Many physicians are viewing the health care reform bill as the final straw in a decades-long process that has eroded physicians’ decision-making authority by replacing their freedom to exercise their expert medical opinion in the best interests of their patients with administrative and bureaucratic interference and government overreach into their professional and business lives.

The end result of this meddling is a compromised physician-patient relationship, a toxic financial environment that forces medical practices to operate at razor-thin profit margins and stifles the entrepreneurial impulse in too many physicians, and a physician workforce, already stretched too thin in key areas like primary care, that may have reached its breaking point.

How long will it be before a critical mass of physicians decides enough is enough and leaves the practice of medicine? If several polls, comments from physician bloggers and readers of our publications and websites, and anecdotal evidence gleaned from conversations and correspondence are any indication, that day may be fast approaching. One such indicator may be found in the results from a survey conducted by The Medicus Firm, a national physician search firm. Medicus surveyed more than 1,000 physicians to “determine their expectations as to the impact of health reform on their practices, income, job satisfaction, and future career plans.” 

The results of the survey were eye-opening

: nearly one-third of respondents said they would consider leaving the practice of medicine if the Democrats’ and President Obama’s health care reform proposals became law. A full 46% of primary care physicians who responded to the survey said that “they would leave medicine  or try to leave medicine  as a result of health reform.” Nearly 50% of respondents said that their income and practice revenue would be “negatively impacted” by health care reform legislation. This included 14% of respondents who said that income and practice revenue would “decline or worsen dramatically” and 36% who said it would “decline or worsen somewhat” because of health care reform. In remarks about survey, Kevin Perpetua, managing partner at The Medicus Firm, said that “many physicians feel that they cannot continue to practice if patient loads increase while pay decreases,” and that “the overwhelming prediction from physicians is that health reform, if implemented inappropriately, could create a detrimental combination of circumstances, and result in an environment in which it is not possible for most physicians to continue practicing medicine.”

That detrimental business environment will come about in large part because of the further reduction in fees and reimbursement that will be the natural result of adding millions of patients to Medicare and then reimbursing physicians at or below Medicare rates to provide care for them. Increased patient volume plus declining pay per visit is a recipe for disaster in the long run. It’s a shame that the health care system now seems set to take advantage of physicians’ altruism and sense of calling by piling more financial burdens on them and placing additional obstacles between them and their patients.

Where this all will end and what it will ultimately mean for physicians and their patients has yet to be determined, but the early signs are far from promising. If the initial reaction from the physician community is any indication, proponents of the current health care reform bill may get more than they bargained for if physicians and patients have to make do with less.

Articles

Editor's Note

Who Will Be Left to Care for All of These Newly Insured Patients?

Choosing the Right Asset Protection Plan for You

	Your plan should be designed specifically to deal with the particular source of liability risk that you face. If you are like most physicians, protection from the financial threat of a malpractice lawsuit should be one element of your legal planning. If this is your primary concern, then your plan must effectively counter the legal tactics available to a plaintiff in a malpractice case. An asset protection plan should defend against the source of the most likely threats. For example, the plaintiff’s lawyer in a malpractice case is often focused on the settlement value rather than the trial outcome of his case. Taking a case to trial always involves significant financial risk to the plaintiff’s attorney due to the high

	upfront litigation costs and the uncertainty of the amount and timing of a damage award if a trial is necessary. Most cases settle before trial because the extreme unpredictability of the outcome makes the financial risk simply too great for both sides.

	Based upon these economic realities, our primary goal in asset protection against malpractice liability is to enhance our bargaining power in any future settlement negotiations. If you have substantial and reachable assets, which are available to

	satisfy the excess uninsured liability, the plaintiff’s lawyer holds the negotiating leverage. When your personal assets are “in play” in a malpractice case and you face the threat of loss, the plaintiff’s bargaining position is very strong. When your assets are protected from a claim, the plaintiff effectively loses the “uncertainty” and risk-of-loss bargaining chip.

	Another important concern these days is the lawsuit risk from a potential default on a mortgage loan. Except in limited situations (

), in the case of a mortgage default, a lender generally has the right to collect from the borrower the amount of any deficiency (the amount by which the loan exceeds the foreclosure sale proceeds). Even when the lender agrees to a short sale, we have seen lenders aggressively pursue collection for the unpaid loan balance from the borrower’s remaining assets.

