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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.

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

“The reasons practices are dismissing patients aren’t so much related to the things people were worrying about — that if [insurers reimburse more for] quality of care, doctors might start cherry-picking patients,”  said Dr. Ann O’Malley, Mathematica Policy Research senior fellow and lead author.

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
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O’Malley said some of these reasons are “perfectly legitimate reasons to dismiss a patient.” 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.

The reasons behind patient dismissals can be controversial, too. For instance, many pediatricians have treated children whose parents are opposed to vaccinations. As the anti-vaccine movement has grown, the American Academy of Pediatrics last year said that doctors may dismiss such patients as a last resort so long as they provide information about finding a new doctor and provide emergency care in the short term.

Have you fired a patient? Have you been fired by your doctor? Tell us below.

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  • 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!

  • These reasons for termination do seem reasonable on the surface. But not many people have read pain contracts carefully. How about if the pain contract you must sign to receive care means you can’t travel to the adjacent state to visit a terminally ill parent without risking termination? I’m a physician and a patient. The physicians have the power. I had to sign such a contract that meant I couldn’t visit my dying mother. I had no other option at the time. People with degenerative systemic diseases are at a serious disadvantage and no one is interested.

  • “Doctors might start cherry-picking patients” What? You mean like patients and payers cherry-pick doctors? Oh no! A level playing field where everyone has to earn their position. Hmmm…sounds like a rational system with proper feedback mechanisms. If patients and payers thought that no other shoe would drop in the consumerization of healthcare, its time to reevaluate that assumption.

  • “O’Malley said some of these reasons are ‘perfectly legitimate reasons to dismiss a patient.’”

    They ALL seem like perfectly legitimate reasons to me.

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