Are patients responsible for HEDIS results?

Refusals can mar physicians’ scores

Health plans want all your eligible patients to receive mammograms, immunizations, pap smears, and other preventive care. But what if you provide a referral, and the patient refuses to go?

In a study of Health Plan Employer Data Information Set (HEDIS) data by the California Cooperative Healthcare Reporting Initiative (CCHRI), a collaborative of health plans, purchasers, and providers, about 8% of patients did not receive mammograms because they refused, and 5.5% of patients refused immunizations for their children.

Cultural issues and strongly held patient beliefs or values may influence their decision not to seek certain preventive care, notes Susan Black, MD, FAAFP, a family practitioner in Lowell, MA, and vice president of the American Academy of Family Physicians, which is based in Kansas City, MO.

For example, Black treats some young Portuguese and Greek women who do not want pelvic exams. She also treats women from Southeast Asia who do not want to undress before strangers and won’t get a mammogram, despite Black’s explanations about the need.

"[Health plans] want over an 80% mammogram rate on HEDIS every two years," she says. "Some of my statistics were in the 60% and 70% ranges because women were refusing to get them."

MCOs put on the pressure

Black receives letters from managed care organizations about her mammogram rate along with printouts of patients who haven’t received the exams. She sometimes calls patients and tells them their insurance company really wants them to have a mammogram. But ultimately, compliance is up to the patient.

"It’s frustrating to get letters that make it look like you’re not doing a good job when you know you are," says Black, who has not been disciplined in any way. She sends information to the health plans about the patient refusals.

Any analysis of HEDIS at the physician or group practice level needs to take into account patient noncompliance, says Bernard M. Rosof, MD, FACP, president-elect of the American Society of Internal Medicine in Washington, DC, and a member of the Practicing Physicians Advisory Council, which provides input on HEDIS to the National Committee on Quality Assurance. "Patients will always have that choice [to receive HEDIS-related care]," he says.

At the Cedars-Sinai Medical Care Foundation in Beverly Hills, CA, chief administrative officer Mary Denton, RN, tries to come up with ways to lure young, healthy patients into the office for health screenings.

The group has extended its hours into the evenings and weekends. The practice sends reminder postcards to patients and participates in health fairs hosted by health plans and employers.