Home Forums Discussions General Discussion Discharge for Non-Compliance

I have some very polite Medicare patients who absolutely refuse to follow my treatment for diabetes, cholesterol, or hypertension along with refusing all cancer screening and vaccination.

I'm interested to hear how you discharge patients for non-compliance or non-adherence. What is your criteria and how often do you employ it?

This will sound like a silly answer and I hope not condescending. And, you will get way better specific answers.

But, have you asked them why they even come to the appointments?

Love it Bert!!
I have begun explaining to our Medicare patients what the doctor is held accountable for in regards to their actions or non actions as a patient.
I have read to them the audit requests from Humana and explained that we have to do this and if the patient does not get us the information, go for tests or get vaccinated the doctor is held accountable. Believe it or not, I have had a few patients change their mind . We can't force them to get the test, follow diets, exercise or get vaccinated but, we can educate them about what the doctor is held accountable for, in regards to the patient's healthcare, by the insurance company. Some patients say" I love Dr. Clinch and I do not want her to get in trouble". It makes me angry that the providers are more accountable than the patients but, not much to to but stop taking Medicare and that won't happen. We have a huge need for providers in our small town and surrounding areas.
Allison
Family Practice

I think Wendell's signature line says it all:

"The patient's expectation is that you have all the answers, sometimes they just don't like the answer you have for them."

Used without permission from Wendell's posts but credit given

Bert you have permission to use that anytime you want!

Another option is to make a contract with the patient. Have them sign that they will take meds, follow regimens etc, or will be discharged from the practice. On the next visit either they have complied or need to move to the next step (see below).

If they will not make the contract ("I like my french fries too much doc") then pull the option to terminate them. Inform them (with another document) that 30 days hence you will no longer provide care if they are not willing to sign that contract and get their signature on THAT document. Let them know the number to some service that will link them to another physician (state medical society, "1800 doc") or the like. You have given them alternatives and another option for care so you cannot be accused of abandonment. If they will not sign that paper, you must send a letter to their house by certified mail informing them of the same.

Sometimes shock and awe are necessary!

Y'all are too nice. I just document that they were advised and either declined or failed to followup. Patients (and people) are free to make poor choices.

As far as MACRA changing the rules to sanction doctors with non-compliant patients, that may be a game-changer in the future. We may need to terminate these folks for our financial survival. I hope there is some exemption if the doctor made an effort but the patient balks.

I just say, "Are you going to get your vaccines today."

Parent: "No, I am still against vaccines."

Bert: "Do you still have Aetna and are paying your copays?

I don't understand this Nazification of medicine.
Doctors are teachers, advisors, sometimes surrogate mothers and fathers -- but not drill sergeants.

We are in a free country, where it is not illegal to be stupid, make poor choices, or march to a different drummer. We are not in the Army -- at least I am not.

Where does the idea come from that whatever the insurance company says is law, and that the duty of the doctor is to enforce it?

My patients come to me for advice. Sometimes they take it, sometimes they don't.
Sometimes they are right and I am wrong. It's an ongoing conversation.

Medical orthodoxy is subject to change -- and then what was once ironclad rule becomes anathema. Nowhere is this more glaringly obvious than in the treatment of chronic pain.

It is of course, the right of any physician in a free country to refuse to treat anyone who doesn't agree with him or her -- but I can tell you that my practice is made a lot more interesting by I including people who disagree with me. I learn a lot from those folks.

Again, you really should be a writer. And, I also tend to agree with you. I have never dismissed anyone for non-compliance that I recall. And, we have a pretty open vaccine policy as well. I usually talk about it at each visit just a little and eventually, they may get some shots. Of course, it is a lot easier when there is a Pertussis epidemic. And, I am sure if a Lyme vaccine for humans and not just dogs comes out, they will be the first to get in line, given it is rampant here in Maine.

