Posted by: notdeaddinosaur | February 18, 2013

And So It Begins

I called it! Almost three and a half years ago, to be precise.

  • The date: September 24, 2009.
  • The topic: Defining “Quality” of medical care
  • My take:

What if [a] doctor decided that the best way to improve his P4P data was to discharge all the patients from his practice who, for whatever reason, failed to achieve acceptable control of their blood pressure and diabetes? Or who didn’t stop smoking? Or who refused to get a flu shot, or go for a mammogram, pap smear, or colonoscopy? As it happens, there’s nothing in the Hippocratic Oath against discharging patients. With enough money at stake in a P4P arrangement, this is inevitable.

Now along comes this, a question to Dr. Lin, the Common Sense Family Doctor:

For the past two years, I have been searching for a primary care physician who will not require that I undergo prostate cancer screening as a condition of accepting me as a new patient. Usually physicians don’t admit this directly when I ask them in the initial interview; sometimes, they actually agree with me that the PSA test and digital rectal examination are neither necessary nor beneficial. But something strange and frustrating happens after I leave each office: these physicians decide that they require screening after all and send me a letter, telling me in a short sentence that they won’t or can’t accept me as a new patient.

The comments reflect bafflement at what is going on here. Isn’t it obvious?

I’ll bet you dollars to doughnuts that most of these practices participate in some version of an Accountable Care Organization, or are beholden to insurance companies, which provide financial incentives too juicy to risk by accommodating patients with perfectly reasonable requests to forego needless health screenings. The real reason doctors have begun “requiring” that patients undergo all manner of screening interventions is to enhance their compliance ratios. After all, the quickest way to get to 100% is to get rid of everyone who falls short.

At first, I admit it sounded a little far-fetched. Would doctors really be so blatantly unethical as to “sneak” in unwanted screenings? Why on earth would they do it? It’s downright disgusting, but frankly, it’s the only (semi) legitimate explanation that comes to mind.

FSM help us as we continue our slide down this slippery slope. Today, it’s just reporting that we measured A1c’s and blood pressures; tomorrow, we doctors will be on the hook for the actual results. Watch as the trickle of discharge letters becomes a deluge.

Remember: you saw it here first.


  1. Yes, it seems inevitable. I blogged about it this past summer:

  2. And who is most aggressively campaigning for the expansion of P4P programs? It’s those brain-dead prostitutes running the AAFP. They don’t even try to hide their hostility towards practicing physicians any longer.

  3. Oh yeah. The practice of medicine has been reduced to following guidelines and protocols (and thus reducing the risk of malpractice suits). Forget what the patient wants and needs…

  4. Procrustean solutions always backfire in the end. Never before a great many innocent people are harmed… Too bad they don’t backfire in the beginning.

  5. So glad I’m Australian where the insurance companies can’t form liaisons with the doctors. Looking after the health of individuals should be the brief of general practitioners, not prescribing or treating for public health. Allowing malpractice claims for very rare events has wrecked the system in the USA and is starting to gain some ground here, unfortunately, with obstetricians almost unable to practise due to the high insurance overheads. Now people are starting to claim for ANY negative condition a baby arrives with, not just delays during birth or failure to do a caesarean to rescue a distressed bub. A friends daughter was going to sue the doctor because her baby’s upper eyelids would not lift! Surely that was a chance occurrence?

  6. […] represent only 21 percent of the population; the great majority of us don’t own guns.”) And So It Begins Can You Trust Jared Diamond? One thing he could learn from traditional societies: Show your work. […]

  7. I believe that in a few short years there will be an “underclass” of noncompliant patients who will be unwelcome in any practice because they negatively affect P4P numbers.

  8. Mamadoc, you are correct. However, as more people become educated about all of this unneccesary testing (and the costs), there may also be a loss of income in some practices as they compete for the ever-smaller number of “compliant” patients. If this happens, it will be interesting to see how it plays out…

  9. Do insurance companies or medicare come up with P4P measures on their own? No – they get input from physicians. It’s easy to blame greedy insurance companies for this, but what about the greedy physicians and groups who keep insisting on double-to-triple CPI increases every year?

    Is the solution to ignore performance when negotiating payment?

  10. No, the solution is to be sure to tie payment to measures that really make a difference. And not to tie payment to patient behavior that is outside the control of anyone except the patient. And by the way, my group hasn’t seen any double-to-triple increases in payment for anything ever. Who are these groups so I can go join one?

  11. Tomorrow is here.

    I work with persons who have multiple sclerosis and persons on dialysis (2 jobs). The dialysis center does not get paid to treat patients who don’t meet “adequacy” criteria. No payment at all. The reason doesn’t matter. They are forbidden by Medicare rules from discharging a patient for “noncompliance” but then end up treating them for free. You had better believe the bean counters are happy when one of these patients fails to pay a bill or behaves badly–they can be discharged for those reasons.

    I’m currently working with a gentleman with MS who has not seen a doctor in several years, partly due to lack of funds and partly because he is at a stage where there really are no treatments available other than pain management. He needs to see an MD for something acute, but can’t find a practice that will accept him “because it’s been so long since you’ve seen a doctor.” I’m seriously trying to think of a legitimate reason to send him to hospital in hopes he will be assigned a doc there for follow up.

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