Behavioral science underpinnings for addressing barriers to patient adherence on HEDIS well-care visit measures: Evidence from patient surveys, 2006-2010

Assessments of health plan and provider quality appropriately place most weight on the quality of medical care (e.g., HEDIS: patients' access to clinically-appropriate health care). Measures of patient satisfaction (e.g., CAHPS), however, may receive so much less weight and reward that clinical quality suffers, on measures that rely on patient compliance. This study examines empirical evidence to challenge the assumptions underlying those relative priorities.

(1) Study design: This study explores reasons stated by patients on CAHPS for not getting checkups (HEDIS well-care visits), and compares the relative prevalence of extrinsic barriers versus intrinsic barriers to access. The study examines whether behavioral choices related to patient satisfaction and poor quality service, outweigh traditional barriers of access, as determinants of patient compliance with recommended checkups.

(2) Setting: Data were obtained from annual CAHPS surveys (pooled 2006-2010) in a large and diverse urban Medicaid health plan.

(3) HEDIS and CAHPS as a porous dichotomy: Some HEDIS measures are essentially measuring customer service when clinic staffs and health plans persuade members to get well-care visits. Adherence is a clinical topic on which the social and behavioral sciences have tools that pertain to patient compliance. The social sciences offer tools and options in addition to the clinical interventions that medical science offers on such conditions as obesity, diabetes, asthma, hypertension, etc. These are conditions for which the patient's (or family caregivers') cooperation is vital (a) for controlling diet, exercise, and exposure to environmental triggers; and (b) even for administering treatments and tests at home.

(4) External versus internal barriers to access: A common assumption in Medicaid settings is that improved care relies on removing external barriers to access. If large external access barriers indeed remain, then suggestions from behavioral science on improving patient adherence, do not gain much audience among health care administrators or regulators. This study is designed to test the assumption that external barriers to access overshadow issues of convenience and personal priority as determinants of patient adherence to clinical recommendations regarding periodic checkups.

(5) Findings and implications: (a) Extrinsic barriers (language access, transportation, wait time) remain as barriers. (b) The most frequent bloc of reasons stated by patients for non-compliance with visit guidelines, were intrinsic. (c) Analysis suggests that modifying adherence relies on behavioral science applications in health promotion; training office staffs to contact members; rewarding providers on ability to engage patients as partners in their own care.