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Saturday
Jun132009

AMA Resolution: Identifying Abusive, Hostile or Non-Compliant Patients

The text of the American Medical Association’s controversial “ungrateful patient” resolution followed by a press release from the International Cesarean Awareness Network.

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES

Resolution: 710

(A-09)

 

Introduced by:  Michigan Delegation

Subject:            Identifying Abusive, Hostile or Non-Compliant Patients

Referred to:      Reference Committee G

                         (J. Leonard Lichtenfeld, MD, Chair)

 

Whereas, Many patients are becoming more abusive and hostile toward physicians for many reasons not limited to the economy, increasing co-pays and deductibles, unreasonable expectations and demands, a lack of instantaneous cure, arrogance and/or the belief that they “own” their physicians; and

Whereas, There are decreasing numbers of physicians both in primary care and specialties especially in terms of access; and

Whereas, Increasing noncompliance with treatment can reflect negatively on physicians during black box audits by insurance companies and oversight governmental agencies; and

Whereas, Abusive, hostile, and noncompliant patients result in increasing office resources adding to office overhead and added stress on all of the office personnel, which can lead to potential ill health; and

Whereas, The stress of dealing with ungrateful patients is adding to the stress of physicians leading to decreased physician satisfaction; and

Whereas, Any complaint to any oversight investigative regulatory body leads to uncompensated expenditure of time, resources, and monies to defend physicians or the “guilty until proven innocent” principal; and

Whereas, Physicians need to own the data to simplify patient collection and identification to defend themselves as well as alert outside investigating agencies to the potential nature of the patient’s records; therefore be it

RESOLVED: That our American Medical Association ask its CPT Editorial Panel to investigate for data collection and report back at Annual 2010 meeting: 1) developing a modifier for the E&M codes to identify non-compliant patients and/or 2) develop an add-on code to E&M codes to identify non-compliant patients. (Directive to Take Action)

Fiscal Note: Staff cost estimated at less than $500 to implement.

Received: 05/06/09

 

 

 

International Cesarean Awareness Network issued a press release on June 11, 2009 in response to the AMA’s Resolution 710:

 

AMA Resolution Would Seek to Label “Ungrateful” Patients

Redondo Beach, CA, June 11, 2009 - At the American Medical Association’s (AMA) Annual Meeting next week, delegates will vote on a resolution which proposes to develop CPT (billing) codes to identify and label “non-compliant” patients

The resolution complains:

“The stress of dealing with ungrateful patients is adding to the stress of physicians leading to decreased physician satisfaction.”

“This resolution is alarming in its arrogance and its failure to recognize, or even pay lip service to, patient autonomy,” said Desirre Andrews, the newly elected president of the International Cesarean Awareness Network (ICAN).

If approved, the resolution could hold implications for women receiving maternity care. For pregnant women seeking quality care and good outcomes, “non-compliance” is often their only alternative to accepting sub-standard care. Physicians routinely order interventions like induction, episiotomy, or cesarean section unnecessarily.

Liz Dutzy, a mother from Olathe, Kansas, delivered her first two babies by cesarean and was told by her obstetrician that she needed another surgical delivery. “My doctor told me that I needed to have a cesarean delivery at 39 weeks, or my uterus would rupture and my baby would die.” She sought out another care provider and had a healthy and safe intervention-free {home} birth at 41 weeks and 3 days gestation.

A recent report by Childbirth Connection and The Milbank Memorial Fund, called “Evidence-Based Maternity Care: What It Is and What It Can Achieve ,” shows that the state of maternity care in the U.S. is worrisome, driven largely by a failure of care providers to heed evidence-based care practices. For most women in the U.S., care practices that have been proven to make childbirth easier and safer are underused, and interventions that may increase risks to mothers and babies are routinely overused. The authors of the report point to the “perinatal paradox” of doing more, but accomplishing less.

The resolution proposed by the Michigan delegation of the AMA could threaten patient care and patient autonomy for several reasons:

  • Billing codes that would categorize any disagreement and exercise of autonomy on the part of the patient as “non-compliance” “abuse” or “hostility” could create a pathway for insurance companies to deny coverage to patients
  • Use of these labels fails to recognize patients as competent partners with physicians in their own care
  • Tagging patients as “non-compliant” fails to recognize that there is not a “one size fits all” approach to care, that different opinions among physicians abound, and that patients are entitled to these very same differences of opinion
  • Labeling patients as “non-compliant” may, in fact, be punitive, jeopardizing a patient’s ability to seek out other care providers


The resolution also fails to address how it would implicate patients navigating controversial issues in medical care, like vaginal birth after cesarean (VBAC). While a substantive body of medical research demonstrates that VBAC is reasonably safe, if not safer, than repeat cesareans, most physicians and hospitals refuse to support VBAC. The language in the resolution suggests that patients who assert their right to opt for VBAC could be tagged as non-compliant, even though their choice would be consistent with the medical research.

“The reality is that the balance of power in the physician-patient relationship is decidedly tipped towards physicians. The least patients should have is the right to disagree with their doctors and not be labeled a ‘naughty’ patient,” said Andrews.

