Can A American Hospital Turn Away Patient For Lack Of Money

• Periodical Listing
• J Gen Intern Med
• v.16(vi); 2001 Jun
• PMC1495228

J Gen Intern Med. 2001 Jun; 16(vi): 412–418.

"I Can't Afford That!"

Dilemmas in the Care of the Uninsured and Underinsured

Abstract

When patients lack sufficient health care insurance, fiscal matters become integrally intertwined with biomedical considerations in the process of clinical determination making. With a growing medically indigent population, clinicians may be compelled to curve billing or reimbursement rules, lower standards, or turn patients abroad when they cannot afford the costs of care. This article focuses on 3 types of dilemmas that clinicians face when patients cannot pay for needed medical services: (ane) whether to refer the individual to a condom net provider, such as a public clinic; (2) whether to forgo indicated tests and therapies because of cost; and (3) whether to reduce fees by fee waivers or other adjustments in billing. Clinicians' responses to these dilemmas affect on quality of care, continuity, safety net providers, and the liability run a risk of committing billing violations or offering nonstandard intendance. Caring for the underinsured in the current wellness care climate requires an agreement of billing regulations, a delivery to informed consent, and a beneficent approach to finding individualized solutions to each patient care/fiscal dilemma. To issue change, notwithstanding, physicians must address issues of social justice outside of the office through political and social activism.

Keywords: access to care, indigent, clinical determination making, underinsured, uninsured

With nearly 44 million uninsured and an increasingly prevalent underinsured population in the Us, many physicians are confronted with patients who cannot pay for health care they demand.^one While condom net institutions exist where patients tin can receive heavily subsidized or costless medical services, most patients who are medically indigent discover themselves at clinics and hospitals that bill for the services they provide.² As a result, for many physicians, there are frequent encounters with patients who are concerned about the financial implications of the care they receive. This commodity examines the legal and ethical implications of incorporating the financial needs and concerns of patients into clinical decision making and the doctor-patient relationship.

When an individual patient refuses needed care exclusively because of concerns about cost, the medico is confronted with a series of dilemmas that directly affect the physician-patient relationship. When a patient says, "I can't afford that," what is a medico to do? Urge the patient to proceed despite the expense? Compromise the standard of care to reduce costs? Decline to provide substandard care, and therefore any care at all? Endeavor to manipulate reimbursement rules or falsely underbill for the patient's do good? These issues may be ongoing, since patient concerns about cost are probable to resurface at costly junctures in the care plan.

A process of negotiation may ensue in which the physician attempts to justify the needed services and the patient pushes for alternative approaches that cost less. At stake for the clinician are concerns about lowering the standard of intendance, exposure to liability, and professional insecurity nigh straying from well-trodden clinical care pathways that are more often than not recommended. For the patient, the stakes are concerns about financial and physical well-beingness.

The post-obit case is provided as an analogy of the dilemmas a clinician confronts when a patient cannot beget the standard of care. Patient identifiers have been contradistinct to assure anonymity.

Ms. Anna Wade is a self-employed seamstress with no health insurance. She is a 54- twelvemonth-old woman who has been in skilful wellness, has never smoked, and exercises 3 times a week. In September 1999, she began experiencing episodes of chest pain that occurred more often than not later meals and in the evenings earlier going to bed. Occasionally, the episodes occurred when she was exercising on a stationary bicycle in her apartment building. Initially, she ignored the symptoms, only began to worry every bit they worsened over time. She noticed a loss of appetite, and her trousers became loose. One afternoon, she took the charabanc with her sister to a nearby hospital to be seen in the walk-in dispensary. At the desk-bound, she made a $38 prepayment that was required because of her status as uninsured.

The medico listened to her story and performed a physical test. He said that he thought her symptoms were caused by "heartburn," which he explained has nothing to practice with the heart, but is acquired when acrid in the stomach regurgitates upward into the esophagus, causing pain. However, he also emphasized two important diagnostic considerations. Ideally, she should undergo a cardiac stress test to look for signs of coronary artery affliction. In addition, because of her age and weight loss, he recommended endoscopy to dominion out cancer of the tummy or esophagus. If these tests were normal, he would simply treat her heartburn with medications and some dietary advice. When she asked nigh the costs of the tests, he said information technology would be over $1,000.

