AMA delegation seeks to code for non-compliant and ungrateful patients

Update: A twitterer tells me this was just considered by the AMA and defeated – I’m looking for details. Because if they tried this once, they’ll try it again.

Further update: Found it. Details are appended.

The American Medical Association (AMA) is currently considering Resolution 710 (A-09), titled:

Identifying Abusive, Hostile or Non-Compliant Patients

The Resolution has been referred to Reference Committee G, chaired by J. Leonard Lichtenfeld. Unecesarean says that voting is scheduled for Tuesday, June 16, 2009 from 7:00 a.m. to 8:45 a.m – a few hours away.

I reproduce the resolution in its entirety here, for every sentence is about as abominable as the next:

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)

Yes, you heard right. The AMA wishes to develop coding to label ungrateful and non-compliant people. The AMA is pissed off with people who they think hold “the belief that they own their physicians”, which, as it turns out reading the rest of the resolution, is actually a problem with people who hold the belief that they own their own bodies.

Physicians writing this resolution aren’t concerned for the health of people who come to them for recommendations; they are concerned that people who are not sufficiently grateful may not completely follow orders, thereby making the physicians fear looking bad.

Physicians writing this resolution are pissed off because people who can’t afford their ridiculously overpriced healthcare and who can’t get insurance get upset in the face of the choice between bankruptcy and untreated illness or death.

The expectation of accessible, affordable healthcare is “unreasonable” in the eyes of these physicians.

The expectation that physicians are consultants, not military sergeants, is “non-compliant”.

The expectation that physicians treat patients like humans is “ungrateful”. Physicians have a right to have their barked orders followed unquestioningly, because this leads to a more satisfying workplace experience for them.

And if you don’t fit the bill perfectly, if you persistently ask difficult questions, if you decline treatments you believe are unnecessary or harmful, if your illness undermines your ability to adhere to medical treatment – you get coded “Abusive, Hostile, or Non-Compliant”.

And in the USA, if you get coded “Abusive, Hostile, or Non-compliant”, you can guess what is going to happen next. No insurance.

Who could this affect? If you’re currently saying “piffle, that will only apply to methed-up assholes who physically threaten the staff”, think again. (And also, spare a thought for the fact that people with substance abuse issues need medical treatment also.) This is a country that sent law enforcement officers into a woman’s home, bound her legs together, and forcibly operated on her in the name of fetal rights.

If this resolution makes it down to coding level, every single time you decline a doctor’s ‘orders’, you could be threatened with the punishment of having your insurance revoked.

– Every time a woman declines a due Pap smear with a doctor who she doesn’t feel comfortable with but who is the only one she can access right now to get a script for her eczema;

– Every time a woman chooses an abortion when any doctor told her she ‘shouldn’t’;

– Every time a person with severe CFS who can barely function declines a rigorous gym programme;

– Every time a pregnant woman declines a caesarean section for twin or breech presentation or “hey the baby’s looking a little big dontcha think?”, or chooses a vaginal birth after C section;

– Every time a pregnant woman decides that she’d rather not be induced at 40-41 weeks for no medical indication at all;

– Every time a fat person decides not to go on that 800-calorie diet;

– Every time a person with depression decides to try without the medication without her doctor’s ‘permission’;

– Every time a person decides not to fill that antibiotic script for their daughter’s middle ear infection, because she seems to be getting better already by herself;

– Every time a woman decides that her vomiting baby is keeping breastmilk down better than Pedialyte, when the doctor said to feed only Pedialyte;

– Every time someone walks out of the office of an abusive, creepy, rapist, or just ignorant doctor;

– Every time a person who is misdiagnosed as ‘psychosomatic’ and told that they should have psychotherapy for their illness, and doesn’t;

– Every time an ignorant doctor says something utterly ridiculous and you decide to quietly ignore it, and they find out;

– Every time you miss a scheduled appointment or don’t get around to getting those bloods taken or don’t bother with the expensive, inconvenient followup visit because you’re just fine now;

– Every. Time. You. Freely. Choose. Not. To. Give. Your. Informed. Consent;

Every time. Every single person here probably falls into this “non-compliant” category in some way or another. All of you USAns. Which means that every single time you see a doctor and they decide not to head-pat you as a good little girl, you could risk having your insurance taken away.