 

 

 

AMA Resolution (PDF file- Page 102)

 

ICAN Press Releases

 

 

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Reader Comments (14)

This makes the Birth Survey even more important in order to identify hostile practitioners. If doctors are willing to label their maternity clients in this way when they are exercising patient autonomy, women need to be prepared to not only report hostile and coercive behavior by practitioners to hospitals and medical boards, but to take it to the next step and consider filing an assault charge with police if there has been violence or threatened violence. The Law cannot be enforced unless families step forward with specific grievances. This holds true for all branches of medicine, with children and the elderly being the next most vulnerable categories. "Doctor" has become a dirty word in our household because of unethical conduct, and this action by the AMA to further violate patient rights is a grasp for an almost totalitarian medical "rule". Doctors cannot be allowed more power since they have proven by their practices to be untrustworthy and self-interested, and this can be seen as an attempt to be able to blackball clients, who would then face a lifetime of prejudice from other MDs and insurance companies. How many people will buckle under the pressure of knowing that they won't be able to retain an unprejudiced practitioner and that their insurance premiums might rise? I keep seeing people comment that it's up to clients to force a change in practice, but how can that happen if by challenging the status quo a person becomes unable to find a replacement MD?

June 13, 2009 | Unregistered CommenterAnon

Wow. I have often suspected that "advances" in L&D are a reaction to increasing dissatisfaction and empowerment of their patient base (such as the advent of CFM right around the time home birth was gaining steam in the 70s). I have been wondering how the medical association was going to respond to this latest push for patient autonomy, and I guess this is it. Maybe we should just pin a yellow star on any patient who dares to contradict or fail to comply with the orders of their care provider, so everyone will know who the rabblerousers are. Maybe we should then round them all up and put them in an asylum somewhere. I mean, a patient would have to be crazy to not listen to their doctor, right?

June 13, 2009 | Unregistered CommenterEmily Jones

"Doctors cannot be allowed more power since they have proven by their practices to be untrustworthy and self-interested, and this can be seen as an attempt to be able to blackball clients, who would then face a lifetime of prejudice from other MDs and insurance companies. How many people will buckle under the pressure of knowing that they won't be able to retain an unprejudiced practitioner and that their insurance premiums might rise? I keep seeing people comment that it's up to clients to force a change in practice, but how can that happen if by challenging the status quo a person becomes unable to find a replacement MD?"

YES!!! This exactly! We blame patients for a rise in c-sections and who knows what else. It's the patient's fault because of x, z, or z. Then when patients start to ask questions and elect their right to informed refusal dr's get upset? Now we're talking "abusive, hostile, and non-compliant" all in the same sentence as if that's the same thing? Who gets to make the decision as to what qualifies? What about the possibilities for abuse as it's possible doctors could use it in a retaliatory way.

This coupled with the recent Newsweek article about the "medical advice" given on Oprah's show seems to show that conventional medicine types are feeling their business threatened. I wasn't the least bit surprised when they came out with their resolution against homebirth, but this one makes their intentions very clear. I suspect if they keep down this path there could be a fairly large backlash against them (at least I hope so).

June 13, 2009 | Unregistered Commenterpampered_mom

This definitely can cause problems down the road, but it depends on how terms like "non-compliance" are taken -- to what extent? As an example from my days as a pharmacy tech...

We would get druggies in all the time -- they'd go to doctor after doctor (typically dentists, because it's easier to fake a toothache for some Darvocet or Lortab) and get prescriptions filled for pain medication and an antibiotic (to actually take out the infection which is the source of the pain). Then they'd go to the pharmacy, where they would decline to get the antibiotic filled, and say they could only afford the pain medicine. Funny thing, though, when we started telling them they had to get both or neither, they'd somehow come up with the dough.

Anyway -- if "noncompliance" is people not taking antibiotics as prescribed because they quit too soon and then the infection comes back with a vengeance, prompting further and more aggressive and more expensive treatment, then that's one thing. Or patients who don't take their blood pressure pills or diabetes medication -- things they really need if they can't control the health problems themselves. But if it's "a god complex" on the part of the doctor then that's another thing altogether.

June 13, 2009 | Unregistered CommenterKathy

There are legitimately non-compliant and scary patients, obviously. Reality Rounds-- actually, almost every blogging nurse-- has talked about the very difficult patients. And that does not go for women in labor who are just being, you know, women in labor.

It's the "ungrateful" part that killed me. That's like something a dad might yell at a teenager. "You ingrate! You'd better be home with my car by 11 tonight!"

These are all great comments. So many excellent points raised. This whole resolution is just begging for parody. Must... resist... urge... to... be sarcastic.

