Getting patients to commit

My liability insurer recently published its list of major claims for 2005. Two of them involved primary care doctors who had "missed" cancers. In one instance, a PSA wasn't done on a 54-year-old and in another case, a 47-year-old had developed colon cancer. But neither patient had taken it upon himself to schedule an annual physical!

I've developed a strategy to sort out those patients who truly want primary care from those who don't. Perhaps it will work for you.

Step one: Do an annual review on primary care patients. True, the very notion of a requisite annual physical is controversial. However, patients appreciate doctors who are meticulous, and patients (and jurors) don't read medical journal articles advising against physicals. I use the annual physical as a preventive review for my patients to make sure they're up to date on mammo, Pap, DEXA, PSA, urinalysis, guaiac smear test, colonoscopy, etc.

In order to help make my patients' choices clear, I created a list of every patient over the age of 40 who has seen me in the past two years and hasn't been billed 99396 (comprehensive preventive exam) or V70.0 (routine health checkup). I'm careful to never use these codes unless I've addressed all necessary diagnostics in that visit.

The resulting names are those patients who represent my risk exposure for failure to diagnose.* I send these patients a letter inviting them to come in for an annual review and include a return postage-paid postcard, along with their patient identification number.

I ask them to check one of three boxes to signify whether:

I explain in the letter that I'm available for future appointments for all patients, regardless of which box they check. The difference is that I have a higher level of expectation for patients who check the first and second boxes to take the initiative to come in for an annual exam. If they don't make an appointment, I mail regular documented reminders.

Surprisingly, the postcard response rate was higher than 50 percent! I feel that those patients who checked the third box or didn't respond to the mailing have essentially "opted out" of preventive care. This enables me to better focus on patients who want preventive medicine and, for those who have opted out, I have documentation to help defend against a possible claim of negligence down the road.

*The regularity of annual physicals has no bearing on a doctor's malpractice exposure. The issue of negligence or failure to diagnose rests solely on whether a physician exercised an appropriate degree of care during an exam, treatment, and follow-up. We recommend that you consult with an attorney before implementing any plan intended to limit your professional liability.