If there’s any way USAns can lobby against this effectively, please offer your suggestions in comments. Because I’m frightened for you.

[The original Resolution, then titled 3-09A, as it passed through the Michigan State Medical Society. It was introduced by Alan M. Mindlin, an ophthalmologist.]

[via The Examiner and Unecesarean]


Update 16 June 2009 P.M.:

The AMA Reference Committee’s recommendations can be found in this PDF, Report of Reference Committee G


RECOMMENDATION: Mr. Speaker, your Reference Committee recommends that Resolutions 710 not be adopted.

Resolution 710 asks that our AMA 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.

Your Reference Committee heard limited supportive testimony on Resolution 710. The author stated that the intent of this resolution is to identify non-compliant patients, especially as there is an increasing focus on physician performance and releasing of physician data. Testimony was empathetic to the difficulty in working with non-compliant patients, but expressed concerns in labeling patients and acknowledged a desire to be sensitive to the possible mental health issues of non-compliant patients.

Testimony provided by the CPT Editorial Board stated that the appropriate forum for addressing CPT issues is through the CPT Editorial Panel process, not the House of Delegates. In addition, while there are no codes that exist to identify someone as specifically non-compliant, there are existing modifiers to identify patients who do not comply. For example, Modifier 2P (Performance Measure Exclusion Modifier Due to Patient Reasons) is available to report non-compliant patients. The list of reasons for Modifier 2P include (1) “patient declined”, (2) “economic, social, or religious reasons”, and (3) “other patient reasons”. This modifier is intended to be used with performance measure Category II codes. CPT Category II Performance Measurement codes are intended to facilitate data collection about the quality of care rendered by coding certain services and test results that support nationally established performance measures and that have an evidence base as contributing to quality patient care. These codes describe clinical components that may be typically included in evaluation and management services or clinical services and, therefore, do not have a relative value associated with them. Given that there exists an appropriate avenue to code for non-compliant patients and that this issue should be directly addressed through the CPT Editorial Panel, your Reference Committee recommends that Resolution 710 not be adopted.

I am not particularly reassured by this. Are you?

Categories: ethics & philosophy, gender & feminism, health, medicine, social justice, violence

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24 replies

  1. Doctors really need to start understanding that they are not God. A story from my Mum, about a local Dr who had a ‘reputation’ for being difficult (and is in fact the reason that I only ever go to the doctor when I’m really, really undeniably sick or needing a shot of something): a woman she knew was having problems with her blood pressure. Rubbish said the doctor, you are fine. No, she insisted, something is wrong, I want to be referred to a specialist. Dr grumped and grizzled but finally wrote her a referral and put it in a sealed envelope (don’t you hate it when they do that, as if you aren’t allowed to have access to your own health information). An appointment was made with the specialist. Then she opened the letter. The Dr had written, after the usual ‘please see blah blah etc’ “This woman has strange ideas about her own health”. She was not happy.
    So she gets to the specialist, and hands over the letter. When the specialist finishes reading it, she tells him that she has read it too. Then she tells him why the Dr is wrong and what she thinks is wrong with her. She then asks the specialist to treat her as he would any other patient who was referred to him. Which to his credit he does. Tests are done, her blood pressure is too high and in need of medical intervention. The specialist treats her, and her health improves. She changes her Doctor and encourages everyone else she knows to do the same. Unfortunately in a small country town, not everyone has the option of changing doctors. But a lot of them did.

