JAMA Forum: Is “Firing” the Patient an Unintended Consequence of Value-Based Payment?

Diana Mason, PhD, RN

Diana Mason, PhD, RN

How frequent is the practice of “firing” patients? Research is sparse, but one recent survey found that one-fifth of pediatricians said they had dismissed families for refusing childhood immunizations. If you Google “firing patients,” you’ll find discussions about whether physicians and group practices can fire patients, under what circumstances, and how physicians can do so ethically and legally.

For example, the Texas Medical Association advocates firing patients “if the noncompliant or difficult patient continues to misbehave” (emphasis added), and the American Medical Association has guided physicians on how to avoid charges of abandonment when ending relationships with patients. Patients are fired for various reasons, including when they

  • exhibit difficult behaviors associated with mental illness.
  • fail to pay medical bills.
  • have too many “no shows” to appointments.
  • fail to follow recommended care.

As value-based payment methods financially reward or punish practices and health care organizations on their ability to improve outcomes, the firing of patients may become more attractive to those operating on thin margins.

A dismissed patient can usually receive care from other practices or the emergency department. Yet this can disrupt the continuity of care, which in turn can increase the likelihood of hospitalization and raise costs. A colleague who works with patients whose care needs are highly complex told me that she is seeing an increase in patients being fired for repeatedly missing hemodialysis appointments, for overusing opioids or benzodiazepines, and for having a persistently high blood glucose level while not following the treatment regimen. She told me, “The core question in all of this is what level of accountability do we, as a health care system, have for responding to the needs of complex patients?”

The Complexities of Value-Based Payment

A value-based payment approach, which is mandated by the Affordable Care Act, is intended to reward clinicians and health care organizations for improving clinical processes, outcomes, and patient satisfaction, while reducing costs. Medicare’s Hospital Value-based Purchasing and Readmissions programs and the Physician Value Based Purchasing Program are examples.

The Centers for Medicare and & Medicaid Services (CMS) has committed to ensuring that those who serve disadvantaged populations can benefit from the value-based payment programs. But some evidence shows that safety-net hospitals and academic medical centers have not reaped the same financial benefits as those that don’t serve large disadvantaged populations. This may be so for primary care practices serving disadvantaged populations, as well. Researchers have demonstrated that living in a community with a high level of poverty is associated with poorer health and a 24% increase in 30-day hospital readmissions in an academic medical center. Furthermore, safety-net hospitals in California and elsewhere have been penalized under the Medicare value-based payment programs.

The calculations for penalties and incentives are complex. A 2014 RAND report found that value-based payment complicates how success is measured, whether using HbA1c levels, influenza immunizations, or preventable hospitalizations, for example. Should patients who don’t show up for appointments or don’t have the resources to adhere to treatment regimens be included in the “denominator” (the total number of patients considered in the calculation of performance on a measure) in payment calculations?

Although it may not make sense to eliminate poor patients from the denominator, other means of adjusting incentives or penalties ought to account for patients’ socioeconomic status. Poor patients may not have the resources to fill a prescription or pay for transportation to a visit. New York and other states have recognized that adequate housing is essential for improving health outcomes among “dual eligible” patients who receive both Medicare and Medicaid benefits. Patients with chronic mental illness may have difficulties negotiating the health care system, and low health literacy may make it more difficult for a patient to follow a treatment regimen.

The value-based payment model is in its infancy. Last year, a Government Accountability Office report showed that safety-net hospitals received lower bonuses and larger penalties than non–safety-net hospitals in the program’s first 3 years, although the gap was narrowing. It noted that the program didn’t appear to have much effect on care quality but may in the future. The report raises the question of whether clinicians and health care organizations are putting too little emphasis on how to improve health outcomes that matter to patients.

Beyond Firing Patients

Amy Berman, RN, senior program officer for health systems for the John A. Hartford Foundation, told me that the greatest opportunities for reducing costs and improving outcomes under value-based payment will come from the “high utilizers” of the health care system. She argues for removing from the denominator of payment calculations patients whose care goals don’t align with standardized treatments, such as patients who don’t want aggressive care or whose HbA1c levels are increased by another medication. She suggests that CMS require practices to report on whether they elicit a patient’s goals and, if the goals don’t match those of the treatment guidelines, the patient be removed from the denominator.

Some have questioned whether hospitals have a responsibility to address social ills. But as evidence confirms a connection between health and the social determinants of health, there is a growing recognition that we must move toward a model of health care that incorporates social factors and engages community resources. Health Leads, a program to link referred patients to resources that can address social factors affecting health, is expanding because more clinicians and health care organizations understand the importance of addressing social determinants in helping their patients lead healthier lives.

Many clinicians struggle to meet the needs of complex patients when there is insufficient infrastructure in place. Is there a referral process for patients who fall behind on their bills? Is there integrated mental health training for staff to learn how to deal with challenging behaviors? Is there a robust care coordination process in place in a primary care practice? Is there a better process for managing patients who are “no shows” to decrease their negative financial impact?

Lauran Hardin, RN, MSN, CNL, directs the complex care center at Mercy Health of the Trinity Health System, which is attempting to answer such questions. She told me that  “[i]nstead of focusing on changing the patient, we’re focusing on changing the care system for the patient, including beyond the hospital walls.”

Models for improving care of high-need patients exist, and although the evidence on some is equivocal, we need greater support to integrate what works into existing practices. In 2012, CMS launched a Comprehensive Primary Care initiative that requires participating practices to build out access and continuity of care, planned chronic and preventive care, risk stratified care management, patient and caregiver engagement, and coordination of care across the medical neighborhood. The evaluation of the initiative’s first year revealed that it reduced Medicare expenditures and service use. Together with CMS’s accelerated move to global payments, health care practices may be in a better position to improve care processes rather than fire patients.

When I visit my primary care clinician, she makes evidence-based recommendations for common screenings, tests, and procedures. I don’t always take her advice, but tell her why. Sometimes she agrees with me, but not always. I’ve often wondered whether she is financially affected by my “noncompliance.” I hope not. And I hope she doesn’t fire me.

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About the author: Diana J. Mason, PhD, RN, is the Rudin Professor of Nursing and Codirector of the Center for Health, Media, and Policy at the Hunter College; Professor at the City University of New York; and immediate past president of the American Academy of Nursing.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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