My most recent blog post for JAMA News Forum focused on firing patients.The primary points that the post addresses are that firing patients may increase as we move towards value-based payment models–clearly, an unintended consequence of paying for improvements in processes of care and clinical and financial outcomes; and that our health care system has not yet evolved sufficiently to be able to address the complex health needs of those patients who may be high utilizers of services and, thus, costly.
I’ve had some interesting feedback from colleagues and friends. Some of my nurse colleagues have noted that they have had to terminate their relationship with some patients who had overwhelming social needs that the nurse was unable to address. Whether in private practice or working in a team practice in primary care, few nurse practitioners are situated in practices that have developed the infrastructure and processes for helping patient to address social determinants of health, whether housing, environmental issues, or other concerns.
Other colleagues commented on the challenges of patients with severe, persistent mental illness. Again, few practices have developed the capacity to integrate behavioral health into primary care.
There is little data on firing patients but what exists documents that one of the primary reasons that pediatricians fire families and their children is the refusal of vaccinations. If I can fire you for refusing a vaccination, can I fire you for smoking, or not losing weight, or refusing aggressive treatments?
One colleague asked whether patients shouldn’t consider firing providers. Actually, I think they do all the time–if they have choices.
Should health care providers and systems be able to fire patients?