Stephen Bolles: Integrative Practice Issues as Credit Score Firm Begins Monitoring Drug Adherence

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1 Stephen Bolles: Integrative Practice Issues as Credit Score Firm Begins Monitoring Drug Adherence Contributed by John Weeks The Integrator Blog. News, Reports and Networking for the Business, Education, Policy and Practice of Integrative Medicine, CAM Stephen Bolles: Integrative Practice Concerns as Credit Score Firm FICO Begins Monitoring Prescription Adherence Summary: FICO, the company that is famous for monitoring credit scores, has a new line of business: creating consumer "medication adherence scores." In this article, Stephen Bolles, DC points out that what FICO may register negatively as "non-compliance" is actually a consumer's proactive choice of an alternative practitioner. Bolles expresses his dismay at FICO's reductive approach to an extremely complex issue then begins to point a way toward better clarity. He suggests the need for a "registry" of those who are non-compliant and healthier thanks to an integrative practice or practitioner. Bolles, who now heads a new initiative called Consumer Health Union, is a former director of a consumer initiative for UnitedHealth. Here is Bolles' insightful article on the apparently unforeseen aspects of FICO's new business venture. Sent your comments to johnweeks@theintegratorblog.com for inclusion in a future Integrator. Integrator contributor Stephen Bolles, DC, has a keen eye for consumer issues in healthcare. He recognized significant concerns on reading a New York Times article that reported that the dominant credit score firm, FICO, had a new line of business in a "medication adherence score." (See New FICO Analytics Predict Likelihood of Patient Adherence to Prescription Medication.) Bolles pointed that for patients who explore alternatives, FICO's system may punish the proactive consumer. Bolles concludes: "I am incensed by this as a citizen; I am resentful as a consumer/patient; and I am deeply worried and concerned by this as a provider. In my view, we should all be very, very alarmed." I asked Bolles for a piece for the Integrator. Bolles is a past vice president at Northwestern Health Sciences University and a former consumer health leader for UnitedHealth. He presently consults on diverse integrative health projects and heads up a new venture entitled Consumer Health Union. Here is Bolles' article. He suggests some helpful directions. In my comments, I support he suggestion that its time for a new sort of registry. Issues for Integrative Practice in FICO's Medication Adherence Score Stephen Bolles, DC Consumer Health Union sbolles@consumerhealthunion.com

2 Thanks for the invitation to comment on FICO's recent announcement that they were rolling out a new product, a "medication adherence score." Their predictive modeling and experience with credit scoring is being applied to a single metric: whether we fill prescriptions or not. According to their web site, the new FICO Medication Adherence Score is identified as a way to Identify medication adherence and maximize program effectiveness.' Their website promotional materials identify the goal of predicting which patients tend to be non compliant' because they do not fill a prescription given to them by their physician. I first blogged about this at openhealthmedia.com. As you know, for the last half-dozen years I've been greatly concerned about how personal health information is managed. The bottom line is that our personal health information has been monetized without our participation, full understanding, or informed consent. We (consumers, patients) have ceded control over a substantial amount of detail regarding our health to systems and individuals, trusting in (the presumed) paternalistic good intent of those from whom we're receiving care. But we have little or no idea what is actually being done with that information, and what is being done with much of it might surprise and concern us. "FICO's predictive modeling and experience with credit scoring is being applied to a single metric: whether we fill prescriptions or not. When we sign the HIPAA consent form in most medical doctors' offices and check the box that permits them to share our information, we are affirming their ability to transmit data based on their judgment, not ours. Research' sounds good, but it isn't always what we assume it is. Doctors regularly upload data about us to patient registries; they frequently permit other entities like drug companies and researchers to data mine' our information in order to better understand things like what drugs we prefer,

