Second 40% Excise Tax ("Cadillac Tax") Notice Issued for Obamacare

The IRS is coming for you. Part of the Affordable Care Act is  to gain tax revenue to offset the increase in uninsured and to support premium subsidies

On July 30, the Department of the Treasury and the Internal Revenue Service (IRS) issued a second notice regarding the 40% Excise Tax a.k.a. the Cadillac Tax. The notice provides information on possible approaches that are being considered for administering the Cadillac Tax and continues the process of gathering input that will be used to develop regulations.


What are the proposed thresholds?

The Cadillac Tax is a 40% excise tax scheduled to take effect in 2018 to reduce health care usage and costs by encouraging employers to offer cost-effective plans that engage employees in sharing in the cost of care. The tax impacts plans exceeding the following thresholds, which will be adjusted annually for inflation:

$10,200 for individual coverage

$27,500 for family coverage

The notice addresses several issues, including:  Who pays the tax How the tax will be determined How the tax will be paid:

Each “coverage provider” must pay the tax on its share of the excess benefit. A coverage provider is:

           The health insurer for insured coverage.

• The employer for accounts such as Health Savings Accounts (HSAs) to which the employer contributes.
• The plan benefits administrator – the agencies are seeking comments on whether this should be the third-party administrator or the entity that has ultimate responsibility for plan administration, typically the employer.

How the Tax will be Determined

The notice seeks comments on how to calculate and administer the tax. The following are some of the proposed approaches.

Timing – Following the end of each calendar year, employers will need to determine whether and by how much the cost of coverage exceeded the allowed limit for each month. The employer must then notify the IRS and each coverage provider of their share of the excess benefit so the tax can be calculated and paid.

Cost – The cost of coverage may be determined in a manner similar to determining COBRA premiums. 

Age and Gender Adjustments – The current thresholds for 2018 are $10,200 for individual coverage and $27,500 for family coverage. These amounts may be increased for some employers based on how the age and gender of their employee population compares to the national workforce. No downward adjustments will be made. The notice seeks input on how these adjustments should be determined.

Allocation of Accounts – The notice proposes that employer and employee contributions to accounts such as HSAs, Health Reimbursement Accounts (HRAs) and Flexible Spending Accounts (FSAs) would be allocated equally to each month of the plan year, regardless of when the contributions were actually made. For FSAs, the agencies propose that the annual contribution amount be used, regardless of whether all funds were spent during the year or some funds were carried over to the next year.

Employer Aggregation – Related employers would be aggregated and treated as a single employer.

Taxation – No deduction is allowed for the payment of the tax.

How the Tax will be Paid

Each coverage provider will be responsible for paying the tax on its share of the excess benefit. IRS Form 720, the Quarterly Federal Excise Tax Return, may possibly be used to pay the tax. If so, a specific quarter of the calendar year would be designated for payment.

Proposed Regulations Still to Come

The agencies will review all comments and leverage the feedback to help draft regulations.

For more information, view the notice. 

Second 40% Excise Tax ("Cadillac Tax") Notice Issued



The new tax is retrogressive and is actually a double taxation, not allowing any deduction against income, sales, or excise taxes.  There is also no mention of how state tax would be impacted.



The notice reveals a poorly constructed, and poorly thought out notice.  The ACA law is so non-specific in regard to taxes.  It already includes penalties to non-compliant patients in regard to obtaining health insurance, medical device taxes, and now this latest round of mining for scarcer health care dollars.



The mechanism for controlling cost is to tax any excessive premium to penalize all those concerned, even if the benefits are excellent. The Dept. of HHS cares not one bit about quality or excellence of the healthcare delivered.  It wants to reduce it's costs, in a CATCH 22 scenario.

5 things Atul Gawande learned on his return to McAllen, TX

The Brookings Institution is a nonprofit public policy organization based in Washington, DC. Our mission is to conduct high-quality, independent research and, based on that research, to provide innovative, practical recommendations that advance three broad goals: Much of this post is taken from their May 8, 2015 blog report. One of  the 14 Policy groups  is the Center for Health Policy . 

