I have often been asked about the patient who refuses preventive care, treatment, and advice. “What if the patient refuses?” “I can’t drag them there kicking and screaming.” (One of the most recent comments thrown at me). “I refer them, they don’t go.” “I prescribe the medications but they don’t take them.” "I recommend lifestyle changes but they don’t change.” “Patient refused referral” or “Patient declined.”
How can these patients be helped if they won’t cooperate? Are the providers supposed to “disown” them because they seek help but don’t want to follow any advice? Can the patient refuse to undergo preventive testing, not take their prescribed medications or reject health-saving advice?
Do Patients Have the Right to Refuse?
Yes – A patient has the right to refuse. It is imperative they are well-informed of the benefits of undergoing the testing and the possible consequences of not undergoing the requested testing. Ultimately, a patient has the right to refuse medical treatment or testing as long as they possess decision-making capacity to understand the consequences of refusal and should feel free to make the decision without manipulation or coercion.
Reasons for Noncompliance
Perhaps dementia may be the reason many elderly do not participate in preventive care or do not take their medications as prescribed. A recent internet search indicated that nearly 55% of elderly do not take meds as prescribed so how will their blood pressure or diabetes ever be under control. Many elderly refuse mammograms, colonoscopies, and diabetic eye exams – do they truly understand the benefits of these tests.
- Educational issues
When discussing preventive testing or treatment plans, is the information presented on a level the patient can understand? One of the major problems, in my opinion, with hypertension, cancers and diabetes is that you can’t see them until it’s too late. A patient can see a wound on his leg and will seek treatment but may never feel that 400+ blood sugar or 200/100 blood pressure.
- Personal choice
A patient will stop taking a medication if there are disagreeable side effects, smokers will keep smoking regardless of their cough, foodies will keep salting regardless of their blood pressure or swollen ankles and drinkers will keep drinking regardless of the consequences. A person who has heard horror stories about the colonoscopy bowel prep will NEVER HAVE ONE OF THOSE.
Different cultures have different outlooks on healthcare and culinary habits. This diversity can be the topic of an article all in itself.
Another consideration I’m sure. I will have to investigate this one further.
- Physical Limitations
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, etc.
Copays, deductibles, “donut holes”, lack of transportation. It is estimated (according to the internet) 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 others but these were what came to mind. Leave a comment below with your additions!
Benefits and Consequences of Healthcare Compliance
- 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
- 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
- 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
- Benefits – reduces healthcare costs, reduced funds needed for Medicare and Medicaid, tax adjustments would be nice
- Consequences – increased health care costs, more funds needed for Medicaid and Medicare, tax increases
There are ICD-10 codes for noncompliance. Most health plans don’t use these codes in claims or quality monitoring.
- Z91 - Patient’s noncompliance with medical treatment and regimen
- Z53 - Persons encountering health services for specific procedures and treatment, not carried out
- Z28 - Immunization not carried out
Do the providers disown them? Will they only land in another provider’s office and still refuse? Does the health plan have the right to dis-enroll members because they don’t want a colonoscopy or mammogram? Not advisable. Educating these members would be a better choice. Repetition, repetition – information presented in multiple ways showing benefits and consequences of health choices.
Beware of offering incentives or mentioning consequences. The patient does have the right to refuse. It would be unwise to write a patient to tell them “if you don’t do your colonoscopy, we will dis-enroll you.” Imagine how many people in their social network would hear about that. Organizations governing revenue and quality scores frown upon dis-enrolling or rejecting patients purely to improve revenue or quality scores. Offering incentives can be tricky. Be sure to following the rules of all organizations affecting your provider office or health care plan.