Insights from the Outside: Overcoming Patients’ Barriers to Care

Insights from the Outside is a group of practicing clinician - owners. This is a diverse group from many medical specialties, including dentistry, veterinary medicine, cosmetic surgery, ophthalmology, audiology and optometry. This group was uniquely created by CareCredit for the purpose of capturing and sharing “best practices” to some of the common challenges all healthcare business owners face, such as attracting new patients, patient barriers to care, care acceptance, patient retention, social media, team training and empowerment and much more.

This column features dentist Dr. Howard Ong, owner of Seal Beach Dentistry, veterinarian Dr. Kathy Wentworth, owner of PetPoint Medical Center and Resort, Nola Aronson M.A., CCC-A, owner of Advanced Audiology and Dr. Ethan Sadri, owner of Atlantis Eyecare.
What are your patients’ top barriers to care or the reason they hesitate to accept or decline recommended care?
Dr.Ong In dentistry, the top barriers to care have not changed. Consistently patients choose to avoid going to the dentist or they choose not to accept recommended, needed care because of fear of pain, cost, time and unknown outcomes.

Dr. Sadri The barriers for patients who come in for ophthalmology or eyecare are the same you’d find in other “fee for service” or patient share healthcare practices, including dentistry. Similar to what Dr. Ong said, the number one barrier is fear of pain or loss of vision, second is cost and third is integrity and trust of the practice. People are just scared of being in the operating room, being under sedation and having their eye worked on. That’s a natural fear. To accept care, patients have to feel they can trust you as a physician, have to feel there’s a problem to be solved, that they need the care and that there’s a way, clinically and financially, to make that happen.

Dr. Wentworth For clients seeking care for their pet, we have some similar barriers. The first is financial. People are concerned about expenses and afraid they will not be able to pay for appropriate care and treatment necessary to help their pets. And just as people are afraid to go to the dentist or get surgery on their eyes, pets are afraid to go to the vet. If pets have experienced pain or stress during previous visits, they and their owners are reluctant to have another visit. And finally, time. Most veterinarians are not open at night or on weekends. We live in such a busy society now, yet traditional practices have banking hours. Oftentimes clients are only available to bring in their pets on weekends or evenings.

Ms. Aronson Audiology has some similar barriers and a few that are unique. The biggest is the notion that hearing loss is only for old people and has nothing to do with people under the age of 80. Truth is, hearing loss can happen for a variety of reasons at any age. They may have a medical problem, such as wax and fluid. The brain is what hears and with a hearing loss, the brain can be missing information. If left untreated with a hearing device, hearing loss may lead to an increase in the prevalence of dementia or Alzheimer’s. Part of this barrier is the social perception that hearing loss is a disability. When people experience vision loss they will get glasses without hesitation because glasses are socially acceptable, even fashionable. Yet, hearing is the most important sense. And finally, like the other doctors, people have the perception that hearing aids are too expensive, often when they don’t even know what they cost.
How do they get these perceptions prior to even seeking treatment?
Dr.Ong There is healthy pre-conditioning to resist treatment. The obvious barriers do exist. Most patients come into the practice with previous experiences, both negative and positive. Or they have friends who have shared their experiences with a dentist. And, as we know, a negative experience is shared more often than a positive one. And, of course, there’s the historical generalization that healthcare providers are highly compensated.

Ms. Aronson I agree. People’s perceptions, especially of cost, generally come from “low cost” advertising and from word-of-mouth. Many people think that if they come in to get their hearing tested, they are going to be “sold” a hearing aid. And, because they don’t truly know the differences between hearing solutions but do know there are low-cost, low quality options, they believe that the price is too high.

Dr. Sadri Patients do have natural learned biases or barriers to any care. In eye care, specifically laser vision correction surgery, we are challenged by third-party influence. People go to a dinner party and inevitably they hear, like Dr. Ong said, negative stories from people about a friend who had surgery and it “wore off” and they now are back in glasses. A lot of unlearning of these notions must be done.

