I have a very non-compliant patient. 

  • He is a type 1 diabetic on an insulin pump and does not come in but once every 12 to 18 months to be seen. 
  • He makes his own decisions about changing the basal rate, never consulting me.
  • The only way I can get him in to the office is to limit the amount of medication I give him.

His control is excellent.

  • Despite having diabetes since he was a child, he has no kidney or eye damage.
  • His Hemoglobin A1c is always below 7% and usually below 6.5%
  • He has minimal hypoglycemia.

Given the fact that the recommendations are to see these patients at least every 6 months, I somehow feel he should be coming in more often.  He acts apologetic whenever he does come to see me, not following "the rules" like he should.  If I am measured for my "performance" regarding diabetes care, he will be flagged as a "bad" patient in several areas because of the infrequency of his care.

So what?

Isn't the point that he has good control?  Isn't our goal the prevention of the complication of diabetes?  Why should I care if I see him often enough if he does a better job than I ever could with his diabetes?

This is a good argument for appropriate measures of care quality.  If I am to be paid bonuses based on my quality, shouldn't it consider patients like this one to be appropriately controlled?  He is a perfect candidate for e-visits, given that he could just e-mail me his sugar readings and I could send him lab slips.  I still need to do foot exams and blood pressure checks, but why can't a reliable patient do this from home as well?

I know he cares about his diabetes.  Why can't he just care for himself with me as a consultant only when he needs me?  Of course, right now the only way I can get paid is if he sets foot in my office. 

So that is what we do.  I ask him how he is doing, check his feet and blood pressure, give him a lab slip, and we talk about baseball, politics, and his son.  We have to do this.  It's in the rules somewhere.