	In contrast to the typical plaintiff in malpractice litigation, the banks in these cases rarely accept a negotiated settlement. Often the bank is merely the loan servicing agent (LSA) on behalf of the investors who purchased the original mortgage. As such, it is entitled to add and collect servicing fees and litigation costs off the top of the defaulted property, even before the lender/investor gets paid. The economic incentive of the LSA is to drag these cases out for as long as possible while padding the servicing fees and costs.

	The litigation strategy for actually collecting the amount of any deficiency usually depends on how much the real lender (as opposed to the LSA) wants to spend on the litigation, based upon the anticipated recovery from the borrower’s personal assets. A deficiency judgment acts as a lien on all real property standing in the name of the borrower and when the property is sold or refinanced then the judgment lien gets paid off before the borrower receives any proceeds. This lien typically lasts for 20 years or so and the lender may just sit and wait or may actively pursue a foreclosure of the property affected by the lien. To defend against this common tactic of the lender, the appropriate asset protection strategy is to avoid the potential lien of a judgment from attaching to other valuable real estate owned by a borrower. This may be accomplished by holding and shielding these properties from judgment liens within entities such as trusts or LLCs, which can be effective when properly structured.

	Remember: the planning strategies mentioned in this article should be discussed with your attorney who is familiar with your particular situation and understands the fraudulent transfer laws as they apply in your state.

Robert J. Mintz, JD, is an attorney and the author of the book Asset Protection for Physicians and High-Risk Business Owners. To receive a complimentary copy of the book call 800-223-4291 or visit 

The specific structure of an asset protection plan must involve a consideration of the details particular to your situation. A plan that works well for one person may be completely wrong for another. For example, the income tax and estate tax benefits of a plan must be efficiently tuned based on your age, income, accumulated wealth, and your family dynamics. The types of assets that you own can also make a big difference in the planning.

Columns

What Are Your Lawsuit Risks?

There certainly was quite a bit of hype surrounding Apple’s February unveiling of the iPad tablet computer. Now that all of the excitement has died down, let’s take a look at what the device has to offer for physicians and what that might mean for the tablet market. Although I have never been a fan of tablet PCs—and I have multiple issues with Apple’s take on the tablet&mdash;I do believe the tablet market is about to heat up with the introduction of a whole new generation of products. These devices may eventually become the most natural platform for delivering electronic health records (EHR) and other physician-oriented information systems. But right now, they still have a long way to go.

	I agree with many of the criticisms you may have heard about the iPad: it has no built-in camera for taking pictures or video-conferencing; it can’t multitask applications (a potential deal breaker for anyone who planned on replacing a netbook or notebook computer with an iPad); it’s pricey ($499 and up) given its lack of features and abilities; users have to rely on AT&T for 3G service; and, astoundingly, the iPad does not support Flash. The Apple iPad also appears to suffer from the same weak encryption and other security issues that afflict the iPhone, which means that unauthorized personnel could be able to view sensitive personal data and other information. The iPad is also lacking in several other security management capabilities, including the option to protect access via PIN or pass code and remotely lock the device and wipe its memory in case of loss or theft.

	On the other hand, Apple has a strong history of improving its devices over time. The iPhone sold slowly when it first launched, but demand skyrocketed when Apple initiated a series of price cuts. Similarly, the iPod was not an immediate hit. At first, critics lambasted the $400 price tag, the unconventional scroll wheel, and the lack of Windows compatibility. But prices kept coming down, and the devices kept getting better and better. Ifpast experience with Apple is any indicator (and I believe it is), then the iPad will probably follow a similar stellar developmental trajectory. Look for Apple to soon announce a significant price cut for a second-generation device that solves many of the launch product’s failings.

	What might really set the tablet market on fire—and give Apple a run for its money&mdash;will be the introduction of a new generation of PC tablets, some based on NVIDIA’s

	new Tegra mobile processors. At the Consumer Electronics Show in January, NVIDIA, which has declared 2010 as “the year of a tablet revolution,” demonstrated a full HD Internet touchscreen tablet for Verizon 4G wireless networks. Plans for new tablets have also been announced by HP (running Windows 7 OS) and Dell (running Google Android OS).

