When is a patient's life choices not your fault?

[BklynRN]

Just out of curiosity, what do you all think about the health care professional/medical facility now being penalized if their patient comes back within a certain amount of time for the same Dx/problem and that the facility/provider will not be reimbursed..... do you have to start living with these people 24/7 to make sure they adhere to their treatment plans? at what point is the ADULT PATIENT held accountable for their own decisions?

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[Psai]

Not my fault. People will just stop seeing these patients

 

[Jabbed]

Not my fault. People will just stop seeing these patients

Most physicians don't have the option/luxury of turning down Medicare patients.

 

[CubsFan314]

I believe this came about because of the trend of hospitals dismissing patients too early. The financial incentives were structured so that hospitals were "rewarded" for discharging early (same DRG without the expenses associated with an extra day of hospitalization). Some of the unintended consequences of this "bounce-back" rule is what BklynRN is talking about. If someone is hospitalized for heart failure, gets adequately diuresed, educated, and then discharged, but then goes out and eats a pound of salted meats and then gets re-admitted, the hospital gets penalized despite doing everything they could (within reason).

 

[KnuxNole]

Same for medicaid. I feel like if I don't see Medicaid or Medicare patient's, that's taking out like 90% of the patient population :O

 

[username456789]

In a lot of practice environments, it's actually more lucrative not to pursue collections from Medicaid, as you might expend $40 worth of manpower to collect $30.

And by more lucrative, I mean less damaging, financially.

 

[PL198]

A patient's life choices are never my fault. Ever. Nor is it my mechanic's fault if I drive my car without oil. Or my grocer's fault if I decide to eat a gallon of ice cream for dinner every night.

It's funny, society doesn't want "paternalistic" medicine but they don't want to take personal responsibility either.

In the end this will probably just mean the advancement of concierge medicine, as more PCP's decide to treat only well-off compliant patients for $$$$

but medicine is different! It's a calling! You can't compare yourself to a mechanic!

/s

 

[Psai]

Same for medicaid. I feel like if I don't see Medicaid or Medicare patient's, that's taking out like 90% of the patient population :O

See fewer patients, have more time for people you can help and actually want your help, are reimbursed fairly by insurance or private pay. Not sure what the downside is

 

[KnuxNole]

That does sound good, I was worried that there would not be enough people with regular insurance, they seem SO rare!

 

[BklynRN]

Yeah, it's everybody's job to keep them out of the hospital, except the individual. Eventually with baby boomers coming on into Medicare and Medicaid within the next 8-10 years, they will have to again severely cut reimbursement rates to the point where it will be nonsensical to participate at all in Medicare/Medicaid (which it already is).

 

[W19]

but medicine is different! It's a calling! You can't compare yourself to a mechanic!

/s

I hope you are being sarcastic...

 

[Cytarabine]

Just out of curiosity, what do you all think about the health care professional/medical facility now being penalized if their patient comes back within a certain amount of time for the same Dx/problem and that the facility/provider will not be reimbursed..... do you have to start living with these people 24/7 to make sure they adhere to their treatment plans? at what point is the ADULT PATIENT held accountable for their own decisions?

They're held accountable for their own health in the sense that they're passively killing themselves by being nonadherent. As far as a systems level perspective, no, individuals aren't held accountable. I honestly don't expect that to change at any time in the near future. You can just do your best to make and explain your recommendations / tailor your therapy in a way the patient is more likely to be adherent, etc. Maybe at some point in our careers, there will be individual accountability factored in to quality based reimbursement/penalties, but I wouldn't hold my breath

 

[Siggy]

They're held accountable for their own health in the sense that they're passively killing themselves by being nonadherent. As far as a systems level perspective, no, individuals aren't held accountable. I honestly don't expect that to change at any time in the near future. You can just do your best to make and explain your recommendations / tailor your therapy in a way the patient is more likely to be adherent, etc. Maybe at some point in our careers, there will be individual accountability factored in to quality based reimbursement/penalties, but I wouldn't hold my breath

Yea, but if I drive like an a-hole and wreck my car, get it fixed, and then wreck it a second time, the mechanic doesn't take a financial hit because I was an a-hole on the road.

If a patient decides that he wants to go drinking every Friday after dialysis and ends up being admitted on Saturday for fluid overload, the hospital taking care of him gets a financial penalty because the patient was an a-hole.