Ms. Wade looked worried and stared at her feet. "Doctor, I can't pay that much." A discussion ensued in which the physician suggested she go to the public hospital. She responded unfavorably, saying that her sister and an aunt had bad experiences trying to obtain services at that place: "They lose track of you lot and make you wait all day to be seen; I can't afford to take the time." The physician urged her to reconsider, but she remained determined. He best-selling that the hospital's staff were overextended, and began to consider other options.

Although he knew the standard approach for managing such a presentation involved ruling out cardiac disease and a gastrointestinal malignancy, he also recognized that the odds were in her favor that she had neither. The history suggested her condition was gastrointestinal and not cardiac, and in a nonsmoker who was not of E Asian background, malignancy would be unlikely. He thought her poor appetite and weight loss might be related to feet.

1 option would be to care for her empirically for heartburn by starting a proton pump inhibitor. The risks, of form, were that if her condition were cardiac or if she had a malignancy, the consequences of a delay in diagnosis could compromise care. He also idea well-nigh ways to reduce the costs, but his hospital had no clemency policy, and there was no style he could affect billings in the cardiology or gastroenterology clinics where she would be referred.

As they discussed various options, the clinic visit ran overtime. Other patients were waiting. The doctor realized that if he did not take care of her, she was unlikely to go elsewhere. He urged her to undergo the tests at his facility, even if she but paid a portion of the fee. The hospital would write off the losses as bad debt and refer her bill to drove. However, Ms. Wade did not like the idea of being pursued past a collection agency.

Somewhat reluctantly, he resolved to treat her for heartburn with a $117 per month prescription for a proton pump inhibitor. He explained that since they might be missing a serious status, he would see her again in 2 to four weeks. He was peculiarly anxious to meet if she continued to lose weight, raising the suspicion of a malignancy.

As she was leaving, his nurse was able to provide Ms. Wade with some samples of a proton pump inhibitor supplied by a pharmaceutical representative. The doctor reduced the fee of her visit by writing off the professional component of the bill. Information technology was not in his power to cancel the clinic portion, only he undercoded the visit as a 15-infinitesimal appointment when in fact she had received more than 30 minutes of his time.

This case provides an opportunity to consider the dilemmas that face a clinician caring for an uninsured patient. If Ms. Wade had been underinsured, i.e., had health insurance that did not cover the needed services, the physician might have been tempted to dispense reimbursement rules. In a study of a national survey published this year, 39% of physicians acknowledged manipulating reimbursement rules to obtain coverage for services they perceived as necessary for their patients.³ It is useful to review the federal laws that impact on caring for this population.

GOVERNMENT REGULATIONS

Every bit stated, Ms. Wade was uninsured. Physicians are unlikely to encounter legal difficulties providing uncompensated care to completely uninsured patients.^* Since the laws intended to reduce fraud and abuse pertain to arrangements involving 3rd-political party payers, at that place is no violation associated with reducing or waiving a fee when the patient is cocky-pay.

When patients such as Ms. Wade do have health insurance, but are not covered for needed services or cannot afford a deductible or copayment, physicians may endeavor to reduce fees through a variety of billing adjustments. These include undercoding, waiving deductibles or fees higher up insurance, reducing charges below their usual and customary fee, or not billing at all. Nevertheless unwittingly, such physicians may be committing technical violations or be engaged in corruption or fraud.

The Part of the Inspector General in the Department of Health and Homo Services is charged with monitoring federal wellness care programs for testify of fraud or abuse. They are particularly concerned when charge-based providers routinely waive coinsurance or copayment amounts mandated under Medicare. Such practices found false claims, are violations of the Medicare and Medicaid antikickback statute, and may event in overuse of products and services funded by Medicare. A imitation merits occurs, for example, when a physician claims that the charge for a service is $100, simply routinely waives a $twenty copayment. In such an case, the de facto accuse is $80, and Medicare is paying the total sum rather than eighty%. A kickback violation occurs when the routine waiver of co-insurance results in an inducement for beneficiaries to favor a detail provider. When fees are consistently waived, there is potential for overutilization or unfair marketing.⁴

In 1996, Congress enacted a specific prohibition of the Medicare waiver. However, it is permissible to waive copayments on a example-by-case basis for detail patients when financial hardship is documented. The law makes an exception for such cases.⁵ What is critical is that such waivers non be routine and not exist advertised. Furthermore, providers are expected to document why their patient merits a waiver on financial grounds.

