Taking a hard line with noncompliant patients

I have dropped patients for noncompliance in the past and will continue to do so, not for pay-for-performance issues but for liability reasons. As a rural solo pediatrician, I have neither the time nor the desire to try to convince parents about the importance of childhood immunizations, follow-up with specialists, or medications. I tell parents that I have to be able to trust them to carry out the treatment plan, just as they must trust me to prescribe the proper therapy. If neither of us trusts the other, then the patient-doctor relationship is nonexistent and we must go our separate ways. I can easily forgive an innocent slipup or occasional forgetfulness. But if it's a constant battle between the parents and me, I'll let them go.

Wesley J. Sugai, MD
Kailua-Kona, HI

My practice, Stoltz and Hahn Medical Associates, a family practice in the Bucks County suburbs of Philadelphia, has taken an aggressive approach toward noncompliant patients. We've done this for two reasons: First, the impact on the patient and the associated liability of noncompliance; and second, the financial effect on the practice.

For the past two years, we have been flagging the charts of patients who haven't complied with health maintenance issues such as annual mammograms, gynecology visits, bone density tests, lab screens, baseline ECGs, eye examinations, colonoscopies, prostate exams, and so forth. Our office generates and mails a letter to the patient notifying him or her of the testing that has been recommended but not accomplished. A copy goes into the patient's chart, which serves as excellent documentation that we took the trouble to send out a reminder. This, combined with the initial point of service documentation, puts the responsibility squarely on the patient. In the event of a bad outcome—such as a new diagnosis of colon cancer in a patient who never had a colonoscopy—we feel confident that our charts clearly reflect that the patient was informed (in fact, urged) to have the preventive testing, but chose not to abide by our recommendation.

This system has been surprisingly effective in boosting patient compliance. Those who remain noncompliant over a period of time are asked to sign an informed refusal or to find another physician.

Brad Stoltz, DO
Trevose, PA

What comes first— patients or money?

Your article about potential clashes between ethical and financial issues ["Medical ethics: Your heart versus your wallet," May 16, 2008] addresses the ethical implications of dropping noncompliant patients to improve pay-for- performance measures, limiting or refusing to accept Medicare or Medicaid patients owing to declining reimbursements, and yielding to the temptation to undertreat patients to keep costs down or overtreat patients to boost practice income.

Generally I only accept Medicaid patients if they're referred by a primary care doctor I know. Unfortunately, Medicaid patients are more likely than other patients to be noncompliant and to miss appointments, and seem to have an attitude problem as well. And, yes, the reimbursements are too low. I always accept Medicare patients.

I'd never undertreat a patient to keep practice costs down or overtreat to boost practice income. We sometimes order stress tests and echocardiograms that we have reason to believe will be normal, but we do so because we need a baseline. Also, in the case of referred patients, we're obliged to do a thorough workup.

M.P. Ravindra Nathan, MD
Brooksville, FL

I am "old fashioned" and don't turn away non-paying patients. However, we sometimes refer patients to free clinics or an ophthalmology teaching clinic for care. Our hospitals have general medical and surgical clinics for non-paying patients.

Although patients' insurance information is indicated on the chart, it plays no role in the quality of care delivered. We see all Medicare and Medicaid patients. We definitely don't undertreat or overtreat patients with reimbursement in mind.