3 what drugs we don't tend to use, treatment strategies we tend to comply with, those we don't, and so on. Entities are often given access to our information, but we are not notified. While most health care clinics and systems assert forcefully that personally identifiable information is not shared, there are few reliable safeguards actually in place: the National Healthcare Anti-Fraud Association reports that 80% of healthcare organizations have reported one or more data breaches that involved the loss of health information. Security system capabilities in health care IT seriously lag behind what is needed at this point. "Principal among the concerns is what can safely be assumed that it means when someone does not fill a prescription-and becomes, then, non compliant.'" Aside from the umbrage over this further erosion of privacy protections, there are issues that should concern many interested in integrative healthcare. Principal among them in my view is what can safely be assumed that it means when someone does not fill a prescription-and becomes, then, non compliant.' That non act' is the basis of FICO's new adherence score, and anyone who believes FICO won't link credit and medication scoring in their predictive modeling is dreaming. The most insidious problem in this that I see, apart from the continuing erosion of personal privacy, is that there are probably some good reasons why people don't fill their prescriptions; but those reasons are not being tracked. Much as credit scores don't track an adversity index' to contextualize individuals' financial behavior, FICO's medication adherence score will not track any aspects of individuals' decisions when they don't fill a prescription. And it is not hard to envision that individuals who resist persistent followup from their doctors' offices on prescribed medicines will have additional tags and labels attached to their file, multiplying the damage of the scarlet letter' of non-compliance.

4 It is easy to point to many examples where not filling a prescription is a dangerous or life-threatening event, and especially for older adults with memory and financial issues, help is needed. But there are also many examples where not filling a prescription may be a good idea. One is that, given how many medication errors are committed by prescribing physicians annually in the US, the prescription we hold in our hands may actually do more harm than good. Another is that those of us (most) who work with medical and non-medical providers on a given problem frequently end up improving with non-medical care-and not need the prescriptions that may have been given to us preemptively, prophylactically, or without the knowledge that multidisciplinary care was being pursued. As is true in other aspects of integrative health care, what we think we know but cannot prove hurts us... We cannot point to a registry of those who ceased taking a further course of medication while under the later care of a non-medical provider" As is true in other aspects of integrative health care, what we think we know but cannot prove hurts us. We cannot point to a figure that quantifies health improvement or details population health outcomes with the ability to segment those who did not take prescribed medicine as they healed, recovered, or grew more well.' We cannot point to a registry of those who received medication for a problem but did not improve, and then ceased taking a further course of medication while under the later care of a non-medical provider. And we cannot point to a reliable source of data that contrasts trend lines of any changes in the decrease of medication needs against trend lines of clinical improvement under non-medical care. So, again in our sound bite culture' the context for complex individuals' decisions is not being tracked, yet it is being reduced to a single metric. I am incensed by this as a citizen; I am resentful as a consumer/patient; and I am deeply worried and concerned by this as a provider. In my view, we should all be very, very alarmed.

5 Comment: I have a slight re-frame from Bolles' language. I would not use "non-medical" care but rather "nonpharmaceutical" care. Bolles is correct to be alarmed. FICO's reductive metric will add another layer of authority to an the already in-appropriate reductive practices for complex conditions. How many tens of thousands of consumers have been proven right to be "non-compliant" with medications subsequently proved harmful, or likely to exacerbate the conditions they are treating, or even deadly? How many hundreds of thousands begin their path to health by saying no to adverse effects of prescribed drugs and exploring alternative forms of healing? Diminished need for prescription drugs is one of the major benefits from integrative practice. We all know these stories. Yet healthcare planners and public health officials, not to mention FICO, have little awareness of how often alternatives are chosen precisely to avoid or limit dependence on pharmaceuticals. Bolles begins to lay-out a positive strategy. Consider the value of a registry of patients under integrative care who were able to cut back their dependence on prescription drugs. Here is a place where the NIH National Center for Complementary and Alternative Medicine could provide a significant public service. The integration dialogue began 17 years ago with calls for a registry of adverse effects from natural products. Maybe it's time for a registry that is based in a positive postulation that guidance for optimal health care may come from rational decisions to set on a course toward controlled non-compliance with pharmacy regimes through lifestyle change and increased use of natural health providers and products. Sent your comments to johnweeks@theintegratorblog.com for inclusion in a future Integrator.