Undercoding, such as billing for a small-scale visit when the patient received an extended visit, is a misrepresentation of services provided and is a violation of the law. In dealing with federal programs such every bit Medicare, the Health Care Financing Administration (HCFA) advises physicians to bill for the services they provide. Claims are required to exist accurate. When coding is inaccurate, secondary uses of the database are compromised, with potentially serious consequences for other patients. For example, future coverage of services past Medicare and Medicaid could be withheld, based on empirical studies of marred databases showing adept outcomes for patients receiving low-intensity care.

Laws similar to those governing payments for federal programs accept been widely adopted in various forms by the private sector. Thus, physicians are brash to adhere to them consistently, regardless of the payer. One exception is waiving the unabridged accuse for care, for which there is apparently no ban amidst private insurers. An example would exist waiving the charge for follow-up visits for elementary conditions such equally otitis media in children.⁶ Of grade, waiving all fees becomes a violation if information technology is part of a fraudulent scheme that profits the provider straight or indirectly.

DISCUSSION

The dilemmas that face up the clinician when a patient cannot beget medical intendance raise profound issues of social justice. To what extent is the medically indigent patient a victim of unjust social arrangements? Do we view health care every bit a public adept or defer to political processes, allowing the marketplace and elected officials to determine the form our health intendance arrangement takes? The discourse on wellness intendance every bit a right is ongoing.^{seven , eight}

Abstract debates on universal access are of piffling value to the clinician confronted with an indigent patient. The dyad between physician and patient is pragmatic: medical issues need to be addressed and so and there. The physician must practice what is best for the patient, within existing constraints.

Effigy 1 outlines permissible options for a clinician when a patient cannot beget the standard of intendance. Start, the clinician must identify whatever potential resources for assisting the patient both within and exterior of the institution. Often, social workers can identify advisable resources. Within the institution, at that place may be a clemency policy. If and then, free care or a sliding fee scale is made bachelor to patients who meet the criteria of a ways test. Within the community, there may be condom net providers such every bit federally qualified health centers, board of health clinics, public hospitals, or private physicians who may provide charity services. When less plush intendance is available elsewhere, physicians confront their beginning dilemma: Should patients be referred to safety net providers when the cost of intendance is beyond their means?

Provider options when a patient cannot afford needed intendance.

What are the ethical implications of terminating the physician-patient relationship considering of an inability to pay? Inability is the operative discussion here, indicating that a patient is medically indigent (as opposed to unwilling to pay). The dr.-patient human relationship involves mutual responsibilities, and one of those is for the patient to remunerate the physician. Only what if the patient is unable to do so? Might it be abandonment to deny further care? Should a long-standing physician-patient relationship exist viewed differently than a first visit? What if the patient had simply never been ill earlier and hence had no prior inclination to run into a doc?

What are the quality-of-intendance implications of terminating the relationship for financial considerations? Volition the patient likely receive inferior care if sent elsewhere or, alternatively, better service at a site where costs are less likely to constrain care? Will the resulting delay involved in referral cause damage?

To respond these questions, the physician must consider both the quality of care available at nearby prophylactic cyberspace providers, and the likely need for costly tests or interventions. Since public institutions often have more expertise than private practitioners in caring for weather common amidst low-income patients and in treating certain subgroups, such as not-English speaking patients and individuals with substance corruption comorbidities, referral may atomic number 82 to better intendance. Such forward thinking should begin at the showtime meet, and so as to avoid embarking on an extensive work-upwardly just to be batty midstream because of patient concerns near cost. Since patients may not raise concerns about payment until costly tests are required, clinicians should raise the matter with all at-take chances patients at the first see.