I guess I would go to an attorney or a financial advisor and end up making my own choice, but it seems kind of silly to seek advice and not follow it. Although medicine is slightly different. It is a conversation and a two-way street. But, I had to give these links to a couple of Jimmy Kimmel Live shows. They are very educational and hilarious. A warning on the first one. It starts with a Victoria's Secret commercial, and know I didn't rewind the video. It also had a major spoiler for Breaking Bad. The second one is even funnier than the first.

https://www.youtube.com/watch?v=QgpfNScEd3M

https://www.youtube.com/watch?v=i2mdwmpLYLY

Bert--
I ask advice, or at least ask for an opinion, from lots of people, all the time that I have no intention of following.

So many "experts" are so completely self-serving and venal and generally just so full of [censored] that I wouldn't think of taking their advice without qualification. I just include it in the picture of reality that I am constantly building and re-building

The Quakers have a saying -- "everyone has a piece of the truth".

I do not disagree at all. I am just a little more likely to follow advice if I have researched that expert and am paying him or her. That's just for me. Now do I care if anyone follows my advice? Not really.

Wendell's response: You just need to find another doctor who is willing to practice poor medicine

This is my take as well. Anyone that has been doing this a while knows that medical "wisdom" is constantly changing and that a good portion of current recommendations is going to change. This is especially true in preventive medicine which is where Medicare and insurers seem to be focusing. I am giving my patients my best advice at the time of the appointment but it's up to them whether to take it.

Again, I don't completely disagree. I tend to give my patients choice.

While medical wisdom is constantly changing, you can only go with one is known at the time. I strongly encouraged Rotashield to my patients before it was taken off the market due to possibly causing intussusception. Then I recommended Rotatek.

Now, I do get a colonoscopy every five years. Maybe it will change next year and only be recommended every seven years.

Patients should have the right to do what they want, but it seems unwise to make that decision based on the advice may change down the road.

Bert-

You forgot to mention that Dr. Oz knows a lot more than you or I.
My patients have to balance his wisdom against mine.
I don't always win.

Tom,
I agree 100%. We absolutely should not be making decisions on whether to terminate with patients based upon fears of government reprisal.

I think it is critical to look at the relationship we have with our patient. There is a reason they are coming. We may not understand that reason. The doctor patient-relationship is the foundation of patient care not whether or not our patients comply. In fact, I would say that trying to understand the barriers to adherence and maintaining an empathetic stance is at the core of what defines our role as healers--and makes our job more interesting.

Vaccine issues aside, so what if a patient a patient with diabetes is not following a diabetic diet--risking their health and making our job harder. That same patient may later develop cancer and we may be the only doctor they trust us to help him or her during a life threatening illness. Sure there are rare times to terminate with a patient but usually not for non-compliance alone. I thought paternalism was out of vogue.

I know I am a psychiatrist but I firmly believe that the best thing we can do for our patients is to listen to them.

I'm just glad my dentist doesn't discharge me for not doing x-rays as much as he recommends.

Recommendations are just that. We are not infallible. We pushed mammograms yearly from 40 and now realize it is not that useful. We pushed yearly pap smears til forever... on and on.

As frustrating as it is with more "quality" measures looming, I support my patients rights to have choice within reason. (e.g. I'm all for California's mandatory vaccination in for public schools due to frickin' measles again). And I'm all for raising cigarette and soda tax to pay for their societal health costs.

I agree with most of what everyone says. Hell, there are very few people who take pediatric patients who refuse vaccinations here. I let them. It's their kid.

I don't think Chris completely meant it in the way everyone took it. I guess I would look at it more like venting.

I had a patient bring their three-week-old infant in for colic, vomiting, eczema and diarrhea in the stool. Slam dunk milk protein intolerance. No, we don't need Zantac. I don't like medications. Not going to argue the merit of Zantac. And, that is one that is no big deal. Seems like you need Nutramigen. At least until we make the diagnosis. It's too expensive, can we wait? I'm like sure. (you'll be back) You don't outgrow an acute cow's milk sensitivity. How about hemoccult cards. Nope.

So, venting, "Why did you even come in?"

