Doctors are Firing Complex/Difficult Patients

Missing appointments? Skipping doses? You might get fired by your doctor – By Max Blau @maxblau – May 15, 2017

A new survey of primary care doctors reveals an interesting statistic:

9 out of 10 practices have told a patient not to come back. 
The doctors have fired their patients.

The research, published in JAMA Internal Medicine on Monday, found that firing patients doesn’t happen often, but it’s making some health experts nervous that doctors will expunge difficult patients from their rolls as insurers move toward reimbursing them more for benchmarked health outcomes than actual services provided. 

The study’s authors say it could happen, but they’re not seeing that yet.

What does that even mean? Pain patients are “seeing it” all over as doctors try to get rid of patients that require opioids because of the regulatory issues that could cause them to lose their license.

As much as we pain patients feel helpless and abused when it happens to us, we must remember that all of that doctor’s patients will lose care if such treatment leads to loss of the doctor’s license.

Among the reasons the nearly 800 practices surveyed gave for cutting ties with a patient:

  • Violent, “disruptive,” or inappropriate behavior toward doctors or staff
  • Violation of policies related to chronic pain and controlled substances
  • Failure to show up to scheduled appointments
  • Repeated disregard of a doctor’s medical recommendations
  • Violation of bill payment policies

“Violation of policies related to chronic pain”?  The only policies are against opioids and no one cares that some severe intractable pain can only be controlled with opioids – none of the woo-woo alternative medicine treatments are effective for it.

She said that “a dearth of literature” exists on the subject of patient dismissals. But as more doctors rely on value-based reimbursements, patient dismissals could still rise.

How could this NOT happen?

Did no one think of the very obvious adverse effects these new pay-for-performance/value reimbursement plans were going to cause?

It seems ridiculously obvious that if a doctor is paid a one-time, simply-calculated flat fee for “fixing” a patient, doctors will find ways to exclude complex or difficult patients from their practices.

Chronic pain patients require so much more time and effort than complaints about a runny nose or even a sprained ankle, that a flat fee would not reimburse a doctor for all the work such patients need.

Links [given in article]

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6 thoughts on “Doctors are Firing Complex/Difficult Patients

  1. leejcaroll

    This relates to primary care. docs would be interesting to see date on pain management docs. (That said if you dont want to follow recommendations then it makes sense if you stay they may fire you.
    Anecdote: I have chronic eye situation I call a ‘chronic emergency” My eye docs are great I call and they say well fit you in.
    They have wanted for past 30+ years to sew my eye closed permanently (it dries out this owuld protect it form potential ulceration). I have refused and it has been done by them as a temporary fix a few times over the years.
    If I were they I would have fired me (and I tell them this). They told me what they think should be done and I refuse. It makes sens to me then that a doctor would say I gave you my best recommendation. You wont agree so I am obviously not the doc for you. (My eye guys are wonderful, obviously ((*_*)) ).

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  2. Emily Raven

    Well when asking questions or explaining dangerous side effects you’ve had gets you labeled combative and a department they referred you to refusing to take you because they’re full gets you labeled as non compliant what are we to do besides acquire our (even non narcotic) meds from “alternative” sources?

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    1. leejcaroll

      I had a doctor “fire me” and write in the chart I was roo unpleasant a patient despite another doc in practice about 3 mths before writing me an apology for something he had done and telling me I was always welcome there.
      This other guy fired me after 2 incidents. 1) he was not needed in a med mal case costing him a couple 1000’s$ and 2) an aide had insisted I do a test I never do because it causes so much pain. She then said “How can you expect the doctor to cure you if you wont do the tests?” My situation in this instance is uncurable and lifetime with only the potential of worse outcomes I insoisted on an apology. Aftere not getting one and office manager apologizing for her I adit I got loud. They used that to fire me . If I were spo unpleasant they would not have seen me for at least 8 tears, my chronic emergency never reauiring an appiintment but I called and they said come (not the above guys in my commnet who have been wonderful) My other eye doc noted in my chart I was not unpleasant patuent.
      I would one ask to have note inserted if you feel you are not combative.If the department is full I can understand theyrenot taking you on but it makes no sense they would label you non compliant if they havent seen you.
      As to getting meds from “alternative sources” I cant comment to that.
      Im sorry you are having these issues with your med care

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      1. Emily Raven

        It was a pain management department in a hospital that did this. Pain management most places can get away with whatever they want because of the contracts they have you sign. The funny thing about the situation was the referral was for PT and the phone number for PT was right on the wall, so they easily could have called them to verify the 8 month backlog of patients. I only found out later from my primary doctor that they wrote that. Even she wasn’t very happy with that. They wanted me gone because they put me on a cox 2 when they knew I had heart problems and it made my symptoms worse (and very annoyingly did nothing for pain or the swelling that happens when I dislocate a joint. Advil doesn’t work for the pain much either but at the very least it helps the swelling a TINY bit so it’s easier for me to put the joint back in place myself.) I think it was a case of they knew they messed up and couldn’t make money off me because injections are harmful in my case (I want to try Botox trigger point because I can’t tolerate steroids. But they don’t offer that around here because the real money maker is epidurals.) It’s such a redicuous situation I honestly couldn’t make it up. But I have heard others say their spouses or parents they brought to the appointment got labeled as “violent” for asking for medical records and things like that, so I guess I shouldn’t be surprised.

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  3. lawhern

    I entered the following comment at STAT:

    As a patient advocate, I talk to pain patients every day who have been “fired” as drug seekers, for requesting medications that they have ample reason to know will work for them from previous experience. In reality what is going on may have much more to do with doctor and nurse stigmatization of people in pain because they are difficult to treat and consume a lot of physician time. With that in mind I must ask: when you “fire” a patient, how is your action different from deserting them without care?

    We’re not talking about violent behavior. That’s rare. Likewise, questioning the reasons behind a physician’s recommendations is not discourtesy. It is prudent interviewing. Doctors are not high priests or magicians. They get it wrong sometimes — and in chronic conditions, they rather OFTEN get underlying diagnoses wrong on the first go.

    If you as a doctor are refusing to develop a treatment team approach to your patients, then you’re ignoring a literature that demonstrates quite conclusively that outcomes are better when the doctor and patient are mutually respecting and communicating with each other. When the relationship is negative, the opposite is true. Go look up “nocebo effect.”

    And get over yourself!

    Liked by 1 person

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