Beauty Health for Life

While the physician Disease Management Care Blog understands the logic behind essential health benefit determinations, believes good health care includes access to reproductive services and also knows that an unintended pregnancy poses special threats to a womans health, it also sympathizes with the U.S. Catholic Bishops stand on birth control pills. 

Such is the luxury of cognitive dissonance.  Yet, the DMCBs real discomfort is over the broader health policy implications of defining BCPs as an essential health benefit that must be covered with only a few exceptions:

1. There are really two ultimate paths to a federal takeover health care.  The first is obvious: formal through the "nationalization" of either the payment or delivery of services. The second is de facto is through the creation of laws, regulations and standards that amount to an expanding domination of the payment or delivery of services. From an end-user perspective, the DMCB thinks there is little difference between the two and believes we are underestimating the ultimate end game for this and multiple other rules and regulations.

2. Decision-making like this can cut both ways.  While womens health advocates can take comfort in the Obama Administrations courage in the face of the Bishops push-back, its possible that future hyper-rational, inflexible, evidence-based, legalistic, uniformist and technocratic decision-making like this will result in endless legalistic, politically charged and awkward decision-making that will always vex some big constituency.  This is the same science used to provoke the controversy over the merits of mammography in women less than age 50 as well as prostate cancer screening in men.  To make the point, the DMCB poses this silly but troubling thought experiment:  since men are just as responsible and should be given every incentive to not cause unwanted pregnancy, should condoms be an essential health benefit?  If persons with cancer run out of treatment options, should a right to control their own bodies and its technical availability make assisted suicide an essential health benefit? 

This time it was the Catholics turn.  The next one could be yours.

3.  Without some sort of accommodation (which may be in the works), the Bishops arent going to back down.  While a majority of their parishioners may believe in and have used birth control, that test fails at two levels: 1) societys institutions are supposed to stand for a higher standard and 2) decades and even centuries of religious interpretation are not up for a vote.  Standing for something is what faith is all about and Church leaders are simply not going to roll over on insurance that covers birth control for their employees and theyre not going to offer access to birth control pills in the course of the provision of health care. Their only choice, other than millions in fines is to exit the health care arena.  David Brooks has an excellent discussion of why thats a problem. 

4.  It is said that the art of politics is the art of the possible: to work out compromise where everyone can walk away a winner.  While coverage of birth control pills is a victory for womens health advocates that a "base" can feel good about, this is also arguably a failure for a President who was committed to bridging differences and creating a health care system that had broad support.

Image from Wikipedia

Suspecting that the poorly controlled [insert name of chronic condition here] is the result of not taking the medication as prescribed, the doctor says: "Remember to take the [insert name of pharmaceutical here]!"

After silently concluding that the benefit of the medicine is less than the cost, hassles, side effects and long-term risks, the patient thinks "Like hell!"

That scenario has probably been played out thousands of times today in clinics across the United States.  According to Zachary Marcum and colleagues writing in the May 22 JAMA, thats costing $100 billion a year. 

Doctors like the Disease Management Care Blog have responded to "medication nonadherence" with entreaties to take the pills as prescribed. When docs take the time to address the issue with patients, research shows it can make a positive difference.

Marcum et al believe physicians can do better if they understand the six types of behaviors that lead to medicines going unused:

1. Insufficient understanding of the link to health and well-being

2. A decision that the benefit is exceeded by the costs.

3. Complexity of the medication management overwhelms the patient

4. Inattention (or what the authors describe as low vigilance)

5. Irrational or conflicting beliefs about medicine

6. Perceived lack of efficacy

What does the population health management service provider community need to know about this?

1. There are a variety of screening surveys that can be used to identify each of the patterns above; unfortunately for DMCB readers, however, there is no single survey that can do it all. 

2. There is also no single intervention that has been shown to consistently increase medication compliance.  Instead, multiple concurrent supports are needed, including education and behavioral support.  This paper by Ho et al echoes that assessment, pointing out that there is ample evidence that other valuable supports include reducing the number of pills, use of special containers, telemonitoring with interactive voice response, non-physician (nurse or pharmacist) one-on-one involvement and regular clinical follow-up with reminders.  Last but not least this paper in the Annals points out that reducing out of pocket patient costs can also make a difference.

Image from Wikipedia