Finally, in that location is the question of whether a physician is capable of making an unbiased decision nigh referring a nonpaying patient to another provider. In that location is a directly conflict of involvement when a physician's personal income is at stake. Physicians may exist penalized for undue expenses or poor productivity as measured past billing. Safety net providers use the term "dumping" to describe the referral of nonpaying patients to public hospitals when they crave expensive care.⁹

What are the larger consequences of directing indigent patients toward safety cyberspace institutions? Every bit both not-for-profit and for-profit providers compete in the marketplace, the nation's about indigent patients are directed to and full-bodied at a shrinking number of overburdened safety internet institutions.¹⁰ The need for free care far exceeds the capacity of public institutions. Is "dumping" unethical because it further weakens our nation'southward public hospitals and clinics?

If a patient is non referred elsewhere and charity resources are inadequate, the physician must lower the expense and often the standard of care. To do so may be beneficent. If the physician concludes that continuity of care provides a benefit that is greater than referral for services available at lower cost elsewhere, such a decision may be justified. Given his concerns about fragmented intendance and the quality of services available at the local safe net institution, the physician caring for Ms. Wade might reasonably have reached this conclusion. In retaining responsibility for an indigent patient, then, he faces his second dilemma: Should a physician lower the standard of treat financial reasons when a patient's health may suffer?

What is meant by the concept of a "standard of care?" In legal parlance, the phrase refers to the evidence-based consensus of a console of experts as to the best arroyo to a clinical problem.^xi For many conditions, at that place is considerable disagreement about the standard of care. There may exist insufficient outcomes information, and no "standard" tin can accept into consideration unique features of private cases. That is the job of a dr..

The expert consensus in the literature is that weight loss in a patient aged more than fifty years with new symptoms of heartburn is an indication for endoscopy.¹² In the literature, withal, endoscopy is performed with adept follow-up and in a timely mode. When the standard of intendance is unavailable to the uninsured or underinsured patient, it may not exist realistic for the physician to require such a standard. Problems of social justice cannot be solved in the md's part.

Ms. Wade must understand that the decision to turn down referral to the county hospital for endoscopy carries risk. Nevertheless, her concerns about delays in care and poor follow-up should be respected. Given the bear upon of her insurance status, the standard of care as derived in the research setting is not available to Ms. Wade. Finally, at that place is the patient's business organization near her piece of work responsibilities. In the judgment of the dr., post-obit her closely and conservatively may be the best grade bachelor.

For patients to share in the decision about the best course of activity, they must be fully informed near the potential risks and benefits of their various options. This main of informed consent, which is commonly applied to clinical care decisions, must encompass dilemmas resulting from financial constraints when they exist.

As shown in Effigy 1, the 3rd set of issues physicians must accost pertain to the billing procedure. In the case of Ms. Wade, the physician undercoded the part visit and waived the professional fee, without any documentation of her demand. Had she been insured by the authorities or privately, he would have put his institution at legal run a risk. In striving to aid patients financially, then, the doctor faces a third dilemma: Should a physician adjust billing or claims information to reduce costs for an indigent patient?

Although it is non known how frequently physicians who care for indigent patients undercode visits or waive fees, in the report of a national survey cited above, a sizable minority of physicians reported other types of reimbursement manipulations intended to benefit patients, including exaggerating the severity of weather, altering billing diagnoses, and/or fabricating signs or symptoms to secure coverage.³ The American Medical Association and the American College of Physicians-American Club of Internal Medicine forth with other professional bodies have declared that manipulating payment claims is unethical equally a method of advocating for patients.^{13 , 14} The HCFA states that its regulations, which are designed to forestall abuse and fraud, should non prevent the clinician from reducing fees exclusively for an indigent patient's do good. Problems may be aggravated when clinics have not developed adequate protocols for adjusting fees. If the physician caring for Ms. Wade had been able to refer her for a means examination and sliding fee scale, he might take achieved the same reduced fee without miscoding the visit.

LIABILITY

Nearly all physicians call back almost issues of liability when they call back about the standard of care. In civil court hearings for malpractice, disputes of quality of care frequently revolve effectually questions of the standard of care, and whether the patient received it.¹⁵ Expert testimony is summoned to define the standard.

When a patient does not receive the standard of care, documentation is particularly critical. The physician must chart why a detail nonstandard programme of care was selected and that the patient was informed of the risks involved. In the case of Ms. Wade, the physician would need to document, for example, that although he has informed her that endoscopy is indicated, she cannot beget the process and declines referral to a public facility. He would and then need to explain why post-obit her conservatively (treating her with medicine and watching her clinically) is the best option under the circumstances.