	What does this mean for physicians? Will most of your colleagues soon be carrying these mobile devices as they roam between exam rooms? The tablet does make an appealing

	substitute for the traditional chart because it mimics the size and shape of a paper chart. People are already raving about the iPad’s super-slim case and light weight, which makes it easy to hold in one hand. The tablet also allows for a more intimate physicianâ€‘patient experience compared to the larger traditional PC, which acts as a physical barrier between doctor and patient. Finally, the iPad can run for 10 hours on a single battery charge, which makes it easier to get though a whole day of visits without having to worry about running out of power.

	However, I’m not so sure that physicians will wholeheartedly embrace the iPad. I see two major flaws with tablets as they are currently designed with regard to EHRs and other physician health IT applications. The first issue is the lack of a real keyboard for typing freehand notes. I find it frustrating to use a virtual on-screen keyboard; it simply slows me down too much. Of course, this is less of a problem if you use speech recognition software to dictate notes into your EHR. The second issue is the privacy and security of protected healthcare information. As I mentioned, the iPad has some significant security issues that need to be addressed before I would feel safe using one with sensitive patient information. Until hardware and software makers can figure out a way to solve these fundamental issues, I believe most physicians will continue to run their EHR systems on desktop and notebook PCs.

Dr. Bertman is Physician Editor-in-Chief of MDNG: Primary Care/Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

There certainly was quite a bit of hype surrounding Apple's February unveiling of the iPad tablet computer. Now that all of the excitement has died down, let's take a look at what the device has to offer for physicians and what that might mean for the tablet market.

 Will the Apple iPad and other Next-generation Devices Make 2010 the Year of the Tablet PC?

	Doctors in private practice today are facing numerous questions about sustainability, including:

	• Will my private practice be able to compete with hospitals offering employment to new physicians? Can our small group practice survive further declines in reimbursement?

	• Will our young physician partners want to buy our practice assets before or when we retire?

	• Do we want to bear the risk of investing in our own electronic medical record?

	• Can we compete with the hospital for ancillary services?

	• Will the hospital direct its employed primary care physicians to refer only to its employed specialists?

	• Should I sell my practice, cash out my assets (which are declining in value every year), and join my peers who have become hospital employees?

	• Are we willing to take on additional debt in order to update our imaging equipment?

	• How long do I want to keep working at this pace?

	• Has private medical practice become a dinosaur?

	Regardless of what ultimately comes of healthcare reform, physician reimbursement will likely continue to decline. Hospital employment of primary care and specialty physicians is on the rise in most communities. New physicians are shunning entrepreneurship, preferring the security and improved quality of life they perceive as employees.

	Capital for equipment and operating expenses is increasingly difficult to obtain through normal debt financing. The business complexity of medical practice is increasingly challenging and regulatory compliance is almost overwhelming. So, can physicians survive in private practice?

	The simple answer is “Yes…maybe!” A number of factors affect the ability of physicians to remain independent and financially and operationally viable. Some of these factors are within the control of physician entrepreneurs, who can prepare for and/or respond to a changing environment by modifying their strategies and behaviors. For example, as reimbursement declines, some physician groups add screening and procedural offerings to supplement their cognitive services. Other factors may be outside the control of private physicians. For example, a local hospital may decide to create its own group of employed physicians in your specialty, increasing competition in the marketplace.

	In our business consulting practice, we have developed the “Is it Time to Sell?” model to assist independent physicians to evaluate their ability to remain successful in private practice (

). That model evaluates internal factors that relate to the practice and the physicians who comprise that practice. The self-evaluation also

	includes external factors such as local payer tactics, hospital strategies, and the activities of competing physician groups. Physician owners should carefully review these internal and external factors when trying to gauge the ability of their private practice to

	Internal factors fall into four categories: 1) owner demographics, 2) practice performance, 3) strategic capability, and 4) leadership.

	Those involved in recruiting physicians for medical staff development learned long ago that as physicians reach age 55, they become more vulnerable to early retirement, debilitating illness, a desire to “slow down,” or even loss of interest in the work. The age profile of physicians in a private practice has a great deal to do with its survivability. If that age profile is a nice bell curve, with younger physicians and growing patient populations, the practice is likely to remain viable. The interest of physician owners in the business side of medicine, their business savvy, and their satisfaction with the return on their time and energy are significant factors in the success of the enterprise. If several physician owners have developed business skills and participate in practice decisions, the practice will likely remain viable. If the partners have depended on one very interested physician to “run the show” and he retires, good luck!

