Motivation.
How do you motivate the unmotivated.
Those who simply don't care.
Those who simply don't give a crap about themselves.
For example. A VA patient with concurrent Medicare disability because "I can't hold down a job"
His history?
Stroke
Coronary disease with 4 vessel bypass
Uncontrolled hypertension with systolic over 200
Uncontrolled hypercholesterol with total cholesterol over 300
Uncontrolled diabetes with A1C greater than 10.
Heavy smoker with little desire to quite.
And.
He's in his 30's.
What is the reason for not taking his meds? He simply forgets to fill his pill box. Or so he says.
His only motivating factor to take his pills?
If somebody filled his monthly pill box for him.
Monthly.
Now, extrapolate this population out to the millions and millions of people who simply don't care about themselves, throw in a little pay for performance, government style, and you will find yourself with a population of Pyles who don't care and who don't have access as physicians cancel them from their practice like a bad check.
Maybe that's the goal. Maybe the goal is to drive these folks out of the system by deaming them not good patient material. By creating a disincentive for physicians to take on the hardest of patients.
It's certainly one way to control costs.
Think it's not happening?
Think again.
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9 Outbursts:
Why don't you prescribe him that berry juice that you take? How can you blame him when you wouldn't put those poisons in your temple?
I don't even understand that. I'm so motivated to take my meds (just lialda and prednisone) for UC because they keep me from feeling terrible! Oh, and the bit about avoiding colon cancer is pretty compelling, also.
I'm sure he feels awful with angina and hypertensive crises and uncontrolled diabetes and he probably doesn't want to die an early death (or does he?).
Pay for performance has some potential merits, but you point out some obvious down-falls.
Right now, the hospital that I am working is tracking length of stay by diagnosis code. My group always seems to be the outliers (LONG length of stays). Hello??? Pneumonia in a patient with COPD, lung cancer, on chemotherapy with resultant neutropenia isn't going to have the same LOS as a 45 year old who failed out-patient antibiotics. Esophagitis in a patient with esophageal cancer on treatment is not he same disease as the patient who ate to many burritos at Taco Bell.
Are they going to have a modifier for patient non-compliance? The way I see my local hospital tracking data, they certainly are not making allowances for the innate complexity of some patient groups.
So many of the bean counters making the rules don't really understand the medicine.
celeste, without a severity of illness adjustment, your hospital is comparing apples to oranges and is wasting their money by generating meaningless data.
anon, I have no idea what that means.
You could start by treating his probable severe depression. Realize that uncontrolled DM and hypertension can cause brain damage, even without his stroke, that affects primarily the frontal lobes. The frontal lobes control motivation, reasoning, etc.
rebecca, I forgot to mention, the bipolar disorder
and the medication he's on for that
which he doesn't take.
rebecca, I'm with ya. Unfortunately, nobody will pay for him to go into a facility when he's not suicidal. And nobody will pay for him to go to a psychiatry floor because he's not suicidal.
So he's stuck with being a noncompliant couch potato.
At home.
There are different forms of suicidal. Not taking the meds because you would rather be dead is a slow form a of death, no? and no stigma (really) attached, none of the crap about the devastating effects on people around you...It is very hard to take medication that may help you stay healthy when you would like to be dead.
It's too bad that he can't get the psych treatment unless he is acutely suicidal. I think if he said he was going to take thallium in low doses until he poisoned himself, his hair fell out, he was vomiting and his organs stopped functioning someone would admit him.
While I see the difference here, I don't REALLY see the difference.
Reminds me of an alcoholic patient I had, who couldn't be on the liver donor list until she started going to AA on a regular basis, which she refused to do. When I reported this to the SW she mumbled "well, die then, bitch." I couldn't help it. I started laughing.
Ultimately, if this guy doesn't care about his health, why should we?
Michelle,
The answer to your question is: because we are doctors. The answer to your life is maybe you shouldn't be a doctor. Maybe a bouncer or a prison guard. Then you could give people what they deserve (at least what you think they deserve).
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