While good documentation is a doctor'due south best nugget in court,¹⁶ a good physician-patient relationship is the best protection against legal conflict.¹⁷ When a physician works as an ally to help an indigent patient in obtaining medical services, the physician has an opportunity to build an honest, therapeutic human relationship. When a patient is turned away, that opportunity is lost. The literature suggests that patients are most likely to be angered if they feel abased.¹⁸ Information technology appears unlikely, so, that the physician assumes greater liability past working with indigent patients than by turning them abroad.

SHARED Conclusion MAKING

Shared decision making describes a partnership between physician and patient in which each contributes equally to the decision making process.¹⁹ For example, how do physicians deal with alien responsibilities to private patients and to the population? Should the medico caring for Ms. Wade weigh the touch of referring an uninsured patient to the county infirmary on an already overburdened safe cyberspace? Are there ways to help her choose between missing work waiting for medical intendance at the county hospital and the increased peace of heed that may come from knowing her actual cancer and centre affliction risk, and from fugitive the neb collector?

Theories of distributive justice, such as utilitarianism and egalitarianism, have emphasized the importance of applying decision-making principals uniformly and consistently.^{20 , 21} By what criteria does one define consistency? Ms. Wade'southward physician may be consistent in abiding by a framework that adapts to the needs and wishes of each patient. Such an approach emphasizes patient autonomy, and, equally one scholar writes, "clinicians should be exempt from normal social ethics so they are costless to pursue the objective welfare of patients."²² While the conclusion making procedure should rest on rational principals, the physician's judgment must reach beyond algorithms to consider each case's unique circumstances.

Patients such every bit Ms. Wade must choose among options for which the upshot is uncertain. Preferences under conditions of uncertainty are chosen utilities (as opposed to values, which reverberate choices amidst known outcomes). There are a diverseness of methodologies for measuring preferences including standard gamble,²³ time trade-off, and chiselled rating techniques which include magnitude estimation, equivalence, willingness-to-pay,²⁴ and, almost recently, multiattribute utility theory.²⁵ The guided controlling process, known as utility analysis, involves describing options, outlining all prove for possible outcomes, and measuring preferences.²⁶ In essence, information technology is a weighing of risks. Various patient determination support tools take been studied for predefined "utility sensitive"²⁷ dilemmas such every bit whether to initiate hormone replacement therapy in perimenopausal women,²⁸ whether to prescribe warfarin for chronic atrial fibrillation,²⁹ and how to select among equivalent therapies for prostate cancer.²⁵ Unfortunately, formal utility analysis is fourth dimension consuming and has been adult using predefined variables, as in the examples higher up.

While developments in determination analysis are promising, unanswered questions remain about eliciting preferences and incorporating them in clinical encounters under "crushing time pressures."^xxx Until an investigator tin demonstrate how formal methods of decision analysis tin can exist applied to a patient's unique circumstances during a routine 20-minute clinical run into, they will not be applicable to cases such every bit Ms. Wade's. Even so, familiarity with these methods may facilitate shared decision making as a more informal process.

GUIDELINES

The principal thesis of this article is that when fiscal considerations intervene in decision making for the individual patient, the clinician is forced off of well-trodden clinical pathways, leaving uncertainty well-nigh what is best for the patient. In instances where physicians are forced to compromise the standard of care, in that location is a potential reduction in quality. Such instances volition occur until at that place is universal admission to a basic standard of care. If the art of medicine is applying the science of medicine to the context of the patient, the artful doctor volition provide the best intendance possible nether the circumstances. The post-obit are proposed as guidelines.

1. Physicians should explicitly ask about fiscal concerns rather than ignore the problem or wait for patients to raise the upshot showtime. As with other sensitive questions physicians inquire, patients may react with anxiety or discomfort, but the information they provide is important to the care program. If financial considerations volition touch on the commitment of medical services, it is better to know sooner rather than afterward. This will enable the clinician, earlier embarking on an extensive work-up, to consider the ramifications of transferring a patient with a item medical need to an indigent intendance facility versus retaining the individual with a goal of providing care at lower toll.