	The strategic and financial objectives of the physician owners are another critical factor in the sustainability of their private practice. If the owners are interested in the perpetuity of the practice, if they have a clear and shared vision for its future, and if they are able to “cash out” when the time comes, the practice will be more likely to succeed in the long run. If, on the other hand, the owners have no clear strategic goals or direction and want

	to liquidate their practice assets before the value declines further or before those assets need to be replaced, the practice will be less likely to remain viable long-term as a private practice.

	Entire books have been written on the factors affecting successful practice performance. For our purposes, sustainable private practices are those with high physician productivity (above the Medical Group Practice Management Association median for the specialty; (

); they include those practices that are able to pay their physicians competitive market compensation. They have low physician and support staff turnover. They are growing in terms of new patients each week and new referring physicians each month (referral-dependent specialties). Income from ancillary services is adding to their net patient revenue so they are not dependent on cognitive services alone. Sustainable primary care practices may have ancillary income exceeding 25% of their net patient revenue or collections. Sustainable practices manage their receivables, including patient due balances, very closely. Finally, and very importantly, all of the practice physicians have a positive reputation among their peers for clinical quality, and the practice has a great reputation for service quality among patients and referring physicians. Failure in one or more of these performance indicators places the practice at risk of demise.

	The strategic capability of the practice relates to its position in the marketplace and its ability to implement sustainable competitive strategies. The first measure of sustainability is the practice’s access to new patients, either directly or through referring physicians. New patients are the lifeblood of any practice. Even mature primary care practices still need new patients to offset patient departures. If the practice has direct access to adequate numbers of new patients in growing neighborhoods, it will be more likely to survive than if population growth is stagnant. In addition, a sustainable private practice must have access to capital for new technology, maintaining existing infrastructure, and funding growth. Since most private practices use debt financing, the debt ratio becomes an indicator of strategic capability. The heavier the existing debt load, the lower the strategic capability, and vice versa. The ability to recruit new physicians to the practice is a critical indicator of strategic capability. If new physicians are lining up to join the practice, the independent group is much more capable of pursuing critical competitive strategies locally or through geographic outreach. If not, the practice will be vulnerable to those who can recruit (such as the local hospital). Importantly, if the practice and some or all of its physicians offer some unique skills, capabilities, or services to the community, it is much more sustainable and strategically capable than if multiple options exist in the community for the same specialty. The higher the strategic capability score, the more likely the practice can remain independent and successful.

	Some physicians express their desire to abandon the business side of medical practice. Such an attitude is the death knell for independent medical practice (it should also be a “red flag” for those seeking to employ those physicians). The ability of physicians to participate in decision making and oversee successful implementation is a critical indicator of medical practice potential regardless of ownership. If an independent practice is led by physicians with a demonstrated track record of jointly making sound decisions, the discipline to enforce policies and decisions among themselves, and the ability to hold their manager accountable for implementation, the practice will be more likely to remain successful in the long run. Unfortunately, some private practices are an amalgamation of little fiefs, with each physician (and his nurse) acting in his or her own way. Other private practices are dependent on one strong leader who is the glue holding together a loose confederation of goals and opinions. These weak configurations are not sustainable under the pressure of competitive market dynamics.

	Of particular interest among the external factors that affect the sustainability of an independent practice model are the  characteristics and activities of payers, hospitals, and competitive physician groups operating in the local market. Larger numbers of competitors in any of these fields reduces the potential strength of any one player. The competitive approach employed by the player may reduce or enhance competition and sustainability.

	Payer negotiating leverage has a significant impact on the sustainability of an independent practice. The greater the negotiating leverage enjoyed by a practice, individually or in concert with others, the more likely reimbursement will contribute to the sustainability of that practice. Payers have and continue to consolidate around the country, yielding fewer, larger competitors in most markets. Larger competitors generally have more negotiating leverage than do smaller competitors. A market with a larger number of payers is more likely to experience higher levels of competitive intensity than a market with fewer payers or one dominant payer. A payer who is a large portion of your business has more leverage than a payer that is dependent on you for a large portion of their business. Payers trying to “buy” market share using lower premiums as a  competitive strategy will respond differently than competitors just trying to maintain their market share.

