This imaginary letter, penned after attending a Quality Initiative meeting, is fictional today, but I suspect something like it will appear in the near future and be sadly common within five years. I hope I have retired by that time, because it would be truly shameful to actually sign and send such a letter.

Dear (computer generated patient name),

I am writing to express my deepest regret that I can no longer serve as your PCP.  I will continue to provide you with all appropriate care during the next sixty days while you arrange an alternative provider.

The reason I can no longer be your PCP is that your health status does not meet the established criteria for a person receiving good care.  No one person is solely responsible for this. You, I, and various external agencies share culpability. Let me explain.

There was a time when I had a person-to-person medical and billing relationship with my patients. I worked for them, and they worked with me. The patient and I were accountable to each other and shared the responsibility for what we were (or weren’t) able to accomplish. That era is gone. Your insurance (and therefore your access to care) is now provided to you either through work or through a governmental organization. When my employer signs a contract with your payor, my employer has to agree to abide by that payor’s rules. These rules now drive the care I am expected (and allowed) to provide you.

(Next paragraph to be written or adapted, and then inserted by provider to make the computer generated letter seem less impersonal.)

Unfortunately, despite how hard you and I have worked, your diabetes and blood pressure are still poorly controlled, you remain overweight, and you continue to smoke. It is not that we have not recognized how serious these are or worked hard to address them. In fact, we have made substantial progress despite the chaos in your life. I understand that your ability to manage your diabetes and hypertension and quit smoking has been hampered over the last 3 years by the knee injury that keeps you from exercising and that cost you your job (and health insurance), after which you defaulted on your mortgage so you are now living in a friend’s basement. I am sorry that you cannot afford all of your medications and recommended testing, or the counseling to help with your depression or help you quit smoking. We have talked about this multiple times during your visits, and we have made some progress. We both find our visits together rewarding. However, it breaks my heart to tell you that the payors who contract with my employer do not see this as relevant. Therefore my employer does not feel they can afford to make allowances. They say that sewage flows downhill. I, in turn, cannot afford to shoulder this burden, so I am forced to pass it on, primarily to my most needy patients.)

We know each other well and have a solid relationship built on having worked together for more than 20 years. I wish I could continue to be involved in your care. Unfortunately, your payor reimburses my employer less when your diabetes, blood pressure, weight and smoking status are not optimal. In turn, my employer compensates me less. I cannot any longer afford to spend large amounts of time helping you reach what are clearly unobtainable targets.

Your inability to reach nationally recognized standards of health present two problems:

  • It costs your insurer, my employer (and me) money.
  • It forces me and my staff to spend larger than average amounts of time on your care, thereby depriving our healthier patients of their rightful portion of our time and energy.

As a result, I am now forced to limit my patient panel to those individuals who are able to demonstrate the ability to benefit from my services, as measured by nationally determined quality standards, including such things as BMI, systolic blood pressure, A1c, LDL and smoking status. Patients who are unable to reach the 75th percentile within our 12 month quality auditing review cycle will be asked to find care elsewhere.

I will, of course, be happy to provide you with a full copy of your records to bring to your future provider. In addition, if at some point in the future you are able to get your ‘metrics’ back into the acceptable range, I would be delighted to become your PCP again and help you maintain your health.


The Paid_for_Performance (P4P) Doctor


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