2. Physicians demand to be knowledgeable about the resources available at their institution and in the community for the medically indigent, so they can maximize services that aid their underinsured patients. They may do good from ancillary staff, often in social work, who can provide appropriate guidance and referral data. They should be certain that their patients with financial hardship are getting full do good from the public and private resources that are available, such as public assistance and pharmaceutical industry indigent drug programs.

3. In considering whether to retain a patient or refer to a condom net provider, physicians must have into account the loss of continuity of care and uncertainties nearly the level of service available at alternative sites. They should as well consider that services might exist better elsewhere if the referral selection is an academic institution or the patient is from an ethnic minority group with which the safety cyberspace provider is peculiarly familiar. If a decision is made to refer, the doctor should brand straight contact with providers at the referral site to identify a contact liaison to optimize the referral process.

4. If retaining a patient appears to be the preferable or only option, a physician may be forced to provide a nonstandard approach to care in order to all-time serve that individual. Documentation that a patient has declined a recommended study or therapy, including referral to a safety net provider, if available, and has been informed of the risks involved is critical. In such cases, close observation with frequent visits and bones laboratory studies tin can be an inexpensive alternative to ordering costly tests (which may have simply a marginal benefit over conscientious observation). The relationship that develops in this setting tin can be a patient'southward lifeline when a strong physician abet who knows the patient well is needed.

5. Physicians should actively work to lower the cost of their services when they have clear show of fiscal hardship. For underinsured patients, they must do so in a manner that will not be interpreted as financially self-serving or in violation of the law. For uninsured patients, adjustments in fees are allowed. When the demand for free intendance threatens the financial viability of the provider establishment, the medico can promote the adoption of charity policies that help direct subsidies to the most needy patients.

6. To best serve their patients in the broadest terms, physicians must address issues of social justice outside of the office. Within their institution, they can lobby for a charity care policy, the utilise of ways testing, and the application of sliding fee scales. In their customs and through professional societies, they tin can lobby for support of safety net institutions, such as publicly funded hospitals and clinics. At a land and national level, they can participate in educating the public nearly the consequences of unaffordable wellness insurance for tens of millions of Americans. Finally, they tin advocate for reforms that will broaden access to medical care and services, including medications and supplies.

Acknowledgments

The writer would similar to acknowledge Gordon D. Schiff, MD for careful review of the manuscript and helpful suggestions which led to noun changes.

Footnotes

^*An exception is when certain country- or county-funded providers preclude the giving away of publically owned appurtenances and services.

REFERENCES

ane. Kuttner R. The American health care system. Wellness insurance coverage. New Engl J Med. 1999;340:163–viii. [PubMed] [Google Scholar]

ii. Isle of man JM, Melnick GA, Bamezai A, Zwanziger J. A contour of uncompensated infirmary care, 1983–1995. Health Aff (Millwood) 1997;sixteen:223–32. [PubMed] [Google Scholar]

3. Wynia MK, Cummins DS, VanGeest JB, Wilson IB. Dr. manipulation of reimbursement rules for patients: between a rock and a hard place. JAMA. 2000;283:1858–65. [PubMed] [Google Scholar]

four. Special Fraud Alert, Routine Waiver of Medicare Part B Copayments and Deductibles. 1994. 59 Federal Register 65373.

v. Health Insurance Portability and Accountability Human action. 1996. § A(c)(five) [PubMed]

6. Rathbun KC, Richards EP. Professional courtesy. Mo Med. 1998;95:18–twenty. [PubMed] [Google Scholar]

7. Ozar DT. Justice and a universal right to basic health care. Soc Sci Med. 1981;fifteen:135–41. [PubMed] [Google Scholar]

8. Wing KR. The right to health care in the United states. Ann Wellness Law. 1993;two:161–93. [PubMed] [Google Scholar]

9. Bindman AB, Grumbach M. America's condom net. The wrong place at the wrong fourth dimension? JAMA. 1992;268:2426–vii. [PubMed] [Google Scholar]

10. Baxter RJ, Mechanic RE. The condition of local wellness care prophylactic nets. Health Aff (Millwood) 1997;16:7–23. [PubMed] [Google Scholar]

xi. Feasby C. Determining standard of care in alternative contexts. Health Law J. 1997;5:45–65. [PubMed] [Google Scholar]