  2. Every time you don’t understand what your Dr is talking about because English isn’t your first language
    Every time your Dr has had a bad day and decides to take it out on you for trying to be informed about your own health

  3. It was all bad, but the ‘stress of dealing with ungrateful patients’ has to be the worst of it. There is this peculiar entitlement about medicine- accountants don’t complain righteously about ‘ungrateful clients’, electricians don’t complain about ‘ungrateful customers’. Doctors, like everyone else, are paid to do a job. They provide a very important and sometimes life saving service and they are well paid for doing so. Their sense that everyone has to fall to their knees in gratitude on top of this is tedious.

  4. Every time your doctor assumes to know your situation better than you do. Sometimes, even when you diagnose someone as depressed, they can know that they’re safe enough to wait until they can see the counsellor they just wanted a referral for. It’s entirely possible. And in fact, attempting to scare them into compliance by warning that ‘depression can be fatal’ is also fucking uncool (it’s lucky I am already pretty cynical and critical of what goes on in a doc’s rooms, though I’m a little sad I wasn’t together enough to make a complaint about that guy). Or alternatively, someone can need the morning after pill because they’re playing it safe, precisely because they’re not the reckless idiots you’re treating them as, and without actually needing to immediately go on the pill as a result.
    With respect to the report, I found “labeling patients and acknowledged a desire to be sensitive to the possible mental health issues of non-compliant patients” quite problematic: non-compliance just became an indicator of mental health issues. That’s right, because there are no reasons for refusing to comply with your doctor’s wishes… only crazy people do that. I can’t believe how swiftly the medical profession will pathologise anything it doesn’t like.
    And I think huckle’s right, the ‘stress’ claim is especially problematic: it indicates that physician job satisfaction is bound to having others do as they are told. I get that it would be hard to watch someone do something you think is unwise, truly, but that’s the freaking job! That’s a problem involved in most jobs, and people learn to deal! In the end, I think this points out that some serious revamping of medical education is required, namely in circumscribing what, precisely, it is that doctors think they’re doing for the bodies sorry, embodied individuals they can (only sometimes and only ever partially) help. But phew, the sense of entitlement….

  5. 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

    Heh. I’m going to try this line out next time a cityrail inspector asks to see my ticket on the train.

  6. Heh. I’m going to try this line out next time a cityrail inspector asks to see my ticket on the train.

    I think you should spell “principal” like that, too.

  7. This stuff makes me quite uncomfortable, because I work in an industry that does talk about non-compliant patients. Whilst not medical insurance, it’s worker’s compensation insurance, and the compliance measures are actually set out in law (as are most aspects of W/Comp in Australia), and we have provisions to suspend wages benefits (though not treatment) due to non-compliance. I know our company, as policy, will generally, y’know, talk to people about why they don’t want a certain type of treatment, and, contrary to popular opinion about insurance folk, I’ve argued with doctors on an injured person’s behalf because doctor is being an ass, but I know other companies aren’t so much, and I really shudder to think what they do to people. (Don’t even get me started on the fact that I, with my complete lack of medical training, have statutory power to decide whether medical treatment is “reasonable”, whatever the hell that means. That’s a rant for another day).
    I think other people have distilled the God complex and entitlement and “being disobeyed = stress” scariness quite well, but, y’know, this whole idea of compliance skeeves me out generally, because even though I have issues with how it can be applied in my line of work, ultimately if I’m not paying the bills, those people still have access to medical care under the Australian system. The idea of similar compliance measures being applied to health insurance in a country where it’s basically a requirement for general health care skeeves me the fuck out.

  8. I think you should spell “principal” like that, too.

    Myairs. Is it because the presumption of innocence should come first—or just these physicians concerned with [sic]ness?

  9. Holy crap.
    And holy crap on this too – This is a country that sent law enforcement officers into a woman’s home, bound her legs together, and forcibly operated on her in the name of fetal rights. – which I hadn’t seen before.