But, overall I agree. What I don't agree with is saying that there is merit to their not taking advice based on it may debunked later. I know I am possibly twisting it around. But, at the moment, it is difficult for them to think, I will not do it, because you may be wrong in ten years. Sure, it's fine for someone to turn down the flu shot, because it may cause Influenza A, and they have never had it anyway, and they may die from Influenza A pneumonia. We all know that is wrong. If they don't want the shot, fine. But, not because we may find out it that the dead vaccine does cause Influenza.

I don't even argue with them. Just tell them, it would be a good idea to get it. Up to you. But, I do tell them to call me when they see someone get Diphtheria or Polio or Tetanus or H. flu after the vaccine. Then, I will stop vaccinating.

It's funny the type of advice that works. If you have a Medicaid patient, DHHS couldn't care less if they go to any of their well child visits. They don't care at all if they get one shot. Until someone calls to report them for anything. Then they want to know if they have missed one wcc visit or are they up to date with their shots. So, when there have been past issues with DHHS or they are in a custody battle, they won't get the shots because they are helpful, they will get them because not getting them will work against them in court.

I think this is more of an issue in adult medicine. Vaccines in children are pretty straightforward. I do see kids whose parents refuse vaccines. I figure it is better for the kids to be seen and have me tell their parents I think they should get their kids vaccinated than not to be seen at all. And often they do end up agreeing to some vaccines.

In adults I've seen goals for BP, lipids and A1C's change many times over the years. How often to get PSA's (if at all) is still being argued. The guidelines for mammograms, colonoscopies, etc in the elderly also have changed and are still being debated. Often I will tell a patient I am giving them my best advice but if they go down the street and see another doctor they may well tell them something different.

I also see a lot of polypharmacy and have a good deal of sympathy when a patient says "Dr X wants me to take this but I don't want another pill". In that case I explain the reasoning and let the patient make the decision. Sometimes the benefits of medications given to meet "the guidelines" are marginal and the implications of giving them along with ten other meds are unknown. Basically it's my job to give the patient my best advice and their job to decide what to do with it.

Hi Rando,

I agree with you 99.99%. In fact, I probably dismiss patients less than anyone. Hell, you can No show 50 times in a row, and I will likely not discharge you. Just not worth my time to keep track and send letters, etc. (But that is another story).

I do remember early on in my career discussing/debating/arguing with a patient about the need for her child to have an U/S and VCUG after the first UTI. We generally just do an U/S after the first. We also do not think that UTIs and renal scarring necessarily lead to kidney failure.

If I saw that patient again, I would likely tell her it is a good think you didn't take my advice. We now do not recommend a VCUG. But, that is hindsight is 20 - 20 vision type thinking.

Whether or not I think I should dismiss a patient over not following my advice is a separate issue. If the patient says, I will think about your advice and come to my own conclusion, that's great. But, for them to say, "I will think about your advice and come to my own conclusion, especially since it is possible your advice may change after it is debunked ten years down the road," doesn't fly well with me. I can only give my best advice based on the science and the recommendations at that time. THAT is the advice they should heed or not heed. Not the advice that may be given ten years from now.

Suppose a patient is going into kidney failure, has high cholesterol and their blood pressure is consistently high. However, they refuse blood pressure medication and statin treatment, both recommended for preventing worsening of the kidney failure. For your liability, it is very important to document a conversation about how you are trying to save their kidney and their refusal to comply. My insurance also says an "Informed Refusal AMA" is good for them to sign, listing the bad outcome of their choices and the medical recommendations they are refusing. But, when it comes time to signing these things, I start to wonder what the point is of continuing care.

Please familiarize yourself with this code, and use it regularly:
Z91.1 - Patient's noncompliance with medical treatment and regimen

And if you give injections, there is also:
Z86.21 - Immunization not carried out because of patient refusal

Seriously. You should be documenting these.

Thanks Jon. Good idea.

