One question that arises in the shift from volume-based to value-based payment is whether doctors will “lemon drop” patients, dismissing those with complex needs who use a lot of resources.
A study published in JAMA Internal Medicine found that wasn’t the case; doctors didn’t dismiss patients and limit their practice to those for whom they can readily demonstrate value to maximize revenue in a value-based payment system.
The researchers studied 794 primary care practices, 443 of them participating in the Comprehensive Primary Care (CPC) initiative—an alternative payment model—and 351 comparison practices and found no difference between them.
Both types of practices had similar rates of dismissing patients and similar reasons for taking that action. Most CPC practices said the payment initiative had no effect or made them less likely to dismiss patients, the researchers said.
The worry is that in value-based payment systems, doctors will drop patients who are uncooperative and noncompliant if they will not be paid for their effort to treat them. However, the study follows recent research that found more than a third of doctors say they would like to “cherry-pick” patients to avoid treating those with comorbidities or ones that would avoid prescribed regimens. Most (63%) said they would not be selective with patients, while 17% said they would definitely be selective and 20% said it would depend on the situation.
So why did practices dismiss patients? The most common reason in both types of practices was a patient being extremely disruptive or acting inappropriately to clinicians and staff (81%). The number two reason was that the patient violated chronic pain and controlled substance policies (78%). And the third most common reason was when patients repeatedly missed appointments (74%).
Fewer practices reported dismissing patients for repeatedly not following medical recommendations (45%), violating bill payment policies (39%), repeatedly not following recommended lifestyle changes (7%) and making frequent visits to the emergency department or self-referring to specialists (6%).
While there are certainly ethical reasons to dismiss patients, doctors should be sure they safely and fairly terminate that relationship. For instance, doctors can’t leave potentially vulnerable patients in the lurch, Joel Wakefield, a healthcare attorney with the Nelson Law Group in Phoenix, Arizona, said.