Gawande returned to  McAllen after a five  year hiatus since his original visit to investigate the extreme variation in health costs at McAllen,TX vs.the rest of the United States. In May 2015 Dr Gwande published an article on health overspending in the New Yorker In this article he explains,

As a follow up to his seminal New Yorker articles, “The Cost Conundrum” and “The Cost Conundrum: Redux,” surgeon and author Atul Gawande provides an update on the very interesting town of McAllen, Texas and their health care spending problem. Six years ago Atul Gawande went on a fact finding mission to McAllen-- a community with double the average Medicare spending ($14,000 versus $7,000)-- to explore what the IOM calculated to equal a third of all health expenditures including unnecessary, redundant, and medically and scientifically ineffective tests, procedures, and treatments. He found a system in denial and with high rates of hospital admissions, evasive-expensive surgeries, and outpatient home health care.

Gawande returned to  McAllen recently and was greeted by an entirely new system. Inpatient visits had fallen by 10 percent; home health care spending was down 40 percent; ambulance rides were down 40 percent; and cost per beneficiary dropped almost $3,000 resulting in nearly half a billion dollars saved. What happened in Texas was unprecedented.  

But Why?

Five Lessons from the McAllen Experience:  

Evidence is hard to ignore, especially if it is out in the open.

Physicians also do not have all the right information. 

Local clinical leadership and clinical knowledge are important in promoting health.

More evidence shows payment and delivery reforms may be working.

The biggest opportunities for cost reductions are with complicated patients.

The development of an ACO (accountable care organization) may provide resources, financially, with leadership and coordination of care. This may be unique  in McAllen since PPOs, Managed care and other group practices were not in existence during the initial study by Dr. Gwande.

"An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?"

The one that got Gwande thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.  The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

Why Medicare Has Been Slow to Adopt Telemedicine | KQED Future of You | KQED Science

Why Medicare Has Been Slow to Adopt Telemedicine | KQED Future of You | KQED Science

Couples Compete for the Morning Workout - WSJ

A predawn swim; the weekend handoff; children are ‘firehouse ready’

Desanne Martin swims at 5:15 a.m. PHOTO: PETER EARL MCCOLLOUGH FOR THE WALL STREET JOURNAL

"Staking out prime time for exercise is the land-grab of modern day parents. Once children come along, working out often seems more like a luxury than a basic need. Compared with a night out for cocktails, a request for an hour of PILATES would seem like something no one would want to deny a spouse. But that isn’t always the case."

After she had her second child, Michelle Jacobs was desperate to get fit. The 43-year-old baby gear retail executive joined a gym and went every morning at 5:30 a.m.—a big improvement over Jillian Michaelsexercise DVDs in the living room. All was great, until her husband caught the workout bug.

Initially he was content with one SoulCycle class on Tuesday mornings. But then he wanted Thursdays.

Staking out prime time for exercise is the land-grab of modern day parents. Once children come along, working out often seems more like a luxury than a basic need. Compared with a night out for cocktails, a request for an hour of Pilates would seem like something no one would want to deny a spouse. But that isn’t always the case.

Couples squeeze in athletic windows at odd hours, sometimes in the dark of night, to avoid disrupting quality family time. Some spouses push for priority, but promise the workout means a smile and a day of devoted caretaking in return.

With two children to prep for school, and both Ms. Jacobs and her husband commuting from the suburbs into New York City for work, there wasn’t time for both to claim the mornings. Evenings were their only chance to be with the children. Now Ms. Jacobs spins, lifts weights or runs every other morning, plus Sunday, when she tag teams with her husband, tossing the car keys to him as they pass on the front walk.

Eric Roza, 47, a vice president at Oracle Corp.and self-declared fitness nut in Boulder, Colo., admits that tension around workout turf “has been bubbling up.” He does CrossFit weekdays at 5:30 a.m., returning to help get four children through the morning scramble at 6:50 a.m., which means his wife Melissa can never go to a 6:30 a.m. strength class she loves. Until recently, he never considered whether this was fair. “I’ve always had this presumption that my workout comes first. I’m like, ‘Come on, Honey, it’s my self-medication. It’s my therapy,’” he says.

Her less obsessive approach compounded the problem. Her job managing the CrossFit gym the pair own is more flexible, so his work schedule dominated. She was always too busy to exercise midday.

After some “tough conversations”, Mr. Roza says he is prepared to make changes. “I realize now I can’t just keep my head in the sand,” he says.