Dr. Wentworth The idea of being “sold” that Ms. Aronson mentioned also comes from previous experiences. Some clients have been to other practices and walked away because they felt that they were being “sold” possibly unnecessary treatments. When we don’t have an understanding of what treatment is needed and what is involved, there’s natural skepticism. Many people feel that way when they take their cars in for service, for example. Because we don’t understand and don’t feel we have any control, we are cautious when the mechanic recommends repairs. That’s why education is so very important and should start even before the client gets to the practice.

Dr. Sadri I agree with Dr. Wentworth. Educating the patient before they come into the practice is critical. I’m working with a group that does just that – they send videos over from our practice about the procedure they are considering. It’s quality, easy to understand information. Controlling the content that patients see helps enormously. And helps build a connection with the practice. An informed physician should get a list of their patients who are coming in and have one of the team call them, welcome them and ask if they would like to receive some information prior to their visit. It can be online or mailed. It’s much better to have patients come in educated with content you control rather than them coming in with information they found online.

Ms. Aronson We also believe education is the key to helping patients get the care they need. I have a wonderful team who has been trained to ask the right questions, listen to the caller and figure out what issue they may have so we can become the patient’s solution center. This includes listening for gaps in patients’ information and understanding. Because cost is a big barrier, we also let patients know we will check to see if insurance contributes to the cost of the hearing aids, should the patient need them, to help put their minds at rest. When patients call and they don’t think they have a hearing issue, that it’s their “wife’s fault for mumbling,” we know that there is a big barrier – lack of perceived need. We know that hearing loss is a family issue and if the third party is at the appointment, as a team we can work together to a solution.

Dr.Ong Similarly, our team is trained to ask secondary and tertiary questions to gather information, identify barriers and, most importantly, establish a relationship with patient. The patient is asked to specifically look for the team member they spoke with, so the relationship can continue. This is a trained protocol.
When the patient arrives at the practice, what are some of the successful ways you and your team overcome barriers so the patient or pet can get the care needed?
Dr. Wentworth Because we know it’s hard for clients to make great decisions if they are fearful and stressed, we have embraced a fear free philosophy. We have implemented many specifics in our practice to make the client and their pet feel less stressed during a visit. In the reception area we have refreshments for the clients, music, a waterwall, relaxing Zen colors and a spacious area to wait. We also have a nutrition center and a resort, so many pets associate the practice with food or play areas. The examination rooms are spacious and we have a dedicated CatCove to make our feline patients more relaxed. We are open until 8pm during the week so clients who work can bring their pets in the evening (without having to visit the emergency room!). Our practice is also open all day Saturday and Sunday because we want clients to feel like the team is always available to help them. For financial barriers, we have several payment options, including credit cards and CareCredit. Most clients truly want the best care for their pets, and offering a financial solution allows them to provide help immediately. We also have alternative treatment plans to offer if clients truly can’t afford our recommendations. We do not want them to feel guilty about not having substantial resources available because we are truly in business to help them and their pets.

Dr.Ong Lowering barriers requires a system to move the patient along in care by a physical "hand-off" between departments. For example: don't you feel special when you arrive at a world class spa and are greeted warmly like you've been there before, informed about the next step in their experience, then introduced and walked and "handed-off" to the person who will perform a potentially invasive procedure? These are all purposeful systems or trained protocols. So we start with name recognition upon arrival. It’s easy for healthcare teams to greet each patient by name because the patient is on the schedule; it’s not a surprise. We also work hard on customizing information and education. We want it to be appropriate for the patient, meaning different patients want to know different levels of detail when it comes to treatment.