 

[Cytarabine]

Yea, but if I drive like an a-hole and wreck my car, get it fixed, and then wreck it a second time, the mechanic doesn't take a financial hit because I was an a-hole on the road.

If a patient decides that he wants to go drinking every Friday after dialysis and ends up being admitted on Saturday for fluid overload, the hospital taking care of him gets a financial penalty because the patient was an a-hole.

Pretty much. Were you disagreeing with me or just kind of adding on? I don't disagree, that's the system we have, and I don't anticipate in changing in the near future

 

[Siggy]

Pretty much. Were you disagreeing with me or just kind of adding on? I don't disagree, that's the system we have, and I don't anticipate in changing in the near future

I disagree that the response should be, "Well, they're being held accountable because they're killing themselves."

Just because they are killing themselves, they get away with what should be tantamount to theft of services?

 

[Cytarabine]

I disagree that the response should be, "Well, they're being held accountable because they're killing themselves."

Just because they are killing themselves, they get away with what should be tantamount to theft of services?

What's the solution? If they have insurance, they lose it? Lose protection under EMTALA? What does it take for that to happen? Missing every other dialysis? Having a comorbid substance abuse disorder? Forgetting to take a lasix dose now and then, or having difficulty keeping to a fluid/salt restricted diet?

 

[Stagg737]

What's the solution? If they have insurance, they lose it? Lose protection under EMTALA? What does it take for that to happen? Missing every other dialysis? Having a comorbid substance abuse disorder? Forgetting to take a lasix dose now and then, or having difficulty keeping to a fluid/salt restricted diet?

Set a standard and enforce it. If a physician tells a diabetic they need to cut their sugar intake by 50% and take their insulin to get their A1C to an acceptable range and they come in with an A1C of 13%, it's pretty obvious they're not adhering to their treatment course. It's an easily measurable factor that is directly linked to the patient's adherence to pre-set guidelines. If they don't adhere, punish the patient instead of the physician. You don't have to punish them harshly, but when medication that used to cost them $15 to fill a prescription suddenly costs them $50 they'll probably get the picture pretty quick.

Obviously, one couldn't do that for every condition, and the 'punishment' would have to be something that would encourage the patient to stick to their treatment plan without sacrificing their health. However, punishing the providers for behaviors that are totally out of their control isn't the solution, as you already stated.

 

[Cytarabine]

Set a standard and enforce it. If a physician tells a diabetic they need to cut their sugar intake by 50% and take their insulin to get their A1C to an acceptable range and they come in with an A1C of 13%, it's pretty obvious they're not adhering to their treatment course. It's an easily measurable factor that is directly linked to the patient's adherence to pre-set guidelines. If they don't adhere, punish the patient instead of the physician. You don't have to punish them harshly, but when medication that used to cost them $15 to fill a prescription suddenly costs them $50 they'll probably get the picture pretty quick.

Obviously, one couldn't do that for every condition, and the 'punishment' would have to be something that would encourage the patient to stick to their treatment plan without sacrificing their health. However, punishing the providers for behaviors that are totally out of their control isn't the solution, as you already stated.

I'll assume you can find the flaw in punishing treatment nonadherence by increasing the cost of treatment assuming it's just a quick example without much thought. At any rate, I'm all for individual responsibility, but I think working out how to actually incorporate that into practice gets murky. You have 10 patients with an a1c of 13, they may all have different reasons for being nonadherent. Minimal time to prepare healthy meals, dislike needle sticks, diarrhea with metformin, unaware of effects of DM, located in a food desert, passive aggressive move against the physician for some perceived slight, uneducated on proper diet or way to administer medication whatever. All have different barriers to remove to get them to want to or be able to adhere to a treatment. Is there a a single punishment or reward that's going to increase adherence of each?

 

[Siggy]

What's the solution? If they have insurance, they lose it? Lose protection under EMTALA? What does it take for that to happen? Missing every other dialysis? Having a comorbid substance abuse disorder? Forgetting to take a lasix dose now and then, or having difficulty keeping to a fluid/salt restricted diet?

I don't know. I do know that the solution isn't to cut reimbursement to the physician who has no control over the patient's free will.

 

[notbobtrustme]

Maybe if we didn't waste 2 trillion dollars on failed fighter jet programs, we'd be able to afford sensible solutions to our health care problems.

But that Raytheon stock tho.....