	Local hospitals that own primary care practices potentially control a portion of their market share—3000 to 5000 patients per employed primary care physician (PCP; 

). Depending on geographic location, those hospital-owned practices may end up competing with independent primary care practices in the same neighborhoods and threaten their sustainability. Hospitals may place an owned primary care practice in direct competition with an independent practice affiliated with a competing hospital. If the hospital owns a large number of primary care practices, executives may choose to employ specialists to stabilize their service lines and to attract referrals directly from their employed PCPs. In some competitive markets, hospital executives may even mandate that employed PCPs refer only to employed or affiliated specialty physicians, upsetting established referral patterns and threatening the viability of specialty practices that are no longer included.

	Larger multi- or single-specialty medical groups or larger networks of affiliated practices can have a significant influence on the sustainability of other local independent practices. Multispecialty groups may recruit and elect to refer only to their own specialists who contribute to their overhead costs. Large, single-specialty groups may be more accessible than smaller groups, providing their services in multiple locations, offering same-day evaluation service commitments, providing more extensive screening procedures, etc. This size advantage may create a local dynamic that forces smaller, independent competitors into larger networks or into employment models in order for the physicians to survive. On the other hand, a community with a number of small group practices may support the continuation of that model if the practices can remain viable (see Internal Factors).

	Responses to these internal and external Factors provide clear indicators of the ability of an independent practice to remain independent and financially viable. Those practices with high scores are more likely to be sustainable over time. However, given the current pace of change in the healthcare industry in general, and in most competitive markets in particular, independent physicians should assess the sustainability of their practice at least annually. As weakness begins to appear in the assessment score, independent physicians can decide whether they can adapt and remain independent or whether they need to change their approach altogether.

A variety of forces are threatening the sustainability of private practice in today’s medical environment. In the face of these and other trends, can physicians survive in private practice?

A variety of forces are threatening the sustainability of private practice in today's medical environment. In the face of these and other trends, can physicians survive in private practice?

Private Practice Is Fighting for Survival

One of the largest and most costly problems facing the healthcare industry is that patients don’t consistently take the medicine they’ve been prescribed. More accurately, between one-third and one-half of patients in the US do not take their medications as instructed, according to an August 2009 report released by the New England Healthcare Institute (

	There are many reasons why people don’t take their medication as prescribed, “but the number one reason is they simply forget,” says Pam Swingley, founder of RememberItNow, a patient-centric eHealth service (

). “As people get older and get very ill, it becomes confusing as to what pills to take and when to take them.”

	That confusion is costly. According to the NEHI report, poor medication adherence results in poorer health, more frequent hospitalization, a higher risk of death, and approximately $290 billion in added medical spending yearly. Using technology to “jog” patients’ memories is one method for remedying the problem.

	E-mail alerts, cell phone calls, and more recently, text message reminders have been successful in improving adherence and outcomes where prescription medication and its consumption is concerned. For example, study results published in Pediatrics (

) revealed significant improvement in medication adherence “and a reduction in rejection episodes with text message reminders for pediatric recipients of liver transplants.” Similarly, results published in Diabetic Medicine

	from a randomized controlled trial of Sweet Talk, a text messaging system to support adolescents with diabetes, improved both selfefficacy and adherence (

	Positive results? Yes, but Vincent DeBari, PhD, who oversees the division of medical residencies and fellowships at Seton Hall University’s School of Health and Medical Sciences, calls attention to a few caveats. “One of the things that concerns me

	is that the duration of most of these studies is fairly short. The longest was about a year,” DeBari explains. “I’m wondering if there might not be something like message fatigue that would happen over the long run.” He also wonders how generalizeable the data is in terms of patient age, considering the previously mentioned studies focused on pediatric and adolescent populations—groups that tend to have a greater affinity for cell phone and text message use. “On the other hand, if we were alerted to the fact that we have a chronic condition that requires medication reminders, I think [older populations] could learn to keep their cell phones handy,” he says.

