HEDIS And The Patient's Right To Refuse Care | Jane Jackson, RN, CRC | RxEconsult

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HEDIS And The Patient's Right To Refuse Care Category: Healthcare Administration by - November 16, 2016 | Views: 25777 | Likes: 0 | Comment: 0  

Reasons for Noncompliance (contd.)

Culture – different cultures have different outlooks on healthcare and culinary habits.  This diversity can be the topic of an article all in itself.

Religion – another consideration I’m sure.  I will have to investigate this one further.

Physical – vision impairment, unable to open the pill containers, too difficult to get the glass of water to take medication, too difficult to get to the pharmacy or to undergo the prep for a colonoscopy, difficulty with diet – cooking, shopping...

Financial – copays, deductibles, “donut holes”, lack of transportation all contribute to noncompliance. It is estimated that 30% of medications are not taken properly due to the cost of the medication.

Parenting choices – parents have the right to choose what immunizations their child received as well as what testing they undergo. With all the controversy about autism and other such suspected side effects of routine immunizations – can one blame a mother for being skeptical?

There are probably many other reasons for noncompliance but these were what came to my mind. Send me your suggestions if you get a chance.

Benefits and Consequences of Healthcare Compliance

For the Member

Benefits - improved health, more effective interventions with health issues, less hospital days, reduced healthcare costs.

Consequences – undetected complications, later interventions for health issues, more frequent hospitalizations, increased healthcare costs, increased mortality.

For the Provider

Benefits – improved patient population health, less hospitalized patients, better ratings with healthcare plans, personal provider satisfaction, possible monetary incentives.

Consequences – unhealthy patient population, poor rating with healthcare plans, sanctions, and corrective action plans.

For the Care Plan

Benefits – improved Star ratings, reduced expenditures, increased profit margin, improved benefits to offer members, provider incentive plans.

Consequences – poor Star ratings, decreased profit margins, sanctions and corrective action plans by Medicare and Medicaid, potential to lose contracting to enroll members.

For Society

Benefits – reduces healthcare costs, reduced funds needed for Medicare and Medicaid, and reduced taxes (tax adjustments would be nice).

Consequences – increased health care costs, more funds needed for Medicaid and Medicare, and tax increases.

ICD-10 codes for Noncompliance

There are ICD-10 codes for noncompliance but they serve no purpose in satisfying HEDIS measures.

  • Z91 - Patient’s noncompliance with medical treatment and regimen
  • Z53 - Persons encountering health services for specific procedures and treatment, not carried out
  • Z28 - Immunization is not carried out

What is a provider or health plan to do when a member WILL NOT get the requested testing or be compliant with their medical regimen?  Does the provider disown them only for them to land in another provider’s office? Does the health plan have the right to disenroll members because they don’t want a colonoscopy or mammogram? Doesn’t the patient have the right to refuse?

You tell me. Share your perspective by joining the community.

About The Author

Jane Jackson has more than  25 years experience in healthcare, including hospital-based care, home health, and managed care. She enjoys sharing her knowledge and can she be reached at Jane.Jackson@DailyDoseHQ.com. Also visit her blog, Daily Dose HQ.

Also Read:

List Of HEDIS 2017 Measures 

What Is Managed Care?

What Is The 5 Star Rating System For Managed Care? 

Skills And Requirements For HEDIS Review Jobs

Medicaid Versus Medicare 



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