By Bob Coates, M.Div., LMFT
President and CEO, the SyMedica Network
Assessing a physician’s attitude about the legal responsibility for healthcare practitioner rule of “Intent to Comply” with U.S. healthcare statues, regulations and rules is the first step of any healthcare compliance initiative, whether in a private practice or institutional setting. Compliance begins to identify factors that predict physicians’ intent to comply. The ethical guidelines governing any licensed activity by physicians, mid-levels, or support staff are the result of dedication to statutory, regulatory, and rule compliance. We begin our discussion by establishing a theoretical framework from social psychology to assess and understand better the attitudes of physicians towards following their practice jurisdiction’s initiatives to protect the public trust and predict the success of a compliance mentality. What are the identified factors that influenced physicians’ intent to comply with these multiple regulatory and ethical guidelines?
When a practitioner adheres to “Intent to Comply”, there are significant benefits to physicians:
- When intent to comply is clearly demonstrated by the practitioner, criminal penalties are most likely abate when and if a significant non-compliance event occurs.
- While civil monetary or monitoring may occur, the result of non compliance allows for factual compliance efforts;
- “Intent to Comply” MUST be demonstrated rather than just lip service to the concept. Practitioners must establish a clear demonstration of intent to comply. Compliance is evidenced by practitioner integrity programs implemented within the day-to-day operational, clinical, and fiscal landscape of patient adherence, and employee behavior as the result of employer mandate.
- Implementing intent to comply has a positive revenue enhancement end result as well. In SyMedica’s implementation of compliance programs, we discover that approximately 60% of patients in even high watermark licensed pain management clinics have significant issues with adhering to the physician’s plan of care. Thus, the clinic can implement a “disease management program” which increases patient compliance, with increased patient requirements to comply.
- Intent to comply programs is physician practice results in the identification and screening of patients at a higher risk of non compliance, yet leads to counseling interventions which allows the patient to remain in guided treatment as opposed to traditional discharge. Thus patient lives are turned around in a win-win situation for practitioner and patient.
- Patients spread the word that this clinic does not tolerate drug seeking behavior, but requires positive results due to compliance initiatives as a bridge to better health.
Physicians traditionally in real life practice have a responsibility to self-govern their credibility and professional image as being the most important aspects of following all clinical, operational, and fiscal practice guidelines. For the most part, physicians live moment by moment with the responsibility that it was important for them to increase their credibility as a profession and also to improve their professional image. Physicians are asked in professional compliance audits whether following the established professional guidelines would decrease the possibility of feeling obligated to the various commercial pressures, mainly financial related pressures. Almost half have indicated to SyMedica that following the guidelines was likely to decrease the possibility of feeling obligated to the commercial industries, and approximately 62% of practitioners in AMA studies stated that decreasing the possibility of fiscal related commercial pressure obligations was important to them, a finding which could seem to affect the judgment of individual practicing physicians.
Self‐serving bias is unintentional, unconscious and affects choices indirectly by changing the way individuals seek out and weigh information on which they later base their choices when they have a stake in the outcomes. Since more than half of the physicians stated that their satisfaction in following their ethical guidelines in practice was important to them, it might be useful to use this reasoning to promote the ethical guidelines.
Physicians as well identify closely with their colleagues as the most important determinate as to practice behavior as opposed to patient or commercial pressures. Study findings indicate that physicians peer pressure is the best incentive for adherence with guidelines. Although a number of studies indicate that physicians depend on sales representatives for information, the findings from SyMedica’s experience indicate that, with regard to ethical guidelines, physicians see sales representatives in a different light. There is significant perception among physicians that imply that physicians perceive commercial and patient pressures as not wanting them (physicians) to strictly comply with the guidelines. Physicians might think that the feeling of obligation imposed by patient demands on physician care planning and financial pressures to survive in a convoluted industry competition for patient volume might have led physicians to believe that patient demands and financial pressures may incentivize non compliance, resulting in a practitioner not following the ethical guidelines; thus patients in many sub-specialties such as pain management may not want physicians to follow the guidelines established by regulations and rules governing the clinic, it’s employees, and practitioners.
Pretesting by the SyMedica Network in its continuing education events, particularly pain management compliance events in the presentation of pain management seminars indicate approximately 50% of the physicians in our experience had read the guidelines governing pain management with complete understanding, but only approximately 30% of the physicians agreed that they could follow practice guidelines because they knew the guidelines very well. As stated by a physician in the one‐on‐one interviews, physicians are busy professionals.
A potential method to assist physicians in reading the guidelines could be by providing these guidelines for some form of continuing education credit or through education at a professional or a national meeting. It is possible that physicians might have read the guidelines, but not being educated to use them in specific situations might have led to their belief of not knowing the guidelines very well. State imposed regulations to the epidemic of prescribing pressures from patients in pain management indicate it is imperative time to now call for a mandatory approach on pain management compliance. The Pulido Coates Pain Patient Compliance Protocol and Rating Scale (PPCP-S) does just that; it requires patients to demonstrate compliance in the physician’s plan of care rather than subject the physician to dealing constantly, and often blindly, to patient non compliance behavior
Precedents support the theory that self‐regulation is often more effectively used and adopted than applied standards. It is important to note that, although these physicians might not want to follow the suggestions of strict pain management regimens devised by well intentioned regulators, it is possible that their own policies might still be ethical in nature and might conform to ethical standards. Patient self imposed compliance presents a severe conflict.
In all, 6o% of the patients Pulido Coates have assessed using the PPCP-S protocol (n=3200) have scored at some level of non-compliance, indicating patients went against their physician’s individualized plan of care guideline. When physicians were provided with the results, responses varied, but generally 90% of physician responses per case relied upon the PPCP-S to alter patient’s plan of care or discharge the patient. This indicates that most physicians changed their prior decisions about patient’s intent to comply when presented with the PPCP-S results. This finding further corroborates the fact that physicians who want to follow the guidelines do so voluntarily. For future promotion of the PPCP-S guidelines, Pulido Coates has found it helpful to present physicians with scenarios from practice settings, along with the guidelines. It takes a strong ethical position to follow the intent to comply.
The interaction between attitude and subjective norms suggests that if a physician believed that positive outcomes would result from following the guidelines and was convinced that his colleagues want him to follow the guidelines, it is likely that he would do what his colleagues want him to do irrespective of his attitude towards financial or commercial gain, and as opposed to compliance with ethical and regulatory guidelines. The implication of this finding is of great importance, since it sheds light on the fact that attitudes and subjective norms work together in influencing physicians’ intent to comply with the ethical guidelines. Bearing this in mind, it would be easy for rule makers to switch their focus from trying to change physicians’ attitudes to trying to concentrate on the opinions of important referents such as physicians’ professional organization, colleagues and patients. For this reason, Pulido Coates as aligned itself with the SyMedica Network, an accountable practitioner initiative.
To learn more about the benefits of “Intent to Comply”, our Disease Management Program, the Pulido Coates Pain Patient Compliance Protocol and Scale, or the SyMedica Network, contact us at http://symedica.net/pain-management-solutions/, or call us at 888-508-1859.