	Despite the relative success, text message reminders as a means of increasing patient adherence to medication regimens has been slow in gaining widespread adoption. The main reason why, says Ed Fotsch, MD, CEO of PDR Network (

), is that when it comes to sending text message reminders, someone has to receive the message and someone has to send it—and both parties have to want to play. Thus far, physicians have remained on the sidelines. “There are all sorts of good ideas out there, but when it comes to paying for them or their practical realities, they fall short,” Fotsch says.

	In other words, text messaging patients simply isn’t reimbursed. And according to Erica Drazen, a partner in CSC Healthcare Group’s emerging practices unit (

), physicians are already incredibly overburdened, so they’re unlikely to take the lead in the effort to improve patient medication adherence. And, she asks rhetorically, do they even need to? “Any time someone is 16 / 03.10 hcplive.com/primary-care on a complex medication regimen, it helps to be reminded,”

	Drazen agrees. “But for people for whom this is a life-and death matter, they’ve already figured it out. They have their own alarm clock. You can program your cell phone to do whatever you want it to do. Some people are already doing that. So, the reminder doesn’t need to come from the doctor’s office.” 

	Jason Hwang, MD, is the co-founder and executive director, Health Care, of Innosight Institute (

), a non-profit think tank devoted to applying the theories of disruptive innovation to problems in the social sector.

	He suggests there are better solutions to the medication adherence problem than trying to increase reimbursement levels or requiring physician involvement. “I’ve seen business proposals for services that would [provide reminders], especially for patients who have to take a lot of medications, such as HIV patients,” Hwang says. “But better yet is to not use a human at all, but to use technology.”

	That’s the road some enterprising entrepreneurs are going down. RememberItNow’s medication reminder, which launched in January 2010, is an online software program requiring no download. Patients, or their physician or family members, input

	medication name, timing and special instructions, and schedule either a text or e-mail reminder to be sent to their cell phone or other device. The message can be customized for special instructions, such as not to take the medication at bedtime, or to

	use the pill bottle with the red dot. “Patients can set these up, or in the case of an elderly patient, a family member can set it up for them,” Swingley says. “The patient could give their password to their doctor before they left the office and the doctor could log

	in any new medications or special instructions.”

	The program also enables patients to track their health and share progress reports with their doctor as well as family members—a factor that Hwang says is important but is often overlooked. “Today, even patients don’t necessarily get [updated reports], so families are even further excluded,” he says. “There are real missed opportunities here for [third-party entrepreneurs].

	[Families] can play a very important role in ensuring that their loved ones are getting the care that they need.”

	RememberItNow’s calendar function also provides reminders for doctor appointments or other events such, as taking blood pressure. An iPhone application is expected in April 2010; a Droid application is due before the end of the year.

	Last September, Oakland, CA-based Ramsell Technologies (

) introduced its Tele-Adherence product, which utilizes proprietary mobile technology and the Software as a Service (SaaS) delivery model to remind patients to take their medication, answer treatment questions, and track results. Patients can be enrolled in the Tele-Adherence program either by an employer in the form of a prevention and wellness program, or as mandated by an insurer. The program utilizes a variety of methods for contacting patients, but Ramsell president Moses Cesario says the company is “banking on text messaging pretty heavily right now.” He calls the medium “the most efficient way that we can run a large scale program with many lives.”

	Cesario explains that once enrolled, patients are contacted and taken through a setup process in which their preferences for contact are noted. “People have their cell phones with them and they’re interacting with them all the time,” he says. “We’re coming into that realm, so our take is we have to be sensitive in terms of how we utilize that presence for the patient. Our measure for success in Tele-Adherence is whether the patient feels this is a beneficial tool to help them care for themselves.”

	The Tele-Adherence tool is also interactive. Patients receive text message reminders and are asked to send back information. The collected information is then shared with the patient’s physician to enhance treatment decisions. “We want the physician’s access to information to be as rich as possible,” Cesario says. “We want to take that information

	that the system collects and put it at the doctor’s fingertips. Then we’re really providing a connected community of care.”