Who gets priority, and how time is apportioned, can reveal deeper relationship dynamics, therapists say. One partner demanding his or her workout matters more “can be heard by the other as, ‘I’m just a little more important than you are in this partnership,’” says Washington, D.C. psychotherapist Karen Osterle. She adds that gender roles can play a part in the power struggle. “The negotiation is becoming more complex as more women become the chief breadwinners,” says Ms. Osterle.

Swiss trainlike schedules help. “I tell couples to sit down on Sunday night with a glass of wine or cup of tea and the calendar,” says Samantha Ettus,a Los Angeles-based life coach and author of a book on efficient living. “Exercise has to go on the to-do list just like business meetings.”

A rigid routine has allowed Martina Jones and her husband Chris to keep competing, even as parents—she does marathons, biathlons and triathlons, and he is an open-water swimmer. The San Francisco couple both have demanding product management jobs, so “making it explicit is the only way to make it work,” says Ms Jones.

The new emphasis on prevention and wellness is emphasized by the Affordable Care Act. There are also managed care and Medicare Advantage plans that offer complementary memberships in sports clubs. "Silver Sneakers' is one of those programs offered here in California by 'SCAN'. Seniors do not have the same time constraints of parenthood or work.

It is a challenge for millenials and Gen-X adults. Studies have shown the benefits of aerobic exercise, and walking for those with diabetes, hypertension, elevated body-mass index. It has been shown to delay or reverse osteoporosis, reduce the liklihood of colon and breast cancer.

Joanna Strober, who runs a Palo Alto, Calif., weight-loss startup and her entrepreneur husband race for the same treadmill. If he beats her downstairs, she doesn’t get to exercise that day. “I do not complain, but, yes, I’m mad.” A second treadmill wouldn’t work. “We wouldn’t agree on the TV show,” she says.

Couples Compete for the Morning Workout - WSJ

JAMA Network | JAMA | Hospital Characteristics Associated With Penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program

Hospital Characteristics Associated With Penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program

Another paradoxical result becomes apparent impeaching the meaning of statistics in health care. Like the Propublica report on Surgeon grading, the findings of the HAC   Hospital Readmissons Programs reveal that 'better hospitals' (according to JCAH metrics) sometimes perform more poorly than under-rated hospitals. It points out that re-admission rates may be a meaningless benchmark to rate  hospitals. It may only serve to reduce Medicare reimbursements just for it's only purpose.

Main Outcomes and Measures  Hospital characteristics associated with penalization.

Results  Of the 3284 hospitals participating in the HAC program, 721 (22.0%) were penalized. Hospitals were more likely to be penalized if they were accredited by the Joint Commission (24.0% accredited, 14.4% not accredited; odds ratio [OR], 1.33; 95% CI, 1.04-1.70); they were major teaching hospitals (42.3%; OR, 1.58; 95% CI, 1.09-2.29) or very major teaching hospitals (62.2%; OR, 2.61; 95% CI, 1.55-4.39; vs nonteaching hospitals, 17.0%); they cared for more complex patient populations based on case mix index (quartile 4 vs quartile 1: 32.8% vs 12.1%; OR, 1.98; 95% CI, 1.44-2.71); or they were safety-net hospitals vs non–safety-net hospitals (28.3% vs 19.9%; OR, 1.36; 95% CI, 1.11-1.68).  Hospitals with the highest quality score of 8 were penalized significantly more frequently than hospitals with the lowest quality score of 0 (67.3% [37/55] vs 12.6% [53/422]; P < .001 for trend).

Conclusions and Relevance  Among hospitals participating in the HAC Reduction Program, hospitals that were penalized more frequently had more quality accreditations, offered advanced services, were major teaching institutions, and had better performance on other process and outcome measures. These paradoxical findings suggest that the approach for assessing hospital penalties in the HAC Reduction Program merits reconsideration to ensure it is achieving the intended goals.

Policy makers must reassess these programs and remove them if they do not stand the test of time.  Reductions of medicare reimbursement may penalize the wrong hospitals.

JAMA Network | JAMA | Hospital Characteristics Associated With Penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program

More on the Propublica Study of Surgeon Complications

Numerous organizations are focused on reducing complications, reducing hospital admissions, and looking for a means to determine if certain surgeons or hospitals are 'outliers' in terms of complications.

