Shouldn't Patients Be More Responsible for Their Outcomes?

Agnes Shanley


December 15, 2016

Should Doctors Be Penalized for Patient Outcomes?

The move to value-based medicine, which includes measurements of patient outcomes, generates heated debate on the subject of patient adherence.

Now that the Medicare Access and CHIP Reauthorization Act (MACRA) will tie doctors' reimbursement to quality metrics, including reports on patient outcomes, a growing number of doctors are angry about being held accountable for behavior that is beyond their control.

Others see it as the physician's job to improve outcomes, pointing to changes in communication style and advances in mobile apps and electronic communication that can make monitoring patient progress easier.

A recent Medscape article examined this issue, noting best practices for handling and preventing patient nonadherence. Recommendations included providing patients with reminders, ranging from phone calls to emails and texts; simplifying dosing by reducing the number of times a patient has to take a drug, and, if possible, decreasing the number of drugs they have to take; making patients an active part of treatment by soliciting their input (for example, on reactions to medications); showing patients the importance of investing in—and taking—medications (as many would rather spend their money elsewhere); and improving patient confidence in managing chronic symptoms.

One physician advises taking a worst-case approach, assuming that patients won't comply, then building trust and setting up mechanisms for feedback. He also advocates preparing patients for side effects with an "If it stings, it's working" approach.

Responses from readers were strong and numerous, with most arguing that physicians cannot, and should not, be held responsible for what their patients choose to do or not do. Additional criticism was aimed at insurance companies, government agencies, and drug companies. But the most pointed criticism was aimed at medical leadership for failing to speak up for the profession, and to respond more forcefully to plans to evaluate physicians' performance on the basis of patient outcomes. Here's a sampling:

"Patients have free will, and some will choose to make the wrong decisions," one family physician wrote. "I have my own three children to mother. I will educate my patients, but I will not parent them."

"It seems to me that this is about controlling doctors' practices and incomes," a rheumatologist believed. "Is this about HMOs trying to profit on doctors' backs?"

"The only way to successfully practice is to go back to being doctors, charging what we consider a fair reimbursement for our services, and not blindly being minority partners in the government/insurance complex," a vascular surgeon opined.

"How is it my fault if my patient who has heart failure decides not to take his meds and eats pizza and hamburgers every day, or if my patient with five stents doesn't want to take statins and Plavix and continues to smoke?" a cardiologist wanted to know. "Are they now expecting me to check in with him every day? They certainly are not paying me to do so. In fact, they are paying me less and less."

"So many doctors are retiring, quitting, and otherwise abandoning the practice of medicine that a slow sort of physician strike is, in fact, what's occurring," a psychiatrist observed. "But because the process is so gradual, it doesn't seem to be making a difference."

"All doctors should close their offices for the month of December—or rather, since most of us are now wage slaves, not show up to clock in and leave the ER patients to the administrators, and let the OR lights darken," an otolaryngologist suggested. "Then, when we come back in January, if the public still doesn't appreciate what we do, we can take off January too."

"The biggest problem with this whole discussion is that it focuses on medication-based treatment and outcomes rather than on the real causes of disease, which are the real determinants of outcome: lifestyle habits, including diet, activity, sleep, and stress resilience," a preventive medicine specialist asserted.

"The rural population is not going to download an app that has a potential to motivate them to live a healthier lifestyle," a family doctor wrote. "When will rural doctors get their farmers to stop eating everything and start caring about exercising? When hell freezes over. And how many doctors want to practice outside of metropolitan or suburban areas? Very few. Rural medicine is dying, and extinction is on its way."

"Working in a poor rural setting and getting patients to comply is nearly impossible," another rural doctor commented. "Are we to hire staff to call patients all day and see whether they are taking their meds and eating healthy? Or are we to dismiss patients for noncompliance, since we'll get dinged by CMS for lower results, since a patient would rather have food on the table than pay for treatment?"

"What's next?" a neurologist asked. "Will doctors be required to pay for their patients' medications?"

"I will start to limit my practice to those who are compliant with my recommendations," a pulmonologist commented. "I won't be able to see anyone with more than one problem, or who needs to take two or more medications, or who has allergies with a significant family history. Just those who have plenty of money and time to purchase and obtain their medications and exercise and sleep appropriately."

Many respondents used analogies to illustrate the absurdity of holding physicians responsible for their patients' behavior. "Will I be able to hold the grocery store responsible for my bad cooking?" an internist wrote.

"Why aren't the police responsible for people running red lights or bouncing checks?" wondered a urologist.

"Let teachers pay a price because students don't study," agreed an emergency physician.

"Many patients, some quite intelligent, make informed decisions that they do not believe in or agree with medical guidelines," a family doctor pointed out. "For example, they perceive statins and flu shots to be dangerous." Why, he wondered, should he be held responsible for their outcomes?

"Self-responsibility has flown the coop," an emergency physician maintained. "Everyone is blaming someone else for their problems, whether it's hypertension, diabetes, or something else. Now we blame doctors for patients' lack of caring for themselves. Right. Retirement, here I come."


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