	Creating a community of care is also one of the goals at Vitality, a startup company that manufactures GlowCap (

), a bottlecap that reminds patients to take their medications and keeps track of whether they’re taking them when they should. The caps are built into lids that fit on prescription bottles. They contain chips that communicate wirelessly with a home server that’s the size of a nightlight and plugs into an electrical socket in clear view in a patient’s kitchen and bathroom. If the bottle isn’t opened when a patient is scheduled to take his or her medication, the cap and nightlight blink as a reminder. If the blinking isn’t noticed, musical reminders are played. And if the bottle remains unopened for two hours, an automated phone call or text message is sent to the patient with a reminder. The system can also alert a family member that the patient has not taken their medication. “If you look at the history of reminder systems for taking medications, they look like someone bolted a bad watch onto a pill box,” says David Rose, CEO of Vitality. “Our approach has been very different.” 

	It has also been successful. In a beta test of approximately 100 people with hypertension, one group was given the GlowCap

	system that did nothing but collect data, while the intervention group’s system provided all the appropriate medication reminders. The result was a greater than 20% absolute change between the hypertensive patients in the control group who took their medications about 70% of the time and those in the intervention group, which exceeded 95%.

	The information captured by the GlowCaps can help a physician understand why a particular medication isn’t working—is it the wrong medication, or is the patient simply not complying&mdash;and then take appropriate action. Rose says the company plans to market the device to both insurance and pharmaceutical companies. He explains that it costs $4,000 to $5,000 more per year to care for a diabetic who isn’t taking his or her medication, compared with the cost of a diabetic who’s highly adherent. In

	comparison, the cost of GlowCaps starts at less than $20 per month. “There’s a lot of motivation for payors, self-insureds and employers to run a program that can affect this type of change.”

	Beyond the physician reimbursement factor, there are few pitfalls or obstacles to using text message reminders to improve medication adherence among patients. As CSC’s Drazen points feature out, “I don’t think there are any medical/legal issues. And it isn’t the doctor’s  responsibility to ensure the patient is taking their medication, or [doctors] would be more involved.” Still, there are some hurdles to overcome. “There’s a general fear of converting to electronic communications,” Hwang says.

	“The disadvantages are that it’s difficult to document that [medication reminders] are sent. On the other hand, I think the benefits of quick communication, patient access, and empowering patients to do more on their own so they don’t have to engage the provider or the health system every time they have a question, far outweigh any minimal costs or negatives associated with the technology. And as electronic medical records get better, it will be easier to capture the information.”

	One fundamental issue, says Fotsch, is human behavior. The reaction of a patient who’s supposed to be taking asthma medication will vary not only based on the message, but the messenger as well. A text message from a doctor, he says, comes across entirely different than one sent by a patient’s health plan. “If your health plan sends you a message, the first reaction is, ‘Why is my health plan digging around in my medicines? And what else are they doing that I don’t know about?’” Fotsch says.

	“If you get something from Walgreens saying it’s time to refill your prescription, that’s different than a reminder from your doctor, because the pharmacy has an economic incentive. So, the biggest obstacle out there is not the technology. It’s the motivation, and it’s the relationship between those who have an economic dog in the fight and the patient.”

	But if patient satisfaction is any indicator, text message reminders are making positive inroads. According to the diabetic patients who participated in the Sweet Talk trial, 82% felt that the text messaging support system had improved their diabetes self-management, and 90% wanted to continue receiving messages. Published in Archives of Dermatology, a separate trial of text message reminders used to improve sunscreen use found that 89% of the participants said they would recommend the text-message reminder system to others (

	“It’s obviously a growing field, and people are being more responsible about taking their health in their own hands,” Drazen says. “We did a search about four or five months ago, and there’s something like 1,500 iPhone applications for health and wellness. These applications show that the interest is there, and it’s moving in the right direction. It’s just pretty fragmented at this point.”

	Ed Rabinowitz is a veteran healthcare journalist based in Bangor, PA.

Cover Story

One of the largest and most costly problems facing the healthcare industry is that patients don't consistently take the medicine they've been prescribed. More accurately, between one-third and one-half of patients in the US do not take their medications as instructed, according to an August 2009 report released by the New England Healthcare Institute (http://bit.ly/xlZaW).

March 2010

Who Will Be Left to Care for All of These Newly Insured Patients?

What Are Your Lawsuit Risks?

Will the Apple iPad and other Next-generation Devices Make 2010 the Year of the Tablet PC?

Private Practice Is Fighting for Survival

Did you take your medication today?