Most of these studies are intended to decrease costs as a result hopefully of this analysis. Even well designed studies such as Propublica's are fraught with incorrect assumptions. Statistics should only be taken at face value and individual case studies are imperative.  Many cases require a deep dyve to extract information that will improve safety and  diminish complications.

Some controversy and a deeper look into the Propublica Study reveal mitigating information about less than optimal statistics for some surgeons.

photo by Shutterstock

When a bad surgeon is the one you want: ProPublica introduces a paradox

As posted to  KevinMD by DR. SAURABH JHA | PHYSICIAN | JULY 23, 2015

Case #1

Morbidity Hunter’s real name is Harjinder Singh. He migrated from Punjab and works in a safety net hospital in North Philadelphia. Singh wanted to work in Beverley Hills, but to convert his J1-visa to a green card, he had to work in an area of need. Once he started working, he liked his job. His daughters liked their school, and his wife liked the house they bought. Singh doesn’t have shiny teeth. He hasn’t appeared on TV, although his daughters tease that he can play Sonny from Exotic Marigold Hotel.

Singh’s colleagues named him Morbidity Hunter because he operates regardless of how sick his patients are. He never says no. Nearly all his patients are obese and diabetic. The school of public health sends students to shadow him to learn about polypharmacy. The hospital went on a spree of hiring hospitalists when Singh started.

His patients, straddling the Federal Poverty Limit, don’t rate him on Yelp. His patients don’t use Yelp. Even if they were informed consumers they would have to choose Singh, because there are very few orthopedic surgeons who are willing to operate on them in that zip code. His patients haven’t heard of Cherry Picker. They don’t ski, ballroom dance or run half marathons.

Singh, too, is good at his craft. Technically excellent, to be precise. You wouldn’t know that from looking at the rates of readmission, infection, and deep vein thrombosis in his patients. But the staff in the operating room know that, as do his colleagues, whom he has often helped out in tough operations. Even Cherry admires him.

Singh is not in for the money. He doesn’t make as much money as Cherry, but makes enough. He doesn’t operate for glory. He operates for professional pride — an ethereal concept that eludes some health economists.

It’s hard to zap the morale of this sturdy lad from the Punjab. But the data transparency movement achieved that. He always knew that operating on the sickest, poorest and most disenfranchised section of society was not going to be lucrative. But he never knew he was going to be made the captain of their ship — he was happy to captain the placement of their total hip — but what happened before or after they entered the operating room was not his fault, he felt.

People began to call Singh an incompetent surgeon. He objected, but he could not understand the logic behind the numbers which were incriminating him. His complication rates were the highest in Philadelphia. Numbers don’t lie, supposedly. This was too much for him to bear. He didn’t mind losing the pitiful bonuses that CMS was withholding from him, but the reason broke his heart: his poor quality.

Singh was puzzled by people who claimed to lose sleep over the poor. The chasm between their sentimentality and actions baffled him. Punjab began to make more sense than Philadelphia. But then Cherry invited Singh to join his practice in New York. Cherry promised Singh that he could operate on technically challenging patients. Grudgingly, Singh accepted the offer, which made his wife very excited about shopping for Indian food in Queens. She insisted, though, that Singh had to see a dentist first.

Homo sapiens have always sought redemption. Today it is through data. Numbers have replaced Yahweh and Indra. But, just like the old gods were, numbers can be moody, arbitrary and, occasionally, downright unfair. Numbers are a human construct, after all.

Case #2

Cherry Picker lives in the Upper East Side of New York. His patients give him great reviews on Yelp. His patients read every comment on Yelp before making any decision. Cherry Picker has a beautiful family. When he smiles, light refracts from his shiny teeth.

Cherry regularly appears on TV. He writes for the sleek, metrosexual publication, FHM. Cherry specializes in knee injuries in weekend warriors. His patients often call him from the ski slopes in Colorado, Whistler ,and Zermatt. Cherry is good at his craft. But his patients are even better at their craft — post-operative recovery. Cherry doesn’t actively seek such patients. His patients are selected for him by his zip code, reputation, long waiting list and Yelp.

Conclusion:

Simpson’s paradox — where the conclusions are actually, and precisely, the opposite of what is inferred from the data. That is, for example, when a study shows the superiority of an inferior treatment, and vice versa. he data release by ProPublica is a reservoir of Simpson’s paradox. This means when the data says “bad surgeon,” the surgeon might, in fact be a Top Gun — a technically-gifted, Morbidity Hunter — the last hope of the poor and sick.

