Are More Doctors Cherry-Picking and Lemon-Dropping Patients?

Leigh Page

Disclosures

February 15, 2017

In This Article

More Than One Third of Doctors Would Be Selective

So-called "cherry-picking" and "lemon-dropping" of patients remains deeply controversial. Many physicians say it's unethical and wrong, and maintain that doctors should make the extra effort to care for "high-maintenance" or "difficult" patients. Other physicians don't admit that they sometimes cherry-pick or lemon-drop. However, the practice has a good deal of support among many doctors, as the healthcare system moves toward reimbursements based on outcomes and care budgets.

Cherry-picking involves choosing healthier or more adherent patients and referring more time-consuming ones to specialists. A related behavior called "lemon-dropping" involves rejecting less promising patients, especially those who would use a lot of resources. But "cherry-picking" is often used to describe both methods.

Asked in a new Medscape survey[1,2] whether they would cherry-pick or lemon-drop patients "to avoid those with comorbid disease or those who won't follow treatment regimens," fully 63% of doctors said no. But 17% said yes, and another 20% said it would depend on the situation.

By asking whether they "would" cherry-pick, the survey may have drawn doctors into the cherry-picking camp who haven't yet exercised the option but reserve the right to do so sometime in the future.

In comments gathered by the Medscape survey, some doctors specified that they might rate and evaluate patients if reimbursements changed. "There's no reason to treat an uncooperative, noncompliant [patient] if I'm not going to then be paid for the efforts," an oncologist said.

The Ethics of Cherry-Picking Are Complicated

Cherry-picking and lemon-dropping are "unethical," says Jim Bailey, MD, director of the Center for Health System Improvement at the University of Tennessee Health Science Center, in Memphis. "These practices go directly against the central tenet of the Hippocratic Oath, which says, 'Into whatever houses I enter, I will go for the benefit of the sick,'" he says.

Rather than run away from patients with complex conditions, Dr Bailey advises doctors to embrace these patients. "Physicians should seek out payment sources that will cover the extra work they need, such as using multidisciplinary teams that reach out to them to make sure they stay adherent," he says.

Although cherry-picking may be unethical in the eyes of many physicians, it isn't illegal. The newly revised Code of Ethics[3] of the American Medical Association (AMA), issued in June 2016, could be construed as ambiguous about its use. Although the new AMA code doesn't refer specifically to cherry-picking, it states, "Physicians are not ethically required to accept all prospective patients," which reiterates the view of the previous AMA code.

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