I have asked patients why they come to the appointments. My question for you is is it worth dumping them? Are you busy enough where you would rather dump them and open spot for others. If they want to come and waste their time, if you are getting paid, who cares? On the other hand if they are medicare pts and you can fill spots with others i understand.

I would write a letter to them, certified mail and let them know that with their non compliance, it seems there is an inherant trust issue in the doctor patient relationship and that you think that they would benefit from another physician they can trust. Let them know they have 30 days to find another physician.

Hi Ketan,

But, you do sports medicine. People must always do what you recommend.

haha, fired a patient yesterday...did it on the phone told her i will mail her mri results for her kid and she should find another doc because we don't treat people who treat our staff disrespectfully...or have no understanding of the whole system (this mom was upset her kid didn't get an MRI within a day of seeing me cause i wouldn't write it stat for a knee issue)...yeah we do discharge pts every so often...

But everybody gets an MRI the same day, but yells about the price of healthcare in the same breath. Good for you. Patients can and are disrespectful and we are told to take it or they may write something bad about you on all the internet review sites..good for you!

They can write all they want on the Internet reviews. Just don't tell the board they don't like my ties.

The worse part is the MRI will show ligament damage, but the parent will wonder if he/she still play in the state final of fill in the blank.

With respect to the first post it refers to very polite patients that just won't follow instructions. That's a different thing than patients that are disrespectful to the staff or are a pain in other ways.

If a patient is non-compliant but otherwise not causing a problem I don't dismiss them. My reasoning is basically the same as seeing the kids whose parents don't give them vaccines - they are better off seeing me every so often than not seeing me at all. In the patient Boondoc talks about that's going into renal failure but won't treat the underlying problems, at least you can follow the renal function and hope that at some point the patient sees the light.

The exception is patients on controlled substances who have to follow the rules without fail, but even then I don't usually dismiss them from the practice, I just won't prescribe controlled substances for them any more.

This all may change with the Medicare quality measures. To me the problem of doctors getting rid of patients that are non-compliant so they can look better to Medicare is something that was easily foreseeable but Medicare hasn't addressed.

I think documentation is really important, and that is why I started doing the Informed Refusal as suggested by my insurance company. Regardless of the patient's decision, their families can and do sue doctors after grandma dies. It's pretty hard to argue with an Informed Refusal. Our community is really short on Medicare accepting doctors, so I think such a patient may need to move over for someone who wants to see a doctor, has Medicare, and will actually benefit from the care by following directions.

Rando I agree with you on the polite patients and not following instructions. I think my point was simply that document the heck out of it and let the patient know by certified letter.

I document it, but I can't see spending the $3.00 to $4.00 for the envelope and cost of certified mail. Especially when half my practice changes addresses like they change their shoes.

I think it is interesting to realize there are two types of information here. I guess I tend to think like a surgeon in this regard:

There is the what we are talking about above: (not sure what you would call it. Non-compliance:

Documenting when you give advice to patients, and they choose to do otherwise. You may even put that I recommended this based on the prevailing thinking of today and based by the scientific literature of today. I told the patient that while my advice is what is believe to be best today, it could change tomorrow. I also encouraged my patient to read about this and not to just go by what you read on the Internet, but I would be eager to know what they found. I think we all too often just blow off the patient's ability to research their disease. After all, we must research up to 25 or more patients a day while they only have one.

The second is informed consent:

With informed consent you must inform the patient of three things:

Why the surgery will be beneficial and the risks/benefits of it. The alternative of doing nothing and the risks/benefits of that. And, what, if any, other alternatives are there.

I almost think that using informed consent would be helpful here. You can eat a low-fat, high carb diet as recommended by the food pyramid and the food industry. Risks and benefits explained. You can do other diets such as the Mediterranean diet with risks/benefits explained. Or you can do nothing.

I purposefully wrote about the low-fat, high carb diet as that is falling out of favor and is a good example of what those say about our not only being correct. When decades of bad science show something to be true, it is difficult to go against it.

