHAT YOU HAVE TO SAY UNLESS THEY ASK YOU FOR HELP.  This is cold sobering fact of retail.  Unsolicited advice gives you blank stares and a “mind your own business”.

So what this boils down to is that once that patient leaves the store with their pills they are on their own to take them correctly.  Stop wasting your time with the hand-holding, they are on their own to take responsibility of their own health (foreign concept I know).  If the patient can’t get their pills straight, well, that’s a whole lot of their problem isn’t it?.  My problem is making sure that the 20 different medications don’t kill them.

You all may think that I’m being quite the asshole about the subject (gee, thats a first!), but the fact remains that I would rather spend my not-making-the-store-money-by-not-filling-Rxs time helping those whom choose to help themselves.  Choose your battles or you’ll have nothing but losing battles.  DrugMonkey and I should teach a class at pharmacy schools.

Not only are non-compliant patients a detriment to themselves, but are a detriment to the entire system as a whole.  Say Mrs Madeupname gets some glyburide.  She just blows off the doctor (and your) warnings about not taking her medication and gets a refill every month (that she just stores/ditches) so “the doctor wont yell at her”.  On her next visit, the doctor will see little/no change in her glucose.  Doctor increases the dose thinking the current medication isn’t working.  Or doctor switches/adds Avandia/Januvia/Actos thinking that will get more control.  See where this is going?  Then when Mrs Madeupname finally feels like shit because her glucose is 500 and takes her meds, she bottoms out her now maxed out dosages and ends up in the ER.  Doctor calls you all pissed off and blames you for not making sure she is compliant (but you are quick to point out by her refill records, she /is/ compliant as far as you can tell).  PLUS the moment you question her about compliance she quickly transfers her medication to WalMart who “doesn’t butt into her own business” (good riddance!).  All this for a $2 dispensing fee.

Now lets talk about the patients who ARE compliant:

There are only 2 settings where compliance actually takes place; controlled substances and patients with high copays/no free ride.

Controlled substances is obvious, when the patient takes them there is an immediate physiological reward.  Your pain/anxiety/etc is gone (or you get a good buzz).  This rewards you to take another dose, and another, and bug your pharmacist for an early refill.  You don’t take your medications and there is an immediate penalty (pain/anxiety/dealing with your shitty life/etc).

Folks with high copays are also more compliant because not only do they have to shell out the cash for the medication, but most (if not all of them) don’t have the luxury of a taxpayer funded ambulance ride/hospital stay if their health goes down the shitter.  These patients are looking at multi-thousand dollar hospital stays/ER visits – they have no safety net of the nanny-government to pick them up when they fall.

They should teach interrogation and water-boarding in pharmacy school.  While they are at it they should teach a mind-reading class too.