Has your practice experienced an increase in subcutaneous immunotherapy (SCIT) non-compliance? If so, you’re not alone! At the College, six out of nine Practice Management Committee members told us this was a real issue for their practice, and the increase in high-deductible health plans is a major contributing factor. Patient non-compliance isn’t just affecting allergists; the 2018 Physicians Foundation’s survey of almost 9,000 U.S. physicians found that 31% of patients do not or cannot consistently adhere to their physician’s treatment plan. So, what’s an allergist to do? Our crack team of Practice Management Committee experts put together the following recommendations based on their personal experience.
1. Eliminate billing surprises.
The most successful allergy practices make sure patients understand their coverage and out-of-pocket costs for extract and immunotherapy up front – before providing any service. Several committee members require that patients talk with a billing expert who researches patients’ coverage and explains their out-of-pocket costs. Some practices also recommend patients check insurance coverage themselves. “We provide patients with the CPT codes to be billed to the insurance companies, and ask that they call themselves for benefits information, copays and out-of-pocket costs. This helps with an information-based dialog with our office when consent is given,” notes Jennifer Kuehn, CPC, revenue and coding manager for Allergy, Asthma and Immunology Associates in Omaha, Nebraska.
For tips on how to implement patient financial counseling in your practice, check out the College’s free 15-minute educational module on patient financial counseling (part of the part of the Allergy Office Essentials package).
2. Reduce financial exposure.
Get a signed financial authorization before extract preparation, and bill for vials when mixed. “We require patients sign a consent to mix extracts and bill at the time of mixing. If they stop coming for shots, we have already made and billed out the first set of extracts,” says Kevin McGrath, MD, FACAAI, vice chair of the Practice Management Committee.
Before reordering a new set of vials, require patients sign a new financial authorization and have a zero account balance.
3. Use shared decision-making.
Use shared decision-making to confirm SCIT is the best option for the patient. Make sure they understand the time requirement, injection schedule, risks, benefits, costs and alternatives – all before they commit. According to M. Razi Rafeeq, MD, FACAAI, member of the Practice Management Committee, “Educating patients and families is the key to successful compliance to allergy immunotherapy. Time and effort spent by allergists and staff can be very beneficial.” His practice has a very low level of SCIT non-compliance, thanks in part to this strategy. Each potential SCIT patient gets a packet of information (including injection schedule, risks, benefits, alternatives, financial responsibility authorization, informed consent form, and CPT codes for shots and extract) plus a verbal overview of SCIT. Patients are encouraged to consider the practice’s allergy injection hours plus the 30-minute observation time and make sure they can fit it into their schedule. Physicians in his practice emphasize that SCIT is a huge commitment in time, effort and cost – but that long-term, it can significantly improve quality of life, reduce daily chronic medications and lower health care costs. John Tole, DO, FACAAI, member of the Practice Management Committee, says, “Stressing the benefits of allergy shots really gets patients motivated; hopefully they can reduce or eliminate many of their medications in time as they feel better.”
Check out the College’s immunotherapy shared decision-making toolkit for strategies and resources you can use with patients.
4. Make it convenient and comfortable.
Practice Management Committee members agree that making allergy shots convenient is critically important for compliance. Extended shot clinic hours can be especially important for busy patients. Michael Rupp, MD, FACAAI, member of the Practice Management Committee, says his practice is open early and late (7:30 am to 6 pm Monday-Thursday) to accommodate work and school schedules. In Dr. Rafeeq’s practice, patients are allowed to walk in without an appointment during allergy injection hours to get their shots. This is a common and successful strategy in many clinics. Dr. Tole advises that travel time to the shot clinic can also be a factor in adherence.
Finally, take a good look at your shot waiting area, and make sure it’s comfortable and patient-friendly. A welcoming waiting area will encourage patients to come back – and improves the likelihood that they will stick around for the full 30 minutes post-injection.
5. Reward compliance.
Several practices said rewarding and/or recognizing patients for SCIT compliance has had a big positive impact. Mike Tankersley, MD, MBA, FACAAI, member of the Practice Management Committee, has a bubble gum machine and rewards pediatric SCIT patients with this fun, small treat each time they reach a new vial strength in their build-up. In addition, he rewards all patients when they reach maintenance with a templated letter of congratulations that he personally signs along with a $10 gift certificate to a popular local burger place near his office. (And he negotiated a 10% discount on the gift certificates with the restaurant!) These measures have been a hit with patients and parents.
Dr. Rupp raffles off a prize each month and patients receive one raffle ticket each time they come in for shots. “This has actually improved our adherence by roughly 100 patients per week on average over the last year,” he said.
In Dr. Rafeeq’s practice, the nurse congratulates patients when they finish a dilution vial and shows them where they are on the schedule and when they’ll hit the maintenance level.
When they do reach the maintenance dose, the physician sees them for a follow-up appointment and personally congratulates them on their tremendous achievement.
When creating a reward program, beware of rules that apply to Medicare, Medicaid and other federal health programs. Generally, it is okay to give patients gifts of nominal value – no more than $15 each and no more than $75 annually, but the gift cannot be cash or a cash equivalent (such as a general purpose debit card). Gift certificates for a specific type of purchase are okay. And make sure your state doesn’t have specific laws prohibiting gifts to patients.
6. Follow up with non-compliant patients.
Several Practice Management Committee members said they regularly track SCIT compliance and follow up with patients who are behind on shots. Having an honest conversation with patients about the reason for non-compliance can be helpful and can provide an opportunity to address barriers to treatment. Explaining the consequences of non-compliance and emphasizing the benefits of regular SCIT may also help. Dr. Tole informs patients they may have to back down on the dose or back-dilute for safety reasons, and that they need to stay with their regimen to reach the monthly maintenance dose. He also notifies patients of a back-dilute fee, which he will waive the first time only. That usually motivates them to get back on track.
7. Offer cluster and rush.
Three Practice Management Committee members said they offer cluster immunotherapy to save patients time, improve their symptoms sooner and get them to a maintenance dose faster. Note that some insurers allow the 95180 code and others do not, so check with the carriers before doing the procedure. For details about billing for cluster immunotherapy, read the cluster FAQ in the College’s Coding Toolkit.
Immunotherapy compliance is a challenge for many allergy practices, but there are steps you can take to address it. With these recommendations, you can get started on a path to better results – for your patients and your practice.