There is an emerging challenge in all of medicine, especially primary care, and I encountered it head-on in the mail yesterday. I opened a letter addressed to me from the pharmacy benefit management company affiliated with a local health plan, concerning the adherence patterns of a patient I’ve seen recently:
“…We have identified your patients who may not have been fully adherent with their antidepressant therapy during the acute (3 months) or continuation (6 months) phases of a new episode of major depressive disorder. A patient-medication profile is enclosed.”
I remember Ms D well—a young African-American female who presented to our primary care clinic nestled within a local mental health center to establish care a little over 2 months ago. She had been referred by her case manager and was endorsing severe depressive symptoms, PTSD, panic, and episodes of loss of consciousness associated with tics over the past several months. Allegedly, a neurologic work-up involving video-EEG and neuroimaging was negative (though the results were not available for review) in the past 6 months. She had received no benefit from citalopram, and we discussed switching to another antidepressant, fluoxetine, to address her mental health concerns. She was to follow-up within a week as she had fleeting suicidal ideation, and we briefly discussed a safety plan.
On my way out the door, she asked that I complete some court paperwork showing that she was in active treatment for mental health and substance abuse disorders, and I asked that we postpone the request until our next meeting (there were 3 other patients already waiting to be seen). As it were, the paperwork was due to the judge by the following day and she was in danger of losing custody of her children.
After completing the cursory paperwork stating she had arrived for treatment and I had seen her once, she left with her new prescription. Later that day I spoke with her case manager who revealed that she was actively using cocaine (she hadn’t mentioned and I hadn’t asked in our hurried interview). The case manager shared with me her legal troubles and problems with her father. Some of her very complicated living situation came into focus, including the fact that she was unemployed. It was going to be months before she had a psychiatric appointment, and I was asked to help provide mental health treatments in the interim.
Two months later, staring at a letter from her health plan, I’m reminded of the fact that I have yet to see her again. I remember coming across her chart in the pile of charts awaiting appointments the week after I had seen her, noticing that a voicemail had been left regarding her appointment as a reminder. Thinking back about her case now, I feel used and a little frustrated. Cynically, I wonder if she just made the appointment to have her paperwork completed for the court and had no intent in pursuing treatment. I wonder if I’ve inadvertently lied to the court, in a way. I wonder how many of her depressive symptoms are the result of withdrawing from a spurt of cocaine use. I wonder how many other physicians she’s seen lately, emergency room visits she’s had for loss of consciousness episodes, or intensive workups she’s received because the system is so fragmented and dysfunctional.
Finally, I wonder if I am responsible for her filling or refilling her antidepressants. Am I responsible for tracking her down, speaking with her on the phone, and asking that she come back for another appointment? Am I responsible for interviewing her in a way that is non-paternalistic, non-judgmental, and compassionate, so that she may re-engage in care? Am I responsible for reducing her cocaine use? Am I responsible for managing her depression?
Pay-for-performance would say that I am. The health plan will, some day, inevitably, say that I am responsible for all of these things. I will be judged (and paid?) by the percentage of my patients who fill their medications and are adherent to therapies. If modern medicine is going to embrace behavior change, systems must adapt to support the complexities therein. If I am responsible for affecting patients' choices, and, subsequently, their health outcomes, I must adapt my practice to address the emerging challenge in modern medicine: responsibility for the behaviors of others.