Firing the noncompliant patient

Every practice has a handful of patients who, for whatever reason, simply do not follow directions and do not participate in their own care. Whether it’s the patient who never takes his drops or the one who repeatedly misses her appointments, we all have them and we all find them challenging to deal with. We often feel as if we are wasting our time and resources on these patients, and we wonder whether our time would be better spent with patients who are actively engaged in taking care of themselves. Should we dismiss the noncompliant patient to free up our time and resources for our compliant patients?
“The noncompliant patient poses a medical, legal, and ethical dilemma and can disrupt all aspects of our practice,” said Sameh Mosaed, M.D., assistant professor, Department of Ophthalmology, University of California, Irvine, Calif.
She added that noncompliance adds a huge burden to the already-stressed healthcare budget. “Studies have shown that 11% of hospital admissions, 40% of nursing home admissions, and as many as 125,000 deaths per year are directly attributable to noncompliance with medical care.” The importance of noncompliant patients in our practices may become an even bigger issue as we transition toward a pay-for-performance compensation model, as these patients often have poor outcomes arising directly from their noncompliance, Dr. Mosaed said.
Often we consider whether or not dismissing these patients from our practice is the best course of action. Before firing a noncompliant patient from our practice, there are both legal and ethical issues to consider.
“From a legal standpoint, there are many legal precedents upholding the right of physicians to dismiss noncompliant patients from their practices,” Dr. Mosaed said.
However, according to Richard K. Lee, M.D., Ph.D., assistant professor of ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, “Legal justification is not the same thing as moral and ethical justification.” There are a variety of reasons why patients act noncompliantly that are not necessarily their fault. “It is morally and ethically wrong to dismiss a noncompliant patient from your practice if you haven’t first explored the reasons for the patient’s noncompliance.”

Reasons for noncompliance

“Don’t automatically assume that noncompliance is a willful act,” Dr. Lee said. Often noncompliance is not a willful act on the part of the patient. Consider patients who habitually miss appointments. “Perhaps their work schedule is every bit as hectic as yours, and they need you to offer more convenient office hours. Or perhaps they have limited access to transportation.” When a patient shows up 4 months late for follow-up, take a close look at your appointment backlog. “Are you booked out 4 months in advance? Perhaps the patient called to reschedule an appointment and got your next available—4 months later.”
Financial status is an important potential reason for unwilling noncompliance. “Perhaps they miss appointments because they lack the money to pay you,” said Dr. Lee. “Perhaps they don’t take their medications as prescribed because they can’t afford to buy their medications.” In these cases, the solution might be as easy as finding an affordable generic medication or assisting patients in enrolling in the drug manufacturer’s patient-assistance program.
Access to medications is an additional potential source of unwilling noncompliance. “If patients live in a nursing home, they may not have access to their medications and may be at the mercy of facility staff to provide their medication doses,” Dr. Lee said.
“Another important question to ask is whether noncompliant patients are harming anyone but themselves,” said Dr. Lee. Is the patient not paying bills? This threatens the economic viability of your practice and all of your patients, he said. Do they repeatedly not show up for scheduled appointments without canceling or rescheduling? This deprives other patients of those wasted appointment slots. Are they rude or disruptive when they arrive in your office?
“All of these behaviors could potentially harm other patients in your practice, and each of these is a legitimate reason for firing patients from your practice,” Dr. Lee said.

How to fire a noncompliant patient

If you have determined that your patient is willfully noncompliant and you can find no solution to engage the patient as an active participant in his or her own care, you do have the right to dismiss that patient from your practice, said Dr. Mosaed. But be aware that there is a process that should be followed closely to ensure that all of the appropriate medical and legal bases are covered, she said.
“First, document the noncompliant behavior in the medical record,” she said. “If there are multiple occurrences of noncompliance, each should be separately documented at each office visit during which the noncompliant behavior is identified.
“Also, make sure that the patient fully understands the potential consequences of noncompliance,” she advised. “Document that you have informed the patient of the consequences and the patient understands the consequences.
“Next, select a date in the near future and inform the patient that he or she will no longer be offered care in your practice after that date,” Dr. Mosaed said. “Provide the patient with a list of alternate providers in the region, and encourage him or her to arrange follow-up with one of these providers by the upcoming date of dismissal.” Once the patient selects a new provider, Dr. Mosaed advised that you provide all necessary referring documentation to the new provider in a timely fashion.
Dr. Mosaed added that if the patient is in the post-op period, you should make allowances for relevant emergency care during the transition to the new provider.
“If patients are appropriately selected for dismissal and the process is handled properly, dismissal may benefit the patient more than continuing to treat ineffectively, as the patient may develop a more functional therapeutic bond with the new provider and take a more active role in his or her health management,” Dr. Mosaed said.

Editors’ note: Drs. Mosaed and Lee have no financial interests related to their comments.

Contact information

Lee: rlee@med.miami.edu
Mosaed: smosaed@uci.edu