  10. The fact that doctors think all this is mind boggling enough. The fact that they have no compunction in stating it publicly is beyond belief.
    I have been non-compliant for a huge range of reasons, and only rarely because of bad doctoring. The assumption that non-compliance actually reflects badly on the doctor is also flawed.
    And yes, I was a touch horrified by the non-compliance=mental illness implication. I am clearly in need of psychological help immediately, given the number of scripts I haven’t filled, tests I haven’t done – even surgery I refused. Sheesh.
    Ariane’s last blog post..Feminism 101 – for a 6 yr old

  11. These guys need to make up their mind. They desperately fight to preserve private medicine and support their bloated fees, then get jacked off when patients don’t grovel gratefully. Guys, your patients don’t own you THEY RENT YOU, and as such are expecting decent service. The price of preserving your “I’ve got the time if you’ve got the dime” medical system is growing a new pair and recognising that you’re just another service supplier.
    And if black-listing is illegal when insurance companies do it, what makes them think it wont be for doctors?

  12. Who could this affect? If you’re currently saying “piffle, that will only apply to methed-up assholes who physically threaten the staff”, think again.
    I am a 29 year old, middle class professional. I also have Bipolar I. I have been actively non-compliant during manic episodes, usually because I would not allow them to draw blood (oh gee, Im already paranoid and agitated and some stranger is coming at me with a syringe when I have TOLD them about my debilitating phobia of needles. Nice one).
    Under this legislation, I would have been identified as both hostile AND non-compliant. Bye bye insurance. Bye bye being able to afford my meds. Hello to more ‘non-compliance’ and ‘hostility’.
    This is just appalling. I understand the need to ensure doctors and nurses have a safe work environment, but perhaps if better training was given around identifying reasons for non-compliance and ways of addressing these issues (such as better mental health training) then some of these situations could be resolved without becoming a problem in the first place.

  13. So when I had that abusive doctor start yelling at me about addiction 20 seconds into the appointment, and say I needed to be sent into rehab, and I walked out on her, what punishment would I have faced? —
    what about when you consider my regular GP read my subsequent letter, and was very obviously displeased with the first doctor and the only words he would give me about it were “Hurt people hurt people”?
    Sometimes EVEN DOCTORS DISAGREE; one doctor saying something about a patient does not make it The Law Of The Land.

  14. I mean, I can’t count the number of times I’ve had doctors *within the same practice* disagree on diagnosis, treatment course, etc. for me. Much less just different doctors altogether. One doctor thought there was no way I had asthma; five other separate doctors have diagnosed it five separate times (before and after him). OTOH, when I was going through that year before being diagnosed with fibromyalgia, my regular doctor tried to diagnose it as mononucleosis and then an STD. (I was twelve.) despite no evidence in his favor, just casting about for *something* to explain what was obviously very wrong with me.
    It just makes no sense that because the patient disagrees with the diagnosis, will not follow treatment as prescribed, or was less than docile speaking with the doctor, there should be huge consequences for that. And that’s even without considering the patient’s own bodily autonomy ‘n all that silly stuff. Even OTHER DOCTORS might be telling the patient to do (whatever it is). What then?

  15. My D: face is on, and I have a feeling that it will stay for a very long time.
    Way to go, AMA.

  16. It’s not as if there is no precedent for the denial of care, either.
    Some doctors in Australia systematically deny care to all smokers. Pharmacists/doctors/hospitals in various places deny reproductive healthcare to unmarried (or unraped) women. Doctors in the UK deny orthopaedic surgery to fat people. Insurance companies in the USA deny healthcare cover for women who have had a previous C section (hello, double bind calling!) Immigrants and prisoners are denied healthcare frequently, and in the most harrying of ways. And Claims Denial and Denial Management in the USA are probably two of the biggest businesses out there.
    And don’t think the criminalisation (and threat of criminalisation) of birthing at home or declining birth interventions is limited to the USA either, no way, nohow.

