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Spending More to Save More: Interventions to Promote Adherence

David R. Bangsberg, MD, MPH; and Steven G. Deeks, MD
[+] Article, Author, and Disclosure Information

From Massachusetts General Hospital, Boston, MA 02114; and University of California, San Francisco, San Francisco, CA 94110.

Grant Support: By the National Institute of Mental Health, grants RO1 54907 and K-24 87227, and The Mark and Lisa Schwartz Family Foundation (Dr. Bangsberg) and the National Institute of Allergy and Infectious Diseases, grants RO1 and K24AI069994 (Dr. Deeks).

Potential Conflicts of Interest: None disclosed.

Requests for Single Reprints: David R. Bangsberg, MD, MPH, Harvard Initiative for Global Health, 104 Mount Auburn Street, Cambridge, MA 02138; e-mail, david_bangsberg@harvard.edu.

Current Author Addresses: Dr. Bangsberg: Harvard Initiative for Global Health, 104 Mount Auburn Street, Cambridge, MA 02138.

Dr. Deeks: San Franciso General Hospital, 995 Potrero Avenue, Building 80, Ward 84, San Francisco, CA 94110.

Ann Intern Med. 2010;152(1):54-56. doi:10.7326/0003-4819-152-1-201001050-00012
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Medicine often balances patient and population interests. Resource-rich areas, such as the United States, often focus on maximizing benefit for the individual patient, whereas resource-limited settings, such as sub-Saharan Africa, often focus on maximizing population benefit (1). In a data-driven analysis of adherence behavior, disease outcomes, and health care use in this issue, Nachega and colleagues (2) demonstrate that these pressures do not necessarily conflict. They provide compelling data indicating that increasing resources to enhancing HIV-infected patients' antiretroviral adherence is associated with substantial cost savings for the entire public health system.

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Adherence determinants in resource-limited settings.
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Spending Less to Save More
Posted on January 11, 2010
Johnathon S. Ross
Mercy St. Vincent Medical Center
Conflict of Interest: None Declared

Nachega et al. (1) and the accompanying editorial (2) hint at a broader lesson for our own resource rich country. Access to primary, preventive and chronic disease care saves lives and saves money. For those with HIV or any chronically illness, medication is prevention. The Institute of Medicine and others show that care without coverage is probably fatal to about 45,000 Americans every year. (3) They die from treatable illnesses due to lack of health insurance coverage alone. We all pay more when patients fail to adhere to medical advice or treatment due to lack of coverage. They present with complications and advanced illness. We pay the price of a sickly and disabled workforce through lost productivity and lost taxes on earnings. We spend more tax dollars once they are totally disabled and on Social Security disability payments and Medicare. These financial costs ignore the unmeasured social costs of the humiliation, suffering and grief experienced by these patients and their families.

Although legislation is pending to expand and regulate health insurance (this is not reform), many of the newly covered will still find care unaffordable due to high co-pays and deductibles. Financial barriers will result in poor adherence to care and will leave many, including the 20 million who will remain uncovered, resource poor within our resource rich health care system.

We could have the best health care system in the world given what we spend now. Real reform, such as an improved and expanded Medicare for all, could save hundreds of billions in administrative waste while covering everyone, eliminating co-payments and deductibles and allowing complete choice of doctor and hospital. (4) Instead, the President and the best Congress that money can buy allowed the vested interests (the insurers, pharmaceutical manufacturers, the AMA, etc.) to dictate the terms of reform. Mandated to buy high deductible insurance, previously uninsured patients will find that their coverage, like one of those hospital gowns, leaves vital areas uncovered. Tens of thousands will continue to be disabled or die each year due to lack of adherence to care because of financial barriers. Shame on all of us, especially those of us in positions of power and responsibility for this failure of political will. Our failure to reform health care in a way that eliminates the financial barriers to adherence to care will continue kill more Americans than any of our terrorist enemies.


1. Nachega JB, Leisegang R et al. Association of Antiretroviral Therapy Adherence and Health Care Costs. Ann Intern Med January 5, 2010 152:18-25; doi:10.1059/0003-4819-152-1-201001050-00006

2.Bangsberg DR, Deeks SG, Spending More to Save More: Interventions to Promote Adherence. Ann Intern Med. January 5, 2010 152:54-56; doi:10.1059/0003-4819-152-1-201001050-00012

3.Wilper AP, Woolhandler S, et al. Health Insurance and Mortality in Adults. Am J Public Health, Dec 2009; 99: 2289 - 2295.

4.The Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians Working Group for Single-Payer National Health Insurance, JAMA 290(6): 798-805 Aug 30, 2003

Conflict of Interest:

None declared

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