Meds, vaccines, payments: Should physicians ever say never?

Practices face tough decisions these days that deal with how to treat patients in regards to addictive medications, vaccinations, and payments upon services. Increasingly, practice managers must decide whether creating a strict all-or-nothing policy fits their practice.

Last week, we reported that a small group of physicians in Virginia have pledged to stop prescribing opioid pain medications, even for cancer patients. Today's New York Times reveals that a community mental health center in Louisville is planning to phase out writing prescriptions for Xanax. In both cases, physicians and other officials, fed up with the trouble (and perhaps risk) that comes with prescribing highly addictive, sought-after substances, determined that the drugs are of questionable medical benefit.

The main criticism to such absolutes, clearly, is that they unfairly penalize patients who take these medications responsibly.

"What they're doing is a noble idea," Dr. Laurence H. Miller, who heads a committee on public and community psychiatry for the American Psychiatric Association, told the New York Times. But he added, "I could never say never to anything. There are some people who may have done very well on it, are on a small dose and manage their lives on it, and that's probably okay."

But from a practice- and risk-management standpoint, when is "sometimes" not okay? For the practices that stop prescribing certain substances, the tipping point might be when the problems related to satisfying some patients compromise the care or service they're able to provide for the rest. For patients who can't or won't cope with the change, there still appears to be plenty of other (hopefully ethical) physicians they can see.

This isn't the only area in which the gray seems to be slowly fading from practice policies in favor of stark black and white. At Physicians for Children in Roanoke, Va., for example, parents have two choices: Vaccinate their children in accordance with government recommendations or find another pediatrician. As for parents who do want to vaccinate but on their own schedule? Without a valid medical reason for a child to not get the shot on time, there are no exceptions. "As a group of pediatric professionals, the providers will not honor requests to break up vaccines, alternate, or delay their administration over time," according to the practice's new vaccine policy statement.

While the majority of pediatricians have yet to become this rigid, time will tell how many will follow suit.

Finally, this week we also reported that at Fairfield Avenue Family Practice in Pennsylvania, patients who don't pay at the time of service may be asked to reschedule. The practice's two physicians have yet to turn a patient away for financial reasons. However, the threat has been an effective deterrent for patients forgetting their wallets.

Personally, I'm not ready to judge any of these particular practice decisions. I can see the benefit of making rules clear-cut, as well as the downside of being too strict. But the pattern--decidedly black and white--is striking. I'm wondering what you think. Is it a problem? A trend practices should adopt more widely? Unethical? Practical? Would you ever say "never" to your patients? - Deb