June 13, 2009 | Registered CommenterJill

Sigh. Stuff like this makes me embarrassed to have that MD after my name (although I have never paid dues to the AMA, so that's at least some small comfort.) I think this resolution is driven by a couple things.
1. More and more insurance companies are instituting so-called pay for performance measures whereby docs are paid more for certain outcomes. Most of them center around things like did the physician appropriately order tests and procedures - like do your female patients 18-65 get pap smears for example. Their are a lot of big problems with this pay for performance stuff, even though it sounds good in theory. Insurance companies, including medicare, are notoriously bad at gathering information, so often their data is skewed. Also, there is no allowance made for patient preferences. For example, I get letters from the state medicaid program telling me I don't have appropriate vaccination rates in my under-2s sometimes. Some of these children are receiving immunizations through the health dept for lower cost - and so their is no claim for the shots and the insurance company doesn't realize they've had them. The burden in then on me to prove that they have had them. Some children are not receiving vaccinations by parent choice - I'm willing to work with parents who don't vaccinate or selectively or delay vaccinations, but it reflects negatively on my profiling. This pay for performance stuff makes doctors very anxious, especially in primary care, as it puts a big burden of extra paperwork and worry about getting paid. It makes patient "compliance" more of a financial issue than it ever has been.

2. The term "compliance" itself reflects a value system in medicine that is based on a power-differential in the doctor-patient relationship. Doctors order, patients comply or not. Many docs tend to have a lot of emotional investment in having their orders followed, and a patient who won't comply is a big threat to that. (I'm choosing the words patient and comply deliberately here.) In a different model, "compliance" is much less of a power issue. In my practice, my clients and I form a treatment plan. At subsequent visits, we go over how well they are able to adhere to the plan we made. See, I might have great evidence based reasons for recommending a certain treatement plan, but my clients may have much more important life reasons for doing things differently! If the plan isn't working, it may well need to be changed. Removing the power differential means I don't have to feel like my authority is challenged if a client isn't doing what I think is best. And, what do you know, when clients are responsible for participating in all decision making and plan forming, they tend to be a lot more adherent anyway. I definitely have folks who never do anything I think thye should, and I have some truly difficult clients (I mean, I work with human beings after all) but since I don't feel like my self worth is tied up in being obeyed, I certainly don't get as discouraged as docs in more traditional patient relationships. I think medicine would greatly benefit from letting go of the traditional power based relationship. I think not only would people get better care, but docs would be a lot more satisfied.

I do think for the pay for performance type stuff, it might be nice to have a code to add in to show that you ordered whatever tests or meds in keeping with standard of care, but the client declined it, but in general having such ways of labelling patients seems like it would cause more harm than good - especially in a small community like mine where if you don't get along with one doc, there just aren't that many others to choose from!

June 13, 2009 | Unregistered Commenterdoctorjen

"they'd go to doctor after doctor (typically dentists, because it's easier to fake a toothache for some Darvocet or Lortab) and get prescriptions filled for pain medication" ---- so THAT explains it! One time in my early twenties, when I had no insurance, I got an absessed tooth. If you've ever had one of those, you'd know that the pain is excruciating. I needed to have it pulled, but I had no money. So I went to the county hospital (the same hospital "ER" was supposed to be about" and begged them to give me some antibiotics and painkillers until I could get the money for the dental school to pull the tooth. I came into the hospital straight from my job as a dogwalker (so I was kinda dirty and smelled) and when I told the resident what was wrong, she told me to go home and take some tylenol. I was like "Tylenol, are you serious?!?" But I realize now that I probably looked like a crackhead to her (or a meth addict, don't meth addicts have really bad teeth?) Either way, I'm the furthest thing from a drug addict - I don't even like taking OTC medications if I don't absolutely have to, so the judgment I got from that crappy resident was just plain mean. I bet they wrote "drug addict" on my chart somewhere.

June 13, 2009 | Unregistered CommenterTheFeministBreeder

TFB,

Yep, that's why. Sorry! "Don't judge a book by its cover" is a nice cliché, but it doesn't happen often in real life. Ironically, it would have been better for you to have had some medical history with prescription drugs so you could have had a "relationship" with either a doctor or a pharmacy, rather than being of the type not to need/use drugs. Because we knew our regular customers and whether or not they were druggies, but when someone new walked in off the street with just a pain med & abx Rx, the suspicion was that s/he was a druggie. Of course, a high percentage of people like that were like you -- seriously in pain (and not like the guy that slammed his own foot in a door trying to break it so he could get morphine -- yeah, it actually happened!); but a significant minority were suspicious. Most of the time, I think we could tell -- the people that were sitting there kinda dazed from pain were just different in some way from the people who were sitting there dazed from needing a fix. Difficult to describe, but usually easy to spot. I don't think we treated people differently, necessarily, if we didn't *know* they were druggies, but considering how many people try to write false prescriptions or get some drugs for a fix, it was best to err on the side of caution. I could write a book...

June 14, 2009 | Unregistered CommenterKathy

Could and SHOULD write a book, Kathy...

June 14, 2009 | Registered CommenterJill

I think that has to totally unfair. To label someone as noncompliant in order to flag other hcp is just wrong. Each person deserves a new start each day. With a label like that, the person may be treated unfairly at the get go. Not OK. How would the AMA like someone to publish a book rateing Doctors personalities? I think a libel suit would pop up right away. I am going to ask if I can have a copy of my medical records evertime I go for medical treatment. If I had noncompliance in my chart, I could slap them with a libel suit.

June 15, 2009 | Unregistered Commenterpinky
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