5 Ways to Help Your Cancer Patients Be More Compliant

Neil Chesanow

Disclosures

June 19, 2014

In This Article

Finding Time to Help Patients Comply

Getting patients to follow your instructions should be easier than it is -- especially patients with cancer, who are usually under no illusions about the gravity of their illness. Instead, regardless of specialty, not complying with instructions is one of the most complex and intractable problems in medicine. Over 40,000 studies on medication compliance have been conducted over the years, and although pieces of the puzzle have come into better focus, a systematic, evidence-based plan of action remains elusive.[1]

Every doctor struggles with noncompliance in patients, but oncologists probably have the greatest challenge of all. Cancer drugs can cost a king's ransom, regimens can be complicated to follow, adverse events can be severe, patients are often depressed and anxious, and patient education often takes more time than in other specialties -- time that community oncologists, caught between rising costs and declining reimbursements, may not have to spare.[2]

One solution is to make better use of the time you do have by understanding why some patients may not be following your instructions and taking corrective action. Research shows that up to 50% of cancer patients don't take their drugs as prescribed, and that many oncologists, along with doctors in other specialties, may not appreciate the crucial role they could play in promoting compliance.[3]

What can you do to help? Let's take a look.

Before Prescribing a Cancer Drug, Know What It Costs

Across specialties, the number one reason that patients fail to take their drugs as directed is simple forgetfulness, experts maintain.[4] In oncology, forgetfulness vies with what gastrointestinal oncologist S. Yousuf Zafar, MD, MPH, Assistant Professor at the Duke Cancer Institute in Durham, North Carolina, refers to as "financial toxicity" -- the high cost of many cancer drugs.

"Most of us have grown up in an era where talk of money is taboo at the bedside," Zafar notes. "That's not the case anymore. We need a cultural shift. Our data show that, in many instances, patients want to talk about costs -- and have to -- but they see barriers to having a cost discussion, and one of those barriers is that they don't think it's right to talk to their doctors about money."

That's half of the problem. The other half is that oncologists themselves are often reluctant to discuss the cost of the medications that they prescribe. In Medscape's 2014 Compensation Survey, in which over 22,000 physicians took part, 31% of those who were oncologists said that they regularly discuss the cost of treatment with patients; 46% said that they do occasionally, if the patient brings up the subject; 11% said "never," because they don't know the cost of treatments; and 6% said "never," because they don't feel it's appropriate.

In 2013, Zafar took part in a study, including 164 patients with cancer, on the relationship between prescription medication compliance and financial burden, particularly in patients seeking financial assistance.[5] Nearly one half of the participants reported cost-related medication noncompliance; 4% took medications prescribed for another person; 22% took less medication than prescribed; 25% filled a partial prescription; and 27% didn't fill a prescription at all.

Insurers often charge a higher copay for newer oral oncolytics than for intravenous drugs, partly to encourage patients to shop for the best values among their medication options.[6] But it's unclear how patients could do this without an oncologist's guidance. Lacking such guidance, they may visit social networking sites online for "expert" advice on lower-cost treatments from total strangers -- who, it goes without saying, aren't usually physicians, let alone oncologists.

Insurers are trying a new tack: Shift the onus of comparison-shopping for price-conscious medication regimens from patients to oncologists -- and pay them for it. This July, for example, WellPoint will begin a new program in six states and expand it throughout its entire network by mid-2015.[7] The program's initial focus will be on developing clinical pathways, with guidance from oncology groups and other experts, for breast, lung, and colorectal cancer.

Oncologists will receive monthly payments of $350 for each patient treated in compliance with a recommended pathway. WellPoint expects the recommendations to apply to some 80%-90% of its members with cancer. When the full program goes live, the insurer expects to save 3%-4% on treatment costs, totaling around $5.4 billion a year.

As former Surgeon General C. Everett Koop, MD, once remarked, "Drugs don't work in people who don't take them."[3] In Medscape's survey, 61% of oncologists said that discussing the cost of drugs with patients was optional or off the table. Which raises the question: What's the point of educating a patient on dosage, adverse events, and all the rest, only to have the patient discover at the pharmacy that the drug is beyond his or her means to afford?

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