See Wicclair, M., “Dismissing Patients for Health-Based Reasons,” Cambridge Quarterly of Healthcare Ethics 22, no. 3 (2013): 308–318 (discussing reasons why physicians fire a patient); D.B. Resnik, “The Patient's Duty to Adhere to Prescribed Treatment: An Ethical Analysis,” Journal of Medicine & Philosophy 30, no. 2 (2005): 167-188 (“[I]f the pattern of nonadherence continues despite the doctor's concerted efforts to help the patient implement the treatment, the doctor may feel that he or she is wasting time and society's resources… Non-adherence eventually takes its toll. At some point, many doctors decide that they would rather not treat non-adherent patients.”).CrossRefGoogle Scholar

Under pay-for-performance, providers who perform well on selected quality and efficiency measures receive higher payment rates or bonuses while those who perform poorly often receive lower payments. Risk-based alternative payment models such as bundled payments and shared savings hold providers accountable for the cost of care by shifting financial risk to providers. See Damberg, C.L. et al., Measuring Success in Health Care Value-Based Purchasing Programs: Findings from an Environmental Scan, Literature Review, and Expert Panel Discussions (2014), available at <http://www.rand.org/content/dam/rand/pubs/research_reports/RR300/RR306/RAND_RR306.pdf> (last visited November 2, 2018): at xi.+(last+visited+November+2,+2018):+at+xi.>Google Scholar

See McGrady, M.E. and Hommel, K.A., “Medication Adherence and Health Care Utilization in Pediatric Chronic Illness: A Systematic Review,” Pediatrics 123, no. 4 (2013): 730–740 (reporting that a systematic review found that nine of ten studies demonstrated a relationship between medication non-adherence and increased health care use among children and adolescents with chronic medical conditions); Sokol, M.C. et al., “Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost,” Medical Care 42, no. 6 (2005): 521-530 (finding that for patients with diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs, including lower hospitalization rates); L.R. Martin et al., “The Challenge of Patient Adherence,” Therapeutics & Clinical Risk Management 1, no. 3 (2005): 189-199 (explaining that medication nonadherence is a risk factor for a variety of subsequent health outcomes, including hospitalizations and even death).Google Scholar

See Mantel, J., “Refusing to Treat Noncompliant Patients is Bad Medicine,” Cardozo Law Review 39, no. 1 (2017): 127–195. Because providers who treat patients who are sicker on average could perform worse on quality utilization and cost metrics due to patient factors that are not under the provider's control (e.g., age, severity of illness), payors use risk adjustment to adjust scores on quality measures and ensure that comparisons are fair across providers. See Centers for Medicare & Medicaid Services, Fact Sheet: Risk Adjustment (2015), available at <https://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/PhysicianFeedbackProgram/Downloads/Risk-Adjustment-Fact-Sheet.pdf> (last visited November 2, 2018); E. Schone and R.S. Brown, Robert Wood Johnson Foundation, Risk Adjustment: What Is the Current State of the Art, and How Can It Be Improved? (2013): at 1. Risk adjustment, when done properly, thereby deters providers from avoiding sicker patients. Risk adjustment, however, does not account for differences in the extent to which a provider's patients comply with medical advice or adopt healthier behaviors. See, e.g., Centers for Medicare & Medicaid Services (describing the factors CMS takes into account when performing risk adjustment under the Physician Value-Based Payment Modifier program). Consequently, risk adjustment does not account for the impact of patient nonadherence on providers’ quality and cost metric scores.Google Scholar

See Mantel, supra note 4 (summarizing physician surveys indicating that new payment models will lead some physicians to reject noncompliant patients).Google Scholar

See generally id. Anti-discrimination laws prevent providers from refusing to treat patients on the basis of the patient's race, gender, religion, national origin, age, disability, and sexual orientation. Civil Rights Act of 1964, Pub. L. No. 88-352, 78 Stat. 241, 252–53 (codified as amended at 42 U.S.C. §§ 2000d–d-4 (2012)); 20 U.S.C. § 6101 et seq. (age); 20 U.S.C. § 1681 et seq. (sex); 42 U.S.C. § 12181 (2012); Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 1557, 124 Stat. 119 (2010) (codified at 42 U.S.C. § 18116 (2012)). The Emergency Medical Treatment and Active Labor Act (EMTALA) requires physicians to screen and stabilize any individual with an emergency condition accessing a hospital's emergency department. 42 U.S.C. § 1395dd(a)–(b) (2012). Finally, the Hill-Burton Act, enacted in 1946, requires all hospitals and other facilities that received federal subsidies for construction and modernization to make their services available on a nondiscriminatory basis. See Blumstein, J.F., Court Action, “Agency Reaction: The Hill-Burton Act as a Case Study,” Iowa Law Review 69, no. 5 (1984): 1227–1261.Google Scholar

See Mantel, supra note 4.Google Scholar

See American Medical Association, Code of Medical Ethics (2016) [hereinafter Code of Medical Ethics]: at 1.Google Scholar

The AMA's Code of Medical Ethics provides as follows: “Physicians’ fiduciary responsibility to patients entails an obligation to support continuity of care for their patients. When considering withdrawing from a case, physicians must notify the patient (or authorized decision maker) long in advance to permit the patient to secure another physician… ” Id., at 12. See also Snyder, L., “American College of Physicians Ethics Manual: Sixth Edition,” Annals Internal Medicine 156, no. 1 pt. 2 (2012): 73–104.Google Scholar