Aren’t you intrigued and perturbed by this paradox? This means that data may not be just telling half-truths, but flat out lying.

The truth is if you have a great outcome,  you think your surgeon is the best.  If it is less than optimal there is a wide range of reactions. Some surgeons have great bedside manners...sometimes they get away with 'murder' or complications. Some surgeons have no bedside manners. These surgeons may leave patients in doubt, especially if their outcome is less than optimal.

PPACA (OBAMACARE) The Good, the Bad and the Ugly

When the PPACA was passed by the U.S. Congress (heavily Democratic) it was largely an uninown law.  Several years later we know much more about it. As one reads the actual law the print becomes smaller and smaller as you develop nausea,  headache, and confusion.



Statistics out this month reveal how many more millions of people are now insured. That is the 'GOOD"

Analysis reveal the higher  deductibles, and co-pays are the "BAD".

Lack of accessiblity, the limited number of providers accepting PPACA policies, and a 'poverty algorithm defeat some from obtaining health insurance and the involvement of the Internal Revenue Service  are the "UGLY"

Ain't The Way To Die | ZDoggMD.com

Published on Jul 28, 2015

"Just gonna stand there and watch me burn, end of life and all my wishes go unheard." Visithttp://ZDoggMD.com for more on how to start this conversation.

Lyrics and more here: http://zdoggmd.com/aint-the-way-to-die/

Based on the Eminem & Rihanna song, "Love The Way You Lie."

Lyrics by ZDoggMD (Dr. Zubin Damania) and Dr. Harry Duh.

Audio engineering, mixing, production, and chorus vocals by Devin Moore.

Thanks to Success 3.0 Summit for supporting this production and to:

Wake Up The Movie: http://wake-up-the-movie.instapage.com/
Storyworks Production Company
Director, Michael Shaun Conaway
Producer, Alex Melnyk
Editor, Sean Horvath
Colorist, Mark Anton Read

Special thanks to the residents and staff of the University of Nevada School of Medicine.

Please share widely...and thank you Dr ZdoggMD

What are the best three life hacks?

 by:  Dan Holliday, Recruiter, Traveler, Runner, CrossFitter, Philosopher & Lover of History; 

You may be wondering what does the title have to do with Health Train Express ?

We are all on the train of life, and it is an express.  While I came up with this title almost ten years ago, it has served well all these years, providing a transportation through HMOs, Managed care, Health Reform, HIT,  the Affordable Care Act and so on and on.

Not so much "life-hacks" but things that have made me successful(ish):

• Exercise really is the solution to so many of life's issues (moods, health, etc.).  It's not just hype.  My entire life has been changed in monumental ways because of exercise.  If you're not getting enough exercise (or unless you are one of the rare like 1% of people who genuinely can be healthy without it) then you are suffering in some way.  It doesn't have to be CrossFit or running marathons, but you should be exercising.
• Make a list of your priorities (including people).  Update it as necessary, but refer to it frequently.  It will help you make decisions on what is important in life.  It's cold.  It's calculating.  But so are you, we all are; we all have priorities (and we hate to admit that we rank people and things, but you do, we all do -- I'm just honest about it and write it down; if you're in my life, you're on the list).  The difference between those who cannot prioritize and those that do is about two heartbeats in making decisions that most people agonize over.
• It's better to do things than to have things.  I'm not rich, but I can do one or the other.  I can afford nice things. I could have all sorts of great shit that people would look at and desire.  I can travel and do things and have great experiences with my husband.  But I can't do both.  Doing things together builds your relationships; having things seems to distract away from what's important.

Okay, and one more:

• If you have plans, have re-evaluation periods and benchmarks.  It's hard.  It ain't fun.  But if you don't have goals and dates that those goals need to meet, then you are unlikely to succeed in a lot of things you try to do.  Your goals should be flexible (mine change all the time), but the ones I have, have evaluation periods that I look back and think, "Why am I doing this?"  If I'm not on track to meet the goals, if I feel like I'm missing the mark (or that it's no longer worth it), I evaluate and change course.

