Health check guidelines and billing for family physicians caring for adults with intellectual and developmental disabilities

Developmental Disability Adult Visit

Patients with IDD present several challenges to family physicians. They often require nontraditional approaches to communication, help interpreting their internal milieu, monitoring of multiple medications, coordination of multiple medical problems, and advocacy for access to resources and services.^4-6 With increasing complexity, increased supports should follow. A very evident support is extra time: time to listen, build rapport, alleviate anxiety, overcome physical barriers, assist the patient in shared and supported decision making, and locate suitable resources and services. An enhanced code that builds in this time is vital to providing patient care.

Our data show physicians gradually became aware of the adult visit code, and their use steadily increased to 18% over 4 years. Why not more? There are many reasons for the modest uptake of this billing code. First, many physicians lacked awareness of the adult visit code. Family physicians are inundated with vast amounts of information daily. Priorities often fall in the area of medical knowledge and patient safety. Unless a code is used every day, introduction of a new fee code might not draw attention. Second, using the code can be challenging. A physician must bill for the IDD diagnosis and not the presenting diagnosis for the code to be accepted. This is not intuitive; it only takes a few billing code rejections for physicians to abandon a new billing code that they use infrequently and revert to their old style of billing. Third, physicians might recognize a particular patient requires more time for their encounter, more accommodations, and more support to understand and appreciate their diagnosis and treatment, but the patient might not have an IDD diagnosis. Resources for assessing and diagnosing IDD in adults (psychoeducational assessments) are not easily acquired in Nova Scotia. Without a formal diagnosis, physicians could feel uncomfortable billing an IDD code. Fourth, uptake of shadow billings is known to be modest among physicians using alternative payment plans. These results could be underbilled for reasons similar to those of fee-for-service physicians. Also, physicians using alternative payment plans have less incentive to bill strategically or be aware of changes to fee codes that have limited effect on their own payment.

Developmental Disability Complete Examination—Adults

The evidence for an annual physical examination for patients with IDD has been compelling. The systematic review of the literature (1989 to 2013) by Robertson et al in 2014 included 48 publications from countries around the world and patients with varying abilities.⁷ Researchers demonstrated that health checks consistently led to discovering unmet health needs and to targeted actions that would have otherwise been missed in traditional care. These health needs included “minor” diagnoses like cerumen and podiatry issues that can lead to behavioural, communication, and mobility challenges, and also life-threatening conditions such as cancer, heart disease, and compound fractures.⁷

The complete physical examination code had a 3% uptake by fee-for-service physicians over 5 years. Why not more? There are several plausible explanations: physician awareness, difficulties with implementation, lack of awareness in the general population, and compounding challenges. First the launch of the complete examination code and the IDD Canadian consensus guidelines could easily have gone unnoticed by physicians. People with IDD make up 1% to 3% of Canadians²; physicians with infrequent exposure to patients who have IDDs might not have had an occasion to make timely use of the complete examination code or commit it to memory. When physicians choose topics for continuing professional development, topics that apply to most of their population are often a priority.

Second are challenges associated with implementation—eg, scheduling 30- to 45-minute appointments for a complete physical examination among 10- to 15-minute appointments. Longer appointments are not the norm for primary care, and they can interfere with the flow of the day. Organizational barriers in the general practice setting were observed by family physicians in Australia as well.⁸ Despite these barriers, family physicians overall agreed health assessments were an opportunity for a structured encounter that improved communication with patients and caregivers and picked up on undiagnosed conditions.⁸ Canadian family physicians who take part in health assessments suggest multiple appointments and collaboration with family practice nurses could facilitate incorporating such assessments into primary care.⁹

Third is a lack of awareness for most people. Annual physical examinations for the general population are not routinely offered in Nova Scotia. Patients and caregivers are unaware of the importance of a complete examination yearly for people with IDD. Knowledge translation in the public realm could be a good place to focus. Public education could be powerful in the form of public service announcements and endorsements by health care providers.

Finally, there are compounding challenges. Some patients with IDD have anxiety, sensory, or mobility issues that constitute considerable barriers to the physical examination. Many of these patients also have severe or profound IDD and limited communication skills. These patients can have anxiety around health care environments, the instruments we use, or physical contact. These vulnerable patients need a patient-centred approach. Acknowledging their vulnerability and building on the relationship of patient, caregiver, and physician is key.¹⁰

Limitations

Our study has a number of potential limitations. As with many studies relying on provincial billing data, these results cannot be extrapolated to other provinces because billing codes and practices might differ. For example, in Ontario, annual health checks for this period would have been in the vicinity of 22% for patients with IDD. However, this likely reflects Ontario’s support for health checks for the general population during this time period, as 26% of the general population also had an annual health examination.⁵ It is also possible some early entries of the new fee code in Nova Scotia might have been delayed as the new fee was implemented in early April 2012 and paid later retroactively. As a result, it is possible there is some underreporting in spring 2012.

Conclusion

Given that inadequate remuneration can be a disincentive to provision of good primary health care to people with IDD,⁸ having established billing codes should provide Nova Scotia family physicians with a good start in implementing the newly revised 2018 Canadian consensus guidelines for adults with IDD.¹¹

The 2018 Canadian consensus guidelines recommend physicians monitor and seek ways of improving rates and outcomes of comprehensive health assessments of people with IDD in their practice.¹¹ One approach that is under way is to educate patients on the importance of the annual physical examination, creating consumer demand. With continued discussion and promotion of annual physical examinations for patients with IDD, more patients and caregivers might make this proactive care item a priority.