See Martin, E., Concise Medical Dictionary (8th ed.) (2010) (defining beneficence and nonmaleficence).Google Scholar

See DeVoe, J.E. et al., “A Medical Home Versus Temporary Housing: The Importance of a Stable Usual Source of Care Among Low-Income Children,” Pediatrics 124, no. 5 (2009): 1363–1371; M.A. Smith and J.M. Bartell, “Changes in Usual Source of Care and Perceptions of Health Care Access, Quality, and Use,” Medical Care 42, no. 10 (2004): 975-984.Google Scholar

See Gill, J.M. et al., “The Effect of Continuity of Care on Emergency Department Use,” Archives Family Medicine 9, no. 4 (2000): 333–338; Mantel, supra note 4.Google Scholar

See Hussey, P.S. et al., “Continuity and the Costs of Care for Chronic Disease,” JAMA 174, no. 5 (2014): 742–748; Rad-dish, M. et al., “Continuity of Care: Is It Cost Effective?” American Journal of Managed Care 5, no. 6 (1999): 727-734 (finding that increasing the number of primary care or specialty care providers a patient saw was significantly associated with increased prescriptions and prescription costs, more outpatients visits, and increased hospital admissions); Gill, J.M. et al., “The Effect of Continuity of Care on Emergency Department Use,” Archives of Family Medicine 9, no. 4 (2000): 333-338 (finding that Medicaid patients with high provider continuity make fewer emergency department visits).Google Scholar

See Mantel, J., “Taking Aim at the Social Determinants of Health: A Central Role for Providers,” Georgia State University Law Review 33, no. 2 (2017): 217–284. Providers also have taken steps to more effectively identify their patients’ behavioral health problems and integrate primary care and behavioral health care. In addition, providers also have implemented intensive patient education interventions that target smoking and other risky behaviors among high-need patients, and have addressed poor medication adherence by prescribing less complex medication regimens or sending automated reminders to patients who have not refilled their prescriptions. See Mantel, supra note 4. In addition, examples abound of providers targeting the social and economic barriers to good health, including patient's transportation, income and food insecurity needs. See Mantel, supra note 14.Google Scholar

See Hall, M.A., “Law, Medicine, and Trust,” Stanford Law Review 55, no. 2 (2002): 463–527; D. Orentlicher, “Health Care Reform and the Patient-Physician Relationship,” Health Matrix 5, no. 1 (1995): 141-180.Google Scholar

See Shepherd, L., “HIV, the ADA, and the Duty to Treat,” Houston Law Review 37, no. 4 (2000): 1055–1100 (arguing that only patients “[s]ecure in the knowledge that they cannot be legally denied medical care” will then “reveal those aspects about themselves that doctors need to know”).Google Scholar

See Mantel, supra note 4.Google Scholar

The Centers for Disease Control and Preventions defines disparities in health as observed differences in health outcomes or health determinants between populations. See Centers for Disease Control & Prevention, CDC Health Disparities and Inequalities Report United States, 2013 (2013): at 3, available at <https://www.cdc.gov/mmwr/preview/ind2013_su.html#HealthDisparities2013> (last visited November 2, 2018) [hereinafter “CDC Health Disparities and Inequalities Report 2013”].+(last+visited+November+2,+2018)+[hereinafter+“CDC+Health+Disparities+and+Inequalities+Report+2013”].>Google Scholar

See Kullgren, J.T. et al., “Nonfinancial Barriers and Access to Care for U.S. Adults,” Health Services Research 47, no. 1 pt 2 (2007): 462–485 (reporting the results of a survey finding that “barriers in the affordability dimension were the most common reasons for unmet need or delayed care”); Miller, K. et al., Inst. For Women's Policy Research, Paid Sick Days and Health: Cost Savings from Reduced Emergency Department Visits (2011): at iii, 7–8 (finding that workers with paid sick days are less likely to delay seeking care for themselves and their families). Racial and ethnic minorities are more likely than whites to have annual incomes below the federal poverty level. See CDC Health Disparities and Inequalities Report 2013, supra note 18, at 16. Racial and ethnic minorities and lower income workers also are less likely to have paid sick days. See Inst. for Women's Policy Research, Paid Sick Days Access and Usage Rates Vary by Race/Ethnicity, Occupation, and Earnings (2016), available at <https://iwpr.org/wp-content/uploads/wpallimport/files/iwpr-export/publications/B356.pdf> (last visited November 2, 2018): at 2, 5.CrossRefGoogle Scholar

See Drewnowski, A. and Eichelsdoerfer, P., “Can Low-Income American Afford a Healthy Diet?” Nutrition Today 44, no. 6 (2010): 246–249.CrossRefGoogle Scholar

See Rudd, R. et al., Educational Testing Service, Literacy and Health in America (2004): at 3–4; M. Kutner et al., American Institutes for Research, The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy (2006): at v, 9–14.Google Scholar

Selden, C. et al., Health Literacy, Nat’l Insts. Health (Feb. 2000), available at <https://www.nlm.nih.gov/archive//20061214/pubs/cbm/hliteracy.pdf> (last visited November 2, 2018): at vi.+(last+visited+November+2,+2018):+at+vi.>Google Scholar

See generally Mantel, supra note 4 (summarizing studies finding greater nonadherence among vulnerable populations relative to other groups).Google Scholar