12. Talley NJ, Axon A, Bytzer P, Holtmann G, Lam SK, Van Zanten SV. Management of uninvestigated dyspepsia: a Working Party report for the Globe Congresses of Gastroenterology 1998. Aliment Pharmacology and Ther. 1999;13:1135–48. [PubMed] [Google Scholar]

13. Chicago, Il: American Medical Clan; 1997. Health Care Fraud and Corruption: Report of the Council on Ethical and Judicial Diplomacy and the Quango on Medical Service of the American Medical Clan. [Google Scholar]

14. Ann Intern Med. Fourth edition. Vol. 128. American College of Physicians; 1998. Ideals Manual; pp. 576–94. [PubMed] [Google Scholar]

fifteen. Male monarch JY. Practice guidelines and medical malpractice litigation. Med Law. 1997;16:29–39. [PubMed] [Google Scholar]

sixteen. Irving AV. Xx strategies to reduce the chance of a malpractice claim. J Med Pract Manage. 1998;14:130–3. [PubMed] [Google Scholar]

17. Levinson W, Roter D, Mullooly JP, Tiresome VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary intendance physicians and surgeons. JAMA. 1997;277:553–ix. [PubMed] [Google Scholar]

18. Capen 1000. Prevention should be the preferred insurance program for all physicians. CMAJ. 1996;154:138–57. [PMC free commodity] [PubMed] [Google Scholar]

nineteen. Edwards A, Elwyn Chiliad. The potential benefits of decision aids in clinical medicine. JAMA. 1999;282:779–80. [PubMed] [Google Scholar]

20. Olsen JA. Theories of justice and their implications for priority setting in health care. J Health Econ. 1997;xvi:625–39. [PubMed] [Google Scholar]

21. McKneally MF, Dickens BM, Meslin EM, Vocalizer PA. Bioethics for clinicians: 13. Resource allocation. CMAJ. 1997;157:163–vii. [PMC complimentary commodity] [PubMed] [Google Scholar]

22. Veatch RM. Allocating wellness resource ethically: new roles for administrators and clinicians. Forepart Wellness Serv Manage. 1991;8:three–29. 43–4. [PubMed] [Google Scholar]

23. Llewellyn-Thomas H, Sutherland HJ, Tibshirani R, Ciampi A, Till JE, Boyd NF. The measurement of patient'south values in medicine. Med Decis Making. 1982;two:449–62. [PubMed] [Google Scholar]

24. Flowers CR, Garber AM, Bergen MR, Lenert LA. Willingness-to-pay utility assessment: feasibility of use in normative patient decision back up system. Proc AMIA Annu Fall Symp. 1997:223–seven. [PMC gratuitous article] [PubMed] [Google Scholar]

25. Chapman GB, Elstein Equally, Kuzel TM, Nadler RB, Sharafi R, Bennett CL. A multi-attribute model of prostate cancer patients' preferences for health states. Qual Life Res. 1999;8:171–80. [PubMed] [Google Scholar]

26. Taylor TR. Understanding the choices that patients make. J Am Board Fam Pract. 2000;13:123–33. [PubMed] [Google Scholar]

27. Kassirer J. Incorporating patients' preferences into medical decisions. N Engl J Med. 1994;330:1895–6. [PubMed] [Google Scholar]

28. Holmes-Rovner Thou, Kroll J, Rovner DR, et al. Patient decision support intervention: increased consistency with decision analytic models. Med Care. 1999;37:270–84. [PubMed] [Google Scholar]

29. Protheroe J, Fahey T, Montgomery A, Peters T. The touch of patients' preferences on the handling of atrial fibrillation: observational study of patient-based decision analysis. Brit Med J. 2000;320:1380–4. [PMC free article] [PubMed] [Google Scholar]

xxx. Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users' guides to the medical literature XXV. Show-based medicine: principles for applying the User's Guide to patient care. Testify-Based Medicine Working Grouping. JAMA. 2000;284:1290–6. [PubMed] [Google Scholar]

---

Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine

---

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495228/

Posted by: parrottnowed1944.blogspot.com

Share this post