Patient Dismissal by Primary Care Practices

Patient dismissal, the termination of a relationship with a patient by a health care professional, can affect access to care. Although understudied, the topic is important, especially as insurers begin to shift payment from volume to value. Patient dismissal could be an unintended consequence of this shift as clinicians face (or perceive that they face) pressure to limit their panel to patients for whom they can readily demonstrate value in order to maximize revenue.¹ We examined the prevalence of and reasons for patient dismissal among primary care practices participating in the Comprehensive Primary Care (CPC) initiative and a matched sample of comparison practices. The CPC and responding comparison practices had similar market-, practice- and patient-level characteristics.^2,3

The New England Institutional Review Board (NEIRB 13-174) exempted the study based on the federal common rule (section 45 CFR 46.101[b][5]), because the evaluation’s purpose is to evaluate a public benefit program. We analyzed the practices’ responses to a survey fielded in 2016, the last year of the 4-year CPC initiative. The survey went to practice managers who were asked to discuss their responses with others in the practice. All 443 CPC practices and 42% (351) of 849 comparison practices responded, yielding 794 practices. Participating CPC practices were not compensated. Comparison practices and withdrawn CPC practices were compensated up to $125 for responding.

In addition to questions on the practices’ characteristics and approaches to delivering care, the survey asked: “In the past 2 years, has your practice ever dismissed a patient from your practice? By dismissing patients, we mean directing patients to leave your practice and seek primary care elsewhere.” Respondents who answered “yes” were then asked to identify, from specified response categories, reasons for patient dismissal (Table). They were also asked to estimate the number of patients dismissed in the past 2 years by choosing any of the following ranges: 1 to 5, 6 to 10, 11 to 20, 21 to 50, or 51 or more. CPC practices were also asked whether participating in the initiative made it more or less likely that they would dismiss patients. We present descriptive statistics from these data on patient dismissal for CPC practices, comparison practices, and overall.

A similar proportion and distribution of CPC and comparison practices reported ever dismissing patients in the past 2 years (394 [89%] and 314 [92%], respectively). Most practices reported dismissing only a few patients in the past 2 years; 86 (about 10%) did not dismiss any patients, and 530 (67%) reported dismissing 1 to 20 patients (Table). The number of patients dismissed was proportional to practice size (data not shown). CPC and comparison practices dismissed patients for similar reasons. The exception was that comparison practices more frequently reported dismissing patients for violating bill payment policies than did CPC practices (124 [43%] vs 139 [35%]).

Practices that reported dismissing any patients did so for the following reasons: the patient was extremely disruptive or behaved inappropriately toward clinicians or staff (567 [81% of practices]), violated chronic pain and controlled substance policies (552 [78%]), or repeatedly missed appointments (504 [74%]) (Figure). Fewer practices reported dismissing patients for repeatedly not following medical recommendations (313 [45%]), violating bill payment policies (263 [39%]), repeatedly not following recommended lifestyle changes (38 [7%]), and making frequent visits to the emergency department or self-referring to specialists (40 [6%]).

Our results provide early evidence on the influence of one alternative payment model on patient dismissal and the reasons for it. According to most CPC practices, the initiative had no effect or made them less likely to dismiss patients. The CPC and comparison groups dismissed patients for similar reasons.

The limitations of our study include the use of survey data, which may be subject to recall or social desirability biases. We used survey data because it was not feasible to review patient medical records or dismissal letters from the 1292 practices.

Our study contributes new insight into an issue that will be increasingly important as insurers move to reimbursing for value rather than volume. Future research could investigate what medical ethicists consider inappropriate reasons for dismissal.^1,4

Corresponding Author: Ann S. O’Malley, MD, MPH, Mathematica Policy Research, 1100 1st St, NE, 12th Floor, Washington, DC 20002-4221 (aomalley@mathematica-mpr.com).

Accepted for Publication: March 10, 2017.

Published Online: May 15, 2017. doi:10.1001/jamainternmed.2017.1309

Author Contributions: Dr O’Malley had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: O’Malley, Peikes, Day.
Acquisition, analysis, or interpretation of data: O’Malley, Swankoski, Peikes, Crosson, Duda, Heitkamp.
Drafting of the manuscript: O’Malley, Swankoski, Peikes, Crosson, Duda.
Critical revision of the manuscript for important intellectual content: O’Malley, Peikes, Crosson, Duda, Day, Heitkamp.
Statistical analysis: O’Malley, Swankoski, Peikes, Heitkamp.
Obtained funding: Peikes.
Administrative, technical, or material support: Peikes, Crosson, Duda, Day, Heitkamp.
Study supervision: O’Malley, Peikes.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by the Center for Medicare and Medicaid Services, Centers for Medicare and Medicaid Innovation.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies.