“Physicians depend on the trusting relationship we have with our patients to effect change. Patients do not have that trust with their insurance carrier.”
els, based on their business needs and financial constraints, says Cigna’s Mark Netoskie, MD. He is medical director for the South Texas and Louisiana region.
Coding for noncompliance Meanwhile, health plans appear to be exploring other approaches. TMA’s sur- vey reveals that while many insurers are employing data analysis and case man- agement tools, some also are consider- ing whether coding for noncompliance can help gather information for use in reaching out to patients to address gaps in care. Whereas ICD-9 includes just one gen- eral code for “noncompliance with medi- cal treatment,” ICD-10 expands the list to eight more specific codes that address patients’:
• Noncompliance with dietary regimen; • Intentional underdosing of medica- tion regimen due to financial hard- ship;
emergency department or fail to pick up their medication at the pharmacy, for example.
Aetna also tracks whether patients might have missed certain preventive services, such as mammograms and immunizations, as recommended by national quality measures from the Na- tional Committee for Quality Assurance and the Healthcare Effectiveness Data and Information Set. Dr. Vega says Aetna doesn’t financial- ly penalize physicians for patient non- compliance. Rather, Aetna factors it into certain quality improvement programs in the form of an incentive. For example, Aetna offers bonus pay- ments in two pilot programs to physi- cians who get children to complete their regular checkups through the Medicaid Texas Health Steps program (www.dshs
.state.tx.us/thsteps) and pregnant wom- en to get routine care. Dr. Vega says the pilots aim to address what he describes as “under-usage” of certain services, like immunizations and Pap smears. Practic- es could use the pool of money to hire a part-time nurse or assistant, for instance, to help manage patients. “This is more of a carrot than a stick. The stick is the physician’s own responsi-
60 TEXAS MEDICINE April 2014
bility to that patient and [to avoid] miss- ing an opportunity to give the member services to help patients avoid an illness or a trip to the emergency room,” Dr. Vega said.
He acknowledges that such quality
measurement programs don’t directly address patients’ role in the equation, which can be difficult. Any number of financial or social factors can play into patients’ inability to follow through on their care, he says. “We do [quality measurement] as a
proxy for noncompliance, and that’s the weakness of all these programs. We look to providers to manage someone else’s health, when really members also should be incented in some fashion to take care of themselves,” he said. In the commercial world, Dr. Vega says employers are providing that push for their workers. The same strategy falls short, he says, for a Medicaid population that typically does not have stable work to access such incentives. Health plans agree with physicians
that costs, including high deductibles, can pose financial barriers to patients’ ability to follow doctors’ orders. But it’s typically employers that dictate plan design features, such as deductible lev-
• Intentional underdosing of medica- tion regimen for other reason;
• Unintentional underdosing of medica- tion regimen due to age-related debil- ity;
• Unintentional underdosing of medica- tion regimen for other reason;
• Other noncompliance with medica- tion regimen;
• Noncompliance with renal dialysis; and
• Noncompliance with other medical treatment and regimen.
Health plans generally don’t require
such coding as a condition of payment, according to TMA’s survey; nor do physi- cians regularly use it. But Cigna’s Dr. Netoskie says using
the more detailed codes could create an opportunity for health plans to iden- tify potential areas of collaboration with physicians on patients’ noncompliance. Like Aetna, Cigna’s main strategy is arming physicians with as much infor- mation as possible from claims data and other patient programs, he says, adding that noncompliance does not directly af- fect physician pay, largely because most of its participating doctors are still in fee- for-service payment arrangements.
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