Ratings May Also Lead Doctors to Cherry-Pick
Physicians cherry-pick even when reimbursements are not on the line. Physician "report cards" could inspire such behavior, according to Sandeep Jauhar, MD, a New York cardiologist. In fact, 63% of cardiac surgeons acknowledged they were accepting only relatively healthy patients for heart bypass surgery owing to report cards in New York State, he said, citing a survey in the 2000s. "What's at stake could be the doctor's reputation," which is tied to income, he said.
John Bower, a retired Mississippi nephrologist who fought in court for a physician's right to refuse patients, is bothered about physicians exercising that right to improve ratings. "I call that stacking the deck in your favor," he said.
Dr. Bower's legal case involved a patient of his who was a "compliance nightmare." In the middle of dialysis, the man would sometimes clamp shut his lines and simply walk out of the clinic. When Dr. Bower dismissed the patient, he was sued. In 1987, the Fifth Circuit Court of Appeals upheld the physician. The court cited the 13th Amendment, abolishing slavery, to protect Dr. Bower, a white Southerner, from his patient, who was black. Forcing doctors to treat unruly patients, the court said, would be tantamount to "involuntary servitude."
However, Dr. Bower continued to treat the patient after the court decision, "No one else would take him," he explained. He was setting his own limits on the right to avoid patients.
Dr. Bailey called on physician organizations to clarify what kinds of cherry-picking are acceptable and which are not. The American Medical Association Code of Medical Ethics[7,8] does not specifically cite cherry-picking. However, it states that physicians are free to choose their patients and opposes rejecting patients on the basis of "race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination."
Motives May Be Hard to Identify
Identifying cherry-picking can be tricky because the motives aren't always clear. For example, when primary care physicians refer patients to specialists, sometimes they are simply avoiding their own economic loss, said Richard C. Hughes, MD, a retired internist in Oshkosh, Wisconsin. "Patients who take a lot of time might get shunted off to a specialist," he said. This unspoken strategy may have contributed to a sharp rise in referrals. A 2012 study identified a 94% increase in the probability of a physician referring a patient between 1999 and 2009.
In most cases, however, physicians are willing to admit to economic cherry-picking and rule out personal motives, said Herdley Paolini, PhD, a psychologist who counsels physicians at Florida Hospital in Orlando. "Doctors are more likely to be up-front about cherry-picking when there's a financial reason," she said. "If they don't like the patient, they don't want to admit to that."
Avoiding obese patients seems to be an example of the gray area between financial and personal motives. In a 2011 survey reported by the Florida Sun Sentinel, 15 obstetrics/gynecology practices stated that they would not accept obese patients, explaining that that these patients were more likely to sue and that the practice lacked the equipment to handle them. Other studies[11,12] have shown that many physicians do not like treating obese patients.
A similar dynamic may apply to pediatricians won't treat patients whose parents who refuse life-saving vaccinations. In a study of Connecticut pediatricians, more than 30% said they had dismissed families for refusing vaccinations, citing concerns that these patients could spread a disease in the waiting room. But some of these physicians might also feel exasperated with parents who refuse a well-proven preventive measure.
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