  17. Thanks for the link. These are great comments. I was about to reply to WildlyParenthetical’s concern about the sensitivity to mental illness line (that was the one phrase that jumped off the screen at me), but got totally sidetracked by laughing at Liam’s [sic]ness comment.
    Coding for abusiveness and hostility (as behaviors, not attitudes or personality judgments) wouldn’t always be a negative. With relatives that are psych techs and ER nurses, I understand how it might be nice to know if patients have physically attacked others in the hospital before and if they might be going home again with a black eye after a take-down. A few doctors pointed out to me that it is helpful for documentation to be able to note if a patient turned down a recommended treatment (vax, abx, etc.).
    I’ve read so many doctors write about how they are opposed to online ratings of doctors because they’re unscientific or pseudoscientific. I don’t understand what they expect… an RCT conducted to measure someone’s awesome or crappy bedside manner? I think they just don’t want to have people complaining about them openly. And really, who does? What really got me with this resolution was the use of words like arrogance, non-compliance (in the failure to obey sense), ungrateful, stress that leads to illness, physician satisfaction… and on and on. how much more subjective can it get?
    Jill–Unnecesarean’s last blog post..AMA Resolution 710 to Identify Non-Compliant Patients Not Adopted

  18. “people who they think hold “the belief that they own their physicians”
    Anyone who has ever worked in any kind of service industry has experienced clients/customers who are of the belief that they own you for the time that you are taking care of them, even if it’s only for a few minutes.
    I wonder what’s got doctors heads even further up their arses than they already were; is it because of the resources running out, the economy fucking up and things like basic medical care turning into luxuries, that they’re getting so cocky?
    Linda Radfem’s last blog post..My War On The Chaser

  19. @Jill Oh yeah, for sure, I can see the usefulness of keeping a history, especially in terms of providing support both for workers and patients. But the explicit phrasing characterises non-compliance as potentially indicative of mental illness, and that, I think, remains extremely problematic. I’m getting a bit over this tendency to see ‘stuff wot we don’t like’ as a sign of pathology simply because those who don’t like it have the capacity to deem it so (I’m thinking of the updating of the DSM as bringing out some other examples of this tendency:

  20. WP, that was exactly the red flag that waved itself wildly at me when I read the report. Looking at how this resolution or mentality would affect maternity care and women’s health made me concerned about bringing a phony concern for “possible mental health issues of non-compliant patients” into the picture. For some medical professionals, women are considered out of their minds to refuse drugs, anesthesia or c-sections already. Labor is HYSTERICAL and competence is questioned when you’re pregnant. Plus, you’re right… if you don’t comply, you’re clearly crazy, right?
    Jill–Unnecesarean’s last blog post..Watch It, Sister! Your Words Might Get a Little Twisted

  21. You know what my favorite experience in the past year was?
    It was getting a letter from my psychiatrist that he would no longer treat me because I was, basically, non-compliant. Except that the reason for it was because I was seriously ill and my meds were not the right meds for me, and I was in a crisis stage.
    If his decision that I was just wasting his time (and causing him undue stress?) followed me, I don’t care to think where I could be right now.

  22. Such an awful vulnerability, icca, I’m sorry. I hope you’re getting the support you need now. Let’s just hope this kind of thing never becomes standard practice. I have to say, they could have been a *teensy* bit more emphatic with the ‘No’.

  23. And people wonder why I hate doctors. I already have had enough of them talk to me like I was five years old for no apparent reason, assume any physical problems are imaginary since I have mental health issues, threaten me, automatically assume I’m lying, behave as though I am intentionally doing something wrong or just trying to be difficult when prescribed medication makes things worse, tell me being more active would solve everything despite that most of the problems started back when I was considerably more active, insult me to my face… Hell, lots of temporarily-able-bodied mentally “normal” people I’ve known have had horror stories about doctors who ignored serious problems because they wanted to insist it was just them being whiny/crazy/manipulative, or who otherwise behaved nastily just for the sake of the power trip. (Oddly enough, it’s more often women I hear these from when the “WTF is wrong with these doctors” conversation comes up, though. Gee, I wonder how that happens…) Friends/relatives/acquaintances who are have disabilities or are or mentally ill or so on just about always have a much longer list of these incidents.
    Just fucking lovely that they want more power to punish suffering people who are so badly behaved as to not worship them as gods. As if they don’t already do enough damage with the power they have. And no, I don’t feel especially reassured there.

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