By Dr. Anushree Priyadarshini, Change Team, ARCH

Most of us in some capacity or other have endured the frustration of long wait time for a doctor’s appointment. While doctors claim to be working dedicatedly to avoid such scenarios, a key factor resulting in the situation is no show by patients having an appointment. Research shows that people routinely make appointments with doctors throughout the town and take the one where they get in quickest, without canceling the rest.

While only few consumer decisions can be impacted by suggestions alone, for actually modifying a person’s behavior in a long-term manner, there must be a clear incentive to adapt to the new pattern and an equally clear incentive not to turn back.

The concept of ‘bill for no-show’, though common to an extent among dentists, is fast becoming the name to the game for physicians as well, who claim that since implementing the policy, their no-show rate has declined. Dr. Joseph Kvedar, MD asserts, ‘Since we began informing patients of the consequence of not showing up, we’ve had more engagement around keeping appointments versus canceling.’ The well-studied psychological concept that if you give something away it has no value, pertinently underlines this patient behavior.

Another scenario, as researched by Partners Connected Health highlights that patients’ adherence can be enhanced when they are compensated with a small financial incentives.

 An interesting example of incentivizing both patients and doctors is a web-based incentive system developed by MedEncentive, Oklahoma. It financially rewards both the doctor and the patient who are mutually responsible for adhering to proven performance standards. The performance standards for doctors include declaring or demonstrating adherence to evidence-based medicine, or giving a reason for non-adherence. Similarly patients’ performance standards involve stating adherence to recommended treatments and healthy behaviors, or explaining any non-adherence. Both the doctor and patient earn their financial rewards only by allowing the other party to confirm their adherence or reason for non-adherence. This creates a potent interactive check and balance that goes beyond just the financial stimulus and is referred to as by MedEncentive as mutual accountability.

Other alternatives that are being explored for keeping patients engaged are use of patient prompts like appointment reminder software, contacting patients via text, email, or voice and updating the scheduling system based on patients’ response. Providing access to patients to their electronic health records so as to give them a sense of control, research by Rollins School of Public Health and the Department of Health Policy and Management at Emory University suggests positive impact of it on patients’ adherence. Admission rates can also be reduced by offering telemedicine and telehealth services.

However, in contrast to these, is the Ashville project that outlines the case of giving something for free and improving engagement. Wherein, a self-insured employer implemented a system that waived co-pays for medications for certain chronic diseases.

The aforementioned scenarios suggest that conventional wisdom seems to vary for keeping patients engaged, ranging from charging them, to giving something away to remove obstacles, or even incentivizing them for achieving a behavioral goal. It can therefore be envisaged that many variables are at play. Like in the first case when a patient books an appointment, they are already motivated to achieve an outcome, in such a scenario it can be expected that they will be willing to make a financial commitment like copay or missed appointment fee, etc.

In case of the Asheville project, an important aspect was pharmacist involvement with patients and research has outlined that adherence/ patient engagement significantly improves with interaction with a care provider. It can be argued that the idea of doing away with co-pays makes sense where patients have a frequent, engaging interaction with a provider. In that context, the pharmacist is present throughout to remind the patient of the medication therefore giving the medication away makes sense. The waived co-pay in such a scenario may indeed be perceived as a benefit and a persuader rather than indicating that the medication has no value.

The concept of financially incentivizing patients is the most perplexing one. Behavioral research extensively highlights that financial incentives are weak long-term motivators. While they result in easy early attention, over time they become expected and if reduced/removed can have a substantial negative impact.

These are important connotations for health care providers to consider as they take on the risk for population health…how to incentivize patients to adhere to their care plans?

You can contact Anushree on anushree.priyadarshini@ucd.ie or call 01 716 5411.

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