Documenting Noncompliance Won't Protect You Anymore

Mark Crane


November 12, 2012

In This Article

Why Nonadherence Is Likely to Grow With Healthcare Reform

Documenting nonadherence takes on new meaning in the age of healthcare reform, where pay-for-performance programs means that reimbursements to providers will be determined by achieving certain metrics and overall outcomes. That means noncompliant patients could drag down physicians' scores, and payments.

"Under the Affordable Care Act, we're moving to a system where outcomes become enormously important to physicians, who have real skin in the game," said James W. Saxton, a malpractice attorney with Stevens & Lee, based in Lancaster, Pennsylvania. "We'll probably see more noncompliance because there will be greater access to screening and baseline testing, and the movement to preventive services. Because more services are available, noncompliance will probably grow."

"Accountable Care Organizations under Medicare will create a new revenue stream for physicians and hospitals," he said. "If you hit the metrics and prove your outcomes, there will be shared savings to divide up -- at least in theory. Nothing will eat into your shared savings more than poor outcomes due to noncompliance."

"To bend the cost curve, we can't do it without patient cooperation," said Saxton. "We have to prevent illnesses and do a better job of monitoring chronic diseases. Culturally, we need patients to accept more responsibility so they can achieve better outcomes without needless spending."

Noncompliance: Don't Blame It on Stubbornness or Bad Attitude

Volumes have been written on how to improve compliance. Often, patients want to follow your advice but don't because of economic woes or not understanding your instructions.

Many patients who have lost their jobs and health insurance will postpone office visits or needed tests. They also decline to fill prescriptions or sometimes cut pills in half to make them last longer. That creates the potential for conditions to develop into more serious illnesses.

Especially in these hard economic times, physicians should ask about a patient's financial circumstances. "Doctors aren't social workers, but they need to go the extra mile to find out what may interfere with good compliance," said Georgette Samaritan. "Maybe the patient doesn't have transportation. There is often some charity or county transportation system that can help."

James Saxton agrees. "There may be a red flag where the patient says he lost his insurance or has a policy that won't cover the cost of what doctors have prescribed. Doctors need to point out that there may be clinics available, or pharmaceutical companies that have patient assistance programs."

A bigger issue, and one that is also more likely to lead to a malpractice verdict against a physician, is noncompliance that occurs because patients don't understand what was told to them. As many as 1 in 5 patients don't fill the original prescription because the doctor didn't convince them that they really needed it, said Rick Kellerman, MD, Chair of the Department of Family and Community Medicine at Kansas University School of Medicine in Wichita, Kansas, and a past president of the American Academy of Family Physicians.

Asking patients to repeat back to the doctor what they're supposed to do can help. So can written instructions. "Tell patients that this condition requires prompt action, because a delay can make a difference in whether they'll get better," says James Griffith. "Don't be vague or try to sugar-coat it. The advice has to be specific. Explain that if the patient doesn't take the medicine, he's at increased risk for stroke or some other illness -- and document that in the record."

Georgette Samaritan concurs. "Make sure that patients know your advice isn't generic. It's designed just for this patient. You need to outline the long-term risk of what could happen if the patient is noncompliant. It doesn't take that much time to document that the patient explained your instructions back to you and agreed to follow them."