Blog | Monday, March 19, 2012

You're fired! Can doctors really fire their patients?


A Wall Street Journal article that is getting a lot of attention is titled "More doctors 'fire' vaccine refusers." The article discussing the increasing frequency of pediatricians who are "firing" patients/families from their practices because they refuse to take recommended vaccines for fear of autism or other concerns (rampant on the Internet, but all proven untrue).

Many have started to blog or tweet about this. Richard Meyer at World of DTC Marketing.com poses the question Should doctors be able to fire patients? This is an interesting question that I will attempt to answer.

It is important to note that not only should physicians be able to fire patients, they must be able to fire patients. Physicians are allowed to choose which patients they accept (unless they work in the emergency room). This happens every day, when a physician refuses to accept a patient that does not have an insurance they contract with.

However, it would not be illegal (or even unprofessional) for a physician to for example, not accept any patients who currently smoke. Many primary care physicians will not accept a new patient who is a chronic opioid user (or will only accept them under the circumstances that another provider manages their narcotic prescriptions).

However, once a physician sees a patient, she has established a doctor-patient relationship. This is a legal and binding contract that comes with rights and responsibilities, such as confidentiality. In addition, if a doctor-patient relationship starts to sour, the physician cannot simply one day refuse to see the patient. This is called "abandonment" and is subject to legal action. Thus, physicians need to have a process to "fire" (terminate is the technical term) a patient from their practice, or they would become indentured to their patients indefinitely.

The process of terminating a patient usually involves timeliness of notifying the patient, provision of care until a new provider is found in a reasonable amount of time, and assistance with finding a new provider (such as providing recommendations).

The issue of pediatricians firing vaccine refusers is an interesting one, since the typical splits between doctors and patients are usually related to disruptive patients, unhappy patients or patients' inability to pay. The issue of vaccine refusal is more of a philosophical one, though concern for the health and safety of other patients and staff is certainly a reasonable concern.

However, another twist to this issue involves new models of health care where providers are rewarded for improvements in quality of care. Known as "pay for performance", physicians get a bonus if they can deliver better quality. These bonuses are generally delivered on patient population data.

For example, a target might be having 90% of diabetic patients getting annual eye exams or checking blood sugar control. Would it be acceptable/reasonable for a physician to "fire" a patient who refuses to follow the recommendation that the physician is being measured on?

Patient satisfaction is also becoming a popular measure. Would it be acceptable/reasonable for a physician to "fire" a patient who is constantly unhappy and likely to give the physician a poor satisfaction rating that he or she is being measured on?

Should there be laws against physicians firing non-adherent or unhappy patients? If not, and assuming most physicians will wind up incentivized by such measures, which physician would accept a known unhappy or non-adherent patient?

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.