 

[FrkyBgStok]

I think there are two sides to it. I agree that the physician shouldn't be penalized for the choices of the patient, but that being said, handing a patient a pamphlet on their principal diagnosis isn't "education." Patients are quick to blame physicians for their own mistakes but physicians are also quick to throw up their hands and say "not my fault." i am making generalizations, sure, but i have seen attendings and residents presume they know the patient and just chalk up a problem to "the patient not caring about their diabetes." I have listened to doctors give beautiful plans on treating a certain condition and the patient voices understanding, and then when I (the med student) check on them later, they voice that they have no intention of adhering to that plan because they can't afford anything the doctor said and were too embarrassed to say anything. Is this the fault of the patient being poor and not speaking up, or the doctor not actually finding out why the patient doesn't stick to the plan?

I agree that society doesn't want paternalistic medicine, but medicine works hard to be paternalistic. This is all the opinion of a nobody med student so disregard if you choose. Luckily, I will not care.

 

[Stagg737]

I'll assume you can find the flaw in punishing treatment nonadherence by increasing the cost of treatment assuming it's just a quick example without much thought. At any rate, I'm all for individual responsibility, but I think working out how to actually incorporate that into practice gets murky. You have 10 patients with an a1c of 13, they may all have different reasons for being nonadherent. Minimal time to prepare healthy meals, dislike needle sticks, diarrhea with metformin, unaware of effects of DM, located in a food desert, passive aggressive move against the physician for some perceived slight, uneducated on proper diet or way to administer medication whatever. All have different barriers to remove to get them to want to or be able to adhere to a treatment. Is there a a single punishment or reward that's going to increase adherence of each?

Yes, I do realize the fairly obvious flaw, but money talks. You wouldn't need to do something that drastic either. For example, if someone is unable to adhere and comes in with very high A1C you increase the cost of the next dose by a dollar, and another dollar each time they come in without adhering. Then if they do adhere you reward them by bringing it back down to the original cost. Personally, I think a system that provides a bare minimum but rewards people for being adherent/maintaining their health would be more effective than a system which punishes delinquency, but that would have it's own problems.

Out of the reasons you gave, I highlighted the ones that I feel one could make a legitimate argument for. Being uneducated on diet is something that the physician could easily address. It's not that hard to explain to someone which kinds of foods will potentially effect their diabetes negatively, and many of the other reason you gave should be explained by a doc anyway. If a person is really afraid of needles then I'd buy that, but they could also get an insulin pump. If they just don't like needles that sucks, but they've gotta deal with it. Plenty of kids hate needles too, that doesn't mean we don't vaccinate them. The only one that I really think you can make a strong argument for is the diarrhea because it's something they basically have no control over, but I would think that there would be some kind of alternative. When it comes down to it, their choice is to either work to manage their condition or don't manage it and put their own health at risk. If they consciously choose the latter, then I don't think it's right to punish the provider for that or even fair that others with the same insurance company/whatever coverage will pay more in premiums/taxes because a significant number of people aren't willing to manage their own health. That's another argument though.

 

[WingedOx]

Don't think about it as being about fault, think about it as being about outcomes.

Consider it this way....

Let's say Dr. Bob sees a patient for a condition on a typical office visit, writes a Rx, then sends the patient on his way. The patient never fills the script and the condition continues. If you're medicare or any other type of payer, what benefit has Dr. Bob's visit done for you or for anyone else? Your compensation to Dr. Bob for this visit is basically money flushed down his toilet. If this is happening chronically, Dr. Bob is a chronic waste of your money who gets paid to not make your patients any better.

 

[deleted158872]

Let's say, if after you explain to a patient the pros and cons of a procedure and the cons might make the procedure not worth having but the patient insists on it, should you respect their autonomy and perform the procedure?

 

[NickNaylor]

Don't think about it as being about fault, think about it as being about outcomes.

Consider it this way....

Let's say Dr. Bob sees a patient for a condition on a typical office visit, writes a Rx, then sends the patient on his way. The patient never fills the script and the condition continues. If you're medicare or any other type of payer, what benefit has Dr. Bob's visit done for you or for anyone else? Your compensation to Dr. Bob for this visit is basically money flushed down his toilet. If this is happening chronically, Dr. Bob is a chronic waste of your money who gets paid to not make your patients any better.

