The how to is easy, it’s the want to that’s hard
As everyone knows Diabetic Investor occasionally gets on our high horse and rants about the poor quality of patient education. More than once we have noted how effective education is at producing better overall patient outcomes. Still even with overwhelming scientific evidence that proves education works; patient education continues to be the 800 pound gorilla in the room that no one talks about.
Recently several companies have attempted to promote their efforts at helping patients with diabetes. CVS/Caremark (NYSE:CVS) has rolled out a program call Diabetes Advantage which is really no more than a frequent buyer program disguised as a patient education program. Rather than put the interests of the patient first and actually encourage education, the CVS program merely rewards patients with bonus frequent buyer points for buying certain products. How anyone could believe this program actually benefits patients with diabetes is beyond Diabetic Investor.
Others seem to believe that by giving away diabetes medications like metformin that this somehow will actually get the patient to take their medications. As we have noted on numerous occasions therapy compliance is a major factor contributing to poor patient outcomes. Giving away metformin is great for the patient’s wallet but really does nothing to help the patient understand why they should be taking their medication regularly.
Still others seem to believe that patients need an extra incentive to achieve better outcomes, basically using the carrot and stick approach. The most frequently used carrot is old fashioned cash incentives, or put another way patients are paid to achieve better outcomes. An example of this approach can be found in today’s Wall Street Journal in an article entitled; “Employees Earn Cash For Exercising More”. The article states; “At least a third of U.S. companies offer financial incentives, or are planning to introduce them, to get their employees to lose weight or get healthier in other ways.”
One just might think cold hard cash would be a great incentive, especially when you look at the economy. But as the article notes; “Only about 15 to 20 U.S. studies have tried to evaluate the effects of financial incentives on weight loss. Most of these studies were small and didn’t look at whether such measures worked beyond a few months. None could make conclusions about how much money it takes to make a lasting difference for most people.”
The reality of the situation is that all of these so-called attempts to help patients fail to address the underlying problem with patient education. The problem isn’t how to better manage a patient’s diabetes; the problem is getting the patient to want to better their diabetes. Nearly every one of these programs makes the assumption that the patient actually wants to manage their diabetes better but just doesn’t have the tools to do so. The problem isn’t the tools available or lack thereof, the real problem is getting the patient motivated to actually do something and then stick with it.
The main problem with cash payments, whether they come in the form of lower health insurance premiums or payments for health club memberships, is after time the incentive loses its luster. These programs assume that cash alone will be enough to keep the patient motivated.
Diabetic Investor has said it a thousand times; managing diabetes is 24x7x365 job with no days off. Achieving better outcomes does not happen by accident. It’s equally true that the patient may not actually feel any better when they achieve proper control. Diabetes is not like chronic pain where once the pain is gone the patient notices an immediate difference in their lives. In fact there are some who could argue that achieving good control causes the patient an undo amount of stress as they are constantly worrying about controlling their diabetes.
Is it any wonder than that a University of Chicago study showed that patients with diabetes would actually sacrifice years off their lives rather than do all the things needed to achieve better control. Just ask any compliant patient what their average day is like and it’s easy to understand why patients feel this way. Unlike a normal person a compliant diabetes patients lives a life of constantly testing their glucose levels, taking multiple medications each day, watching everything they eat and getting the proper amount of exercise. And even if they do all that there is no guarantee they will actually feel better or avoid many of the complications associated with diabetes.
The fact of the matter is for the majority of the patients they live their lives WITH diabetes and not FOR their diabetes. This is what is fundamentally wrong with many of the programs designed to help patients with diabetes as they falsely believe that patients with diabetes live their lives FOR their diabetes when in actuality the patient is trying to fit their diabetes management into their lifestyle and not make it the cornerstone of their lifestyle.
Diabetic Investor has always divided the diabetes patient population into three categories. In the first category you find self motivated patients who are properly manage their diabetes. These people don’t need any extra motivation as they have taken it upon themselves to become educated about their diabetes and will do whatever is necessary to properly manage their diabetes. These people actually do live their lives for their diabetes.
At the other end of the spectrum you have an equally disengaged group of patients who no matter what you offer them will never become engaged with their diabetes. These patients know they have diabetes they just choose to ignore it.
In the middle you have the largest group of patients who understand they have diabetes and realize they cannot just ignore it. However, they also do not want their diabetes to dominate their lives and are looking for ways to fit their diabetes management into their lives so they can live their lives with their diabetes and not for their diabetes. It is this group of patients who would be receptive to incentives provided that incentives are not the cornerstone of the program. Incentives will get them engaged but without a strong education component the incentives will only yield short term results and will eventually lose their luster.
The reality is long term results can only be achieved when the patient actually understands why they are doing what they are doing. Glucose monitoring is a perfect example of this. For years Diabetic Investor has stated that the reason the majority of patients do not monitor their glucose levels has little to do with the so-called pain factor; rather the patient does not understand what the test results mean or fails to understand how to use this information for their personal benefit. Incentives may get them to test in the short term but without education the patient will revert back to infrequent testing as they really don’t understand why this information is needed to help them better manage their diabetes.
The same principal applies to therapy compliance. Patients with diabetes are not just taking medications to help them manage their diabetes but are also taking medications to help manage other conditions such as high blood pressure or cholesterol. It is not unusual for a patient to take as many as 8 or more pills each day not to mention the ones who also must inject insulin each day. Several of the medications used to treat diabetes come with short term side effects that contribute to therapy non-compliance. It does no good to provide these medications for free if the patient is not educated about these side effects and understands how the drug works and why it’s important to keep taking it.
Finally it should be noted for this middle group of patients who acknowledge they have diabetes and actually want to do something about it that education cannot be forced upon them. Since they seek to live their lives WITH their diabetes and not FOR their diabetes, the education they receive must also be under their control. The fact is adults learn differently than children and unlike children have greater demands on their time then a child. While it somehow gets lost on many of these companies who are trying to bribe patients, these patients have real lives to lead. Just because someone has diabetes does not mean they don’t have a mortgage to pay, children to take care of or a job to perform. Simply put, patients are no different than anyone else they just happen to have diabetes.
Incentives are great way to engage these people but only when combined with education will we see any long term improvements in outcomes. The fact is there is no silver bullet to fight diabetes; we cannot simply drive a stake through its heart to kill the vampire. For the majority of patients it will take a combination of approaches to reach the desired result. Incentives by themselves are like the peanut butter without the jelly. Only when incentives are combined with education do you have a sandwich that works.
It’s no secret how to manage diabetes, the issue is providing patients with proper set of tools so they will WANT to manage their diabetes.