Dr. Sadri I think the information and education should be custom to the client but also very unbiased, almost university type information. We use videos to explain what’s happening with their eyes, what is involved with treatment and what will happen without treatment. We want patients to understand they are not alone and that it’s a common procedure, like cataract surgery, with a common solution that is gentle. People come in and they don’t know what they want or need. Even with cataracts there are surgical options. So we ask about their lifestyle and what they like to do. And then we provide recommendations that will enable them to maintain that lifestyle. We let them know that the procedure is available when they are ready. There’s no pressure to make an immediate decision. I’m not there to sell them anything, just guide and advise them. We don’t immediately discuss cost. First we want to ensure the patient understands what you’re offering them clinically and let that marinate. This may take weeks, which is fine. There is no clinical urgency. Once they understand what the surgery is and the benefits, the barrier of cost almost goes away. Because at the end of the day, it’s their eyes – their vision and ability to see. My team doesn’t talk about cost until the patient is clinically ready. Barriers are natural and you can overcome them through education and making the process clean and unbiased. When patients are clinically ready, we tell them the cost range and tell them about CareCredit. We’re trained to give patients the whole number or total cost, which can be intimidating. Instead, I tell my team to make that number manageable, so we always present the patient portion as a total cost and immediately in terms of a monthly payment.

Ms. Aronson Many people can be educated and told what is happening and what can help. But for others, especially if they are in denial, you have to show them. While I’m doing testing and speech discrimination, I let patients know the words they’ve missed. Then I show them what normal conversation sounds like, where they are and the difference. It’s important to educate them and show them. Also, one way for my team to uncover potential preconceptions and barriers is to ask all patients, before the testing, “If the solution for you is a hearing aid, how do you feel about that?” This gives me insight into their barriers and mindset. If they do accept the fact that they need an aid and aesthetics is the problem, I bring them in front of a mirror and let them try a pair on. They are often surprised how little of the hearing aid shows. Often, the last hurdle is the price. I try to put value into my pricing. I want patients to have the best, so I lower the price of the top-of-the-line and put in $2,500 worth of services so the best is the most valuable, obvious choice. I know they will have a better experience when they get what they truly need and am happy to invest in them. We let patients know about CareCredit, and like Dr. Sadri, we break down the cost into monthly payments.
When a patient walks out without accepting care, do you continue the conversation?
Dr. Sadri In ophthalmology, practices can do a much, much better job about continuing the dialogue when a patient walks out without scheduling a procedure because they’re not ready. We’re so busy fixing what’s in front of us that we’re not looking at the bigger picture and the bigger opportunity. As a consumer I get reminders and a constant dialogue from retailers I’ve interacted with. Healthcare providers need to approach our communications the same way. Of course, not in an annoying way, but provide value - give patients information, suggestions and remind them to come back when they’re ready.

Dr.Ong Dentistry has the unique "recall" ability to touch the patient every few months. Ask the patient before they leave if it’s okay to call or email them in the near future. "No" today does not mean "no" forever. Healthcare professionals take "no" personally sometimes so a shutdown occurs to even continue a conversation. Overcoming that block will allow the conversation to continue.

Dr. Wentworth I agree. When the doctor or staff calls the client soon after the visit to check on the status of the patient, it is usually much appreciated. Often the clients will come back at a later time for continued treatment and care.

Ms. Aronson If a patient who needs hearing aids leaves, it’s our commitment to help them hear, if not now, then when they’re ready. We tell patients it’s our policy to follow up with them should they have additional questions. We ask permission and what time would be best to talk within the next 48 hours. This way they are expecting our call and will be thinking about additional questions they may have.

Dr.Ong What we are striving for is case acceptance by lowering barriers to care, meaning, we are only asking patients to get the care they need or are requesting; it our job to get them there. There are multiple ways before, during and after patient visits. At the end of the day it is the various forms of communication that healthcare providers have, like education or CareCredit, to allow the patient to say “yes” to the treatment you recommend.

Dr. Wentworth Client communication is key and it’s important to treat everyone like a “guest” in your house! Education is important. But so are relationships. People need to trust you.

Dr. Sadri I agree. Education is powerful because they know who you are, what the problem is, what treatment is and how to make it happen. And when you provide clean, unbiased education and treat patients as you’d treat friends and family, even if the patient doesn’t choose to get the treatment, they will have a positive perception of you and your team, which could lead to referrals and recommendations.    

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