Ad Directory “We are entering into an age of data
that is helping us understand in real time where gaps in care are and that allows us to be more proactive,” Dr. Netoskie said. “This is a great opportu- nity to move [health care] to a better place because everybody is somewhat rolling in the same direction, and that’s a great place to be.” But sometimes claims data only go
so far, he says. What may look like non- compliance with a drug regimen for high blood pressure, for example, could be intentional if a patient lost weight and no longer needs the medication. Or it could involve what he described as a “deeper” financial or socioeconomic issue “than simply knowing a prescription was not filled because a claim didn’t come through.”
The new coding, on the other hand,
“really helps define in a more granular way specific issues and could provide ad- ditional nuances to noncompliance that help us further define what actions we need to take as health plans or as phy- sicians and what resources we [health plans] can bring to bear, whether case management or a social worker, that can really help,” Dr. Netoskie said. The information gleaned from the additional coding also could help physi- cians and health plans tackle noncom- pliance on a broader scale at a time when the health care system is evolving toward managing larger populations of patients.
Deborah Fuller, MD, former chair of
TMA’s Council on Health Promotion, has used noncompliance coding and says it’s also a way for physicians to track their patients’ behaviors and communicate that information directly to health plans. “Some plans are reviewing us on whether we are ordering mammograms. Even if I am ordering the mammograms, what is my benchmark on patients ob- taining those mammograms? I check patients’ cholesterol every year, but that doesn’t say they are taking their medi- cations and following up,” she said. “If plans are coming into our offices and re- viewing our medical records and want to get a better handle on their covered lives, that [patient follow-through] is part of what they should be looking at.”
Incentivizing patients Although the Affordable Care Act no longer allows health plans to discrimi- nate against patients with certain condi- tions, Dr. Torres expresses concern the additional coding could unfairly penal- ize patients in the form of more expen- sive insurance costs. She adds patient incentives, such as reduced copays and deductibles, are a more promising ap- proach than penalties to encourage posi- tive health behaviors.
TMA officials also caution against dis-
missing noncompliant patients without heeding Texas Medical Board rules on patient abandonment. (Read “Firing Pa- tients,” May 2012 Texas Medicine, pages 37–40, or visit
www.texmed.org/firing.) While physicians welcome the addi- tional data health plans can provide, the barrage of reports can result in what Dr. Torres describes as data overload. The regular notices she receives about medi- cation reviews, follow-up testing, or pre- ventive exams health plans say patients need are already “things we do daily in each patient visit. When we go back to review the patient’s chart, we have found that these issues have already been addressed by us.” Dr. Torres says she recognizes ad-
dressing patient noncompliance re- quires a team effort but says physicians increasingly must do more with limited resources.
“If I could afford additional personnel in my office to monitor patients’ preven- tive care and follow-up tests ordered, that would be helpful. Health plans sending me letters is not,” she said. She also has yet to see evidence that health plan case management programs have made a significant impact on her patients’ care, adding that insurance companies are missing an important piece of the puzzle that only physicians can provide. “Physicians depend on the trusting re- lationship we have with our patients to effect change. Patients do not have that trust with their insurance carrier,” Dr. Torres said.
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April 2014 TEXAS MEDICINE 61
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