There is also the bias of going against the CDC. When the Hep A vaccine came out, I didn't recommend it form my patients. I have seen one case of Hep A in Maine. I personally think it is unnecessary. Then there was a case 30 miles south of here, where the patient was rather sick. Then, I realized I needed to offer it.

It is also interesting that what is documented is considered what happened and what is not didn't happen. You could talk to someone about the importance of an echocardiogram for 30 minutes, and the conversation didn't happen if not in the chart. You could tell him or her to Google it and document a conversation, and you are safe. This happens with coding all the time.

I do want to say that we have been a little hard on Chris. I don't think the gist of what he asked was completely what he may have meant. It was boiled down to dismissing the patient based on non-compliance (which to be fair is the title of the thread), but I took it more to mean what does everyone do with the non-compliant patient.

Chris, correct me if I am wrong.

Bert:

Valid points for sure. I don't know what I would do in Chris's position with FP patients. with injuries my answer is simple, keep coming in and paying me to tell you how to get better, but it won't kill you if you don't, and you will just live in pain or cut out the inciting activities...no biggie...I got out of general practice for a reason, i got tired in residency of begging patients to take the meds and change habits and use a seat belt and stop smoking...in the end, I just didn't care...i am of the mind, that i am giving advice based on my knowledge, experience, research, current thoughts, etc...you are welcome to take it...but i am not betting anyone to do anything..i am not praying for them to do it..it is their life after all and they can make those choices...

the problem with this thinking is that most pts who won't take the advice, will then turn around and tell people that we didn't fix them..and so the game goes on

Interesting. That is why I like Osgood-Schlatter's or Sever's. I can tell them, hey, play all you want. Let pain be your guide, but it will get better if you stop for a while or choose a sport that lets you run on grass.

But, I had a female in high school who was rated the number one soccer player on the best team in the state. She suffered an ACL tear and needed surgery. I and the orthopedist advised to take a year off, but she just wouldn't do it. Ended up with four surgeries and didn't get to play in college. Delayed gratification is tough for a 15 yo. That is where the parents come into play. Plus, when you are that good of an athlete, you can play most sports and be successful like swimming.

Had one kid with a very loud heartbeat and got an EKG. Super large waves. I just told them to at least wait for cardiology to get an Echo. But, he had to play in the playoffs. Turned out he did have Hypertrophic cardiomyopathy. He made it through the 800 and mile, but why risk it.

I am with you on the advice. Maybe I sound cruel, but I don't say much about their smoking or weight. I will refer to the WOW program for weight, because it has been shown to work, but it is obvious that neither they nor their parents care to work on it. I am not saying that some kids have a much tougher issue with weight; I just think they become frustrated with me for bringing it up. I just show them their growth chart and leave it at that. I have read that bringing up smoking is helpful. I just don't see it. Once they want the nicotine patch, I will help them.

I used to "discuss" compliance with patients until I was blue in the face and running so late I had a waiting room full of angry patients. After almost 30 years, I have grown weary of trying to convince patients that they should listen to me rather than Dr. Oz or the pharmacy tech at Walgreens. I simply tell them I want them to have heard my recommendations and advice because that is what they (or rather their insurance) is paying me for and then they can make their decision. They are adults, I am not their parent and they are free (for the time being) to make their own health care decisions. I do many times, however, tell them that in the very near future they may not have that luxury of making their own decisions. I warn them that insurance companies are beginning to put more of the onus on the patient and that they may no longer cover or will increase premiums of patients who refuse to comply with current standards of care. More and more employers are also demanding that their employees participate in "Wellness" programs.

I have always documented in their chart their decision not to take my advice but, Jon, I was unaware there were codes for this as well. I thank you for that.

Once again, Leslie and I agree. I quote this, because I didn't hear anyone talk about it. Not that they need to. I did recommend it though, and there was non-compliance. Not it just goes along with what we are talking about, and it is very funny.

hahaha!!!

Are you just saying that or did you watch them?

Let's note that Leslie has been waiting, and waiting for the right time to jump in with her 2,000th post. And there it is.

Let's also note that she was waiting to be able to reply to me.