This still opens the question, though, of whether not reimbursing the provider is the fair thing to do. I agree that it makes sense to look at things from an outcome perspective, but irrespective of the outcome the work on the part of the provider was still done: time was spent with the patient that could've spent with another patient, the provider spent time documenting, etc. etc.. From the perspective of the system no useful work was done, but this doesn't square with the reality that work was, in fact, done. I guess the question now is how the system will respond: penalize the service provider since no useful work was done or recognize that work was done and figure out another way to enforce a penalty to prevent further money wasting.

 

[NickNaylor]

Let's say, if after you explain to a patient the pros and cons of a procedure and the cons might make the procedure not worth having but the patient insists on it, should you respect their autonomy and perform the procedure?

If there's a medical reason to perform a procedure then sure, that's the patient's right. The problem is that your conclusion that the procedure is "not worth having" clearly isn't the universal conclusion.

 

[deleted158872]

If there's a medical reason to perform a procedure then sure, that's the patient's right. The problem is that your conclusion that the procedure is "not worth having" clearly isn't the universal conclusion.

Well, let's say, what if the cons outweigh the pros?

 

[Doctor Bob]

What's the solution? If they have insurance, they lose it? Lose protection under EMTALA? What does it take for that to happen? Missing every other dialysis? Having a comorbid substance abuse disorder? Forgetting to take a lasix dose now and then, or having difficulty keeping to a fluid/salt restricted diet?

I am all for restricting access to medical care, or at least EMTALA protected care.
Keep coming to the ED because you repeatedly flare your asthma by smoking, or your CHF by eating all the foods we keep telling you not to eat? Then you need cash up front. And if you don't have it, then sucks to be you; the ED won't see you. Looks like your poor life choices are finally going to catch up with you.

Dr. Bob is a chronic waste of your money who gets paid to not make your patients any better.

Hey... just because I'm a chronic waste of money (and space and oxygen) doesn't mean you have to point it out...

 

[NickNaylor]

Well, let's say, what if the cons outweigh the pros?

Doesn't change the situation. Whether or not the "cons" outweigh the "pros" is completely subjective.

 

[Siggy]

Don't think about it as being about fault, think about it as being about outcomes.

Consider it this way....

Let's say Dr. Bob sees a patient for a condition on a typical office visit, writes a Rx, then sends the patient on his way. The patient never fills the script and the condition continues. If you're medicare or any other type of payer, what benefit has Dr. Bob's visit done for you or for anyone else? Your compensation to Dr. Bob for this visit is basically money flushed down his toilet. If this is happening chronically, Dr. Bob is a chronic waste of your money who gets paid to not make your patients any better.

I wreck my car. The car repair company you own repairs my car. I wreck my car again. Why did you let me wreck my car again? You should get penalized because I can't drive.

Patient's wreck their body (or, life sucks, and they get a genetic disposition). The physician offers advice on how to fix their lives. The patient sucks at driving their own life. Why did you let the patient drive their own life if they suck at it?

 

[chipwhitley]

I wreck my car. The car repair company you own repairs my car. I wreck my car again. Why did you let me wreck my car again? You should get penalized because I can't drive.

Patient's wreck their body (or, life sucks, and they get a genetic disposition). The physician offers advice on how to fix their lives. The patient sucks at driving their own life. Why did you let the patient drive their own life if they suck at it?

You're right, but the minute you tell a patient any of this you become the greedy doctor who only cares about money. It would be better if medicine was treated just like any other service profession where that sort of complaint would be laughed at.

 

[clausewitz2]

Don't think about it as being about fault, think about it as being about outcomes.

Consider it this way....

Let's say Dr. Bob sees a patient for a condition on a typical office visit, writes a Rx, then sends the patient on his way. The patient never fills the script and the condition continues. If you're medicare or any other type of payer, what benefit has Dr. Bob's visit done for you or for anyone else? Your compensation to Dr. Bob for this visit is basically money flushed down his toilet. If this is happening chronically, Dr. Bob is a chronic waste of your money who gets paid to not make your patients any better.

I generally like this way of thinking about it, but this raises the obvious spectre of a flight away from chronically ill populations. If your interventions don't produce consistent and dramatic improvements in a population, how does one justify, on the basis of outcomes alone, treating that population at all?

This thread clearly demonstrates that most physicians(-to-be, anyway) are only going to do it for just as much money as they'd get for more advantaged populations. So do we fund care for folks with many comorbidities on a grant-type basis that doesn't look very hard at outcomes? That is a temporary fix, but I am sure I don't need to spell out the long-term consequences of that from a QI perspective.

TL;DR systems nerdery