All physicians have patients who for one reason or another fail to adhere to the physician's instructions. They don't get the tests they should, they don't take their meds, they smoke, and they eat too much. We are used to that and we hope this ends up being a minority of our patients. Unfortunately, the other day, I had the perfect storm of, for lack of a better term, non-compliant patients.
Sixteen out of 18 patients who, in some form or another, grossly failed to adhere to the medical plan to which they had previously agreed. I also had one no-show who, based on prior visits, would have been the 17th out of 19. Patients on insulin who were either not taking it or not checking their blood sugars, or often both. Patients who did not have their labs done, so there was no way to determine whether their meds were effective or even safe for them to take. Patients who gained 10 pounds since their last visit, even though they "eat healthy," but when asked what that means say, "I don't have dessert that often."
If this had happened a few months ago, I think I would have blown my top after patient number five. I used to feel very frustrated, not just in the patient, but in myself if a patient failed to meet treatment goals. I have finally come to terms with that fact that I can only give advice and it is entirely up to the patient to take it or leave it.
Having said that, I did feel the need to commiserate with fellow physicians after what was possibly my worst office day ever. The outpouring of support was overwhelming. However, there was one interesting topic that came up – what happens when the Merit-based Incentive Payment System (MIPS) is implemented?
I do not claim to be an expert in MIPS or the [Medicare Access and Chip Reauthorization Act] or the rest of the new alphabet soup, but my understanding is that reimbursement will change based on a curve. So a physician is scored based on quality of care, technology use (the replacement for Meaningful Use), cost and practice improvement. It is not clear to me (and to the best of my knowledge, to anyone) exactly how they will assess quality of care, but if it's like the [Physician Quality Reimbursement System], they are going to want to see things like number of patients with Hba1c over nine, number of patients who have had appropriate screening tests, etc. And physicians with better scores than their peers will get an increase in reimbursement, and those who do worse will get a decrease.
Well, this seems to unfairly put a whole lot of responsibility on the physician, doesn't it? I have patients that I have told every three months for the last five years to see an ophthalmologist for a dilated eye exam, and short of me physically dragging him there, I don't know what else to do to make that happen. On that horrible day described above, I had a patient who was just in the hospital for severe hyperglycemia and diabetic ketoacidosis, who hadn't been in the office in over a year, and still isn't checking her blood glucose despite the fact she nearly died two weeks before. I told her I can't go home with her and check her blood sugars for her, and she said, " I wish you could."
So what do I do when MIPS rolls around? Do I take a hit from Medicare because my patients can't be bothered to take their meds? Do I dismiss them from my practice and just keep "the good ones"? Or do I just assume that the rest of my peers suffer from the same problem and hope that they don't send me their harder to manage cases?
I don't want to go back to getting upset at patients who do not adhere to their plan. It does them no good and it makes my head hurt. But if they are their own worst enemy, what am I to do about them hurting the practice's bottom line, too?