Monday, February 2, 2015

The Doctor Won't See You Now

The recent outbreak of measles in the U.S., which is widely believed to be to have started in Disneyland, has produced at least one surprising result: doctors "firing" patients who refuse to get vaccinated.

This could get interesting.

The physician who has been the center of much of the reporting is Dr. Charles Goodman, a California pediatrician.  Dr. Goodman has told parents that they either vaccinate their children or find another physician, out of concern for the health of the rest of his patients.  As he told CBS News, "I have to weigh the risk of a kid in my office getting measles and potentially dying versus the rights of those parents to not immunize when I thought most of them were making that choice based on bad information."

The reluctance to get children vaccinated is usually associated with the MMR (mumps-measles-rubella) vaccine, which skeptics have linked to autism.  Experts, such as at the CDC, refute these claims.  Frank Bruni, in a New York Times op-ed, associates the lower vaccination rates not with poverty -- as might normally be expected -- but with affluence, citing a Hollywood Reporter article that found very low rates in neighborhood like Santa Monica and Beverly Hills.

The AMA Code of Ethics does list patient non-compliance -- failure to follow physician treatment recommendations -- as a reason for terminating the physician-patient relationship.  Purposeful failure to follow established vaccination recommendations would seem to fall into this category, but once that door is open, I wonder how wide it swings.

After all, last year an article in Medscape proclaimed "an epidemic of non-compliance."  It noted a 2011 Consumer Reports survey of primary care doctors which found that patients not following their advice was the physicians' top complaint.  The article went on to note a variety of statistics about patient failure to take medications as prescribed, adversely impacting their health, adding costs to treat them (some $290 billion), and increasing mortality rates (some 125,000 excess deaths per year).  A study in the Annuals of Internal Medicine found that almost 1-in-3 didn't even fill new prescriptions.

Is any of that grounds for being fired?

I was struck by something else Dr. Goodman said:  "That's why I took the stance, believe your doctor, listen to your doctor, not the Internet, or go somewhere else."  He was no doubt referring to the anti-vaccine diatribes available on the Internet, but the horse is out of barn about patients using the Internet to research their conditions and possible treatments.  The Pew Foundation found that 72% of Internet users looked for health information online, and that was back in 2012.

A lot of patients are going to get fired if that happens whenever they show up with information that happens to disagree with the physician's belief system.  Vaccines may appear to be a relatively clear-cut case, but not all information that a physician doesn't agree with is automatically wrong.  As Aaron Carroll and Austin Frakt pointed out recently, many therapies not only benefit fewer people than we might think but many also cause harm to some patients.

Dr. Victor Montori of the Mayo Clinic asserted that non-compliance isn't necessarily the patient's "fault."  Sometimes, he believes, the treatment plan wasn't simply right for that patient.  As he said: "Healthcare right now is all about itself. Healthcare right now is about how do we get bigger, more market share."  In his opinion, we won't get the best health care system until we start shrinking it.

Sometimes not doing what your doctor recommends is a good idea.

And, of course, how many of us have been told by their doctors to lose some weight, eat better, and get more exercise?  Doctors are now starting to actually give prescriptions for exercise, spurred by the Exercise is Medicine initiative of the American College of Sports Medicine.   I'll bet we're even worse about filling those prescriptions than we are about our prescription medicines.

Our persistent failures to take better care of ourselves could have resulted in many of us getting kicked out of our physician's practice.  

The fact that we haven't seen a rash of patients getting fired by their physicians may be viewed as a testament to the power of the patient-physician relationship.  Or, more cynically, as testament to the power of fee-for-service medicine.  But those days may be waning.

HHS Secretary Sylvia Matthews just announced an ambitious goal to move 50% of Medicare payments to value-based mechanisms by 2018, rewarding providers for quality rather than quantity.  And her goal is not just for Medicare; her hope is that other public and private payors follow suit.  A large coalition of providers and payors has already signed on.

The AMA is not quite on board.  AMA Executive Director James Madara admits that: "In many areas of patient care, we do not yet have high-quality outcome measures with enough specificity to drive improvement."  You'd think that an organization supposedly overseeing the professional efforts of its members and concerned with patients' health would be more concerned about that, but, of course, it's more about the money.

So when doctors' incomes become challenged by poor patient outcomes, it will be very tempting for physicians to start winnowing out non-compliant patients.  That's not entirely unfair; I wouldn't want to be held accountable for patients who refuse to follow instructions that would help them maintain their health either.

However, we're in an era, or soon to be in an era, where it will be very feasible for physicians to monitor in real-time whether we're taking our meds, getting our exercise, sleeping enough, and so on.  Big Brother may not be the government, but rather our physician.  We've just ended decades of angst about losing or not being able to obtain health coverage due to health status (assuming ACA isn't overturned or repealed, anyway), but there's nothing stopping our physicians from penalizing us for our bad health habits even more than those health plans used to be able to do.

Still, the line at which such winnowing is appropriate is murky.  Doing so out of concern for the rest of the patients' health is one thing; having a different (yet hopefully informed) opinion about a proposed treatment is something very different.  I have these mental images of the Seinfeld episode where Elaine is unable to escape the notation in her medical record labeling her "difficult," causing her to search further and further for a doctor who will see her.  And that was in an era of paper charts; imagine how our vaunted inter-connected EHRs would facilitate such "blackballing."

The one thing that seems clear to me is that physicians shouldn't kick out patients for their own financial gain.  They probably won't, for the most part anyway.  But there's no shortage of data about physicians performing what would appear to be quite unnecessary services strictly for their own gain (e.g., a recent New York Times article about snowbirds), so I wouldn't rule it out.

Well-meaning as he may be, Dr. Goodman may have helped start something that we're all going to regret.


  1. We may end up with a system of arbitration where "the good of the many are weighed against the good of the few". We may have to resort to such a system if we are to have a chance at control over our health treatments without risking expulsion from our insurance payer.

  2. With ACA, expulsion from our payor is less likely than expulsion from our provider (or ACO).