Let's watch Dustin Garis' TEDxRenfrewColllingwood take on this:

Do you want to grow your material wealth ? or:

"Grow  your wealth of Life Profit"

So  you ask, What does this have to do with Health Care? Nothing, and everything. It should however place a proper priority on life on the Health Train Express.

In 50 years none of this will be relevant.  (I hope much sooner)

Obamacare rates to rise 4% in California for 2016 - LA Times

Peter V. Lee is the executive director of Covered California. James C. Robinson is a professor of health economics at UC Berkeley.

California's Obamacare exchange negotiated a 4% average rate increase for the second year in a row, defying dire predictions about health insurance sticker shock across the country.

The modest price increases for 2016 may be welcome news for many of the 1.3 million Californians who buy individual policies through the state marketplace, known as Covered California.

California's rates are a key barometer of how the Affordable Care Act is working nationwide, and the results indicate that industry giants Anthem and Kaiser Permanente are eager to compete for customers in the nation's biggest Obamacare market.

Leading up to Monday's announcement there had been a steady drumbeat of news about major insurers outside California seeking hefty rate hikes of 20% to 40% for Obamacare open
enrollment this fall.

Overall, 44% of Covered California customers said they found it difficult to pay their monthly premiums now, according to a recent survey. And some people have indicated that they feel shortchanged in terms of the doctors they can see and the service they get from their health insurer or the exchange when problems arise.

Free market forces can be a powerful tool to contain health costs. But for that tool to work, consumers need the support of an active purchaser that can go toe-to-toe with the insurers. Other states and the federal exchange would be wise to look at what's working in California.

California's exchange posted tepid enrollment growth in its second year, falling short of its 1.7-million goal. Health policy experts said signing up more people is key if Covered California wants to sustain its momentum on rates. The next open enrollment begins Nov. 1 for policies effective in January.

So how exactly is California getting such g 

Shopping for a Doctor Who 'Fits' - The New York Times

MIKKAEL A. SEKERES, M.D.

All newly minted physicians go through a learning curve. They have learned all the ABCs of medical science, and then some.

Life experience comes to us through dribs and drabs if we are fortunate, or it may hit us in the face all at once.

At times physicians must 'unlearn' best practices, ethics, and other ethereal values or face consequences.

At times bad manners, or poor judgment rather than a medical error results in a medico-legal situation. And there are many attorneys willing to help there, on either side.

Shopping for a Doctor Who 'Fits' - The New York Times

Second opinions are a normal part of my line of work. I specialize in rare diseases affecting the bone marrow, and feel privileged both to practice at a hospital where I can focus on these esoteric illnesses, and to be considered competent enough at what I do that people seek my input on their diagnoses and therapies. At the same time, I never discourage my own patients from seeking the opinions of others, as their conditions are unusual and serious, and frequently deserve advice from more than one doctor. It’s what I would ask for if one of my own family members became sick.

But that wasn’t exactly why this woman was seeing me. She had arranged this appointment because she didn’t like her other doctor, and wanted to see if she liked me better.

These kinds of clinic visits have also become a normal part of my practice.

Decades ago, when physicians worked within a much more paternalistic system, such “doctor shopping” would have been considered inappropriate. Your doctor’s medical opinions were considered authoritative, incontrovertible and often final. Patients who challenged them were labeled “difficult,” and worried about developing a reputation that would influence their care, both with their own doctor and with others – as in the 1996 “Seinfeld” episode called “The Package,” in which Elaine is blackballed from being seen in medical offices and tries to steal her own medical records to erase her “difficult patient” status.

In recent years, patients have become more empowered to demand both good care, and a good attitude. Given some of the stories I have heard, I can’t say that I blame them.

One patient recounted how, when she mentioned to her primary oncologist that she wanted to seek my opinion, he told her to take her medical records with her because if she did see me, he would refuse to ever treat her again.

Another patient called me from his hospital room to give an account of his recent interaction with a doctor who recommended a course of chemotherapy for his refractory cancer.

“When I asked some questions about it, she basically told me it was her way or the highway. This is a big decision,” he told me. “I don’t want to go into it lightly.”

I reaffirmed that he, and not the other doctor, was in control of his destiny and treatment options, and reviewed the possibilities with him so that he could make a decision. I then called that doctor to relay his choice, which happened to be what she recommended – but on his terms, where he was included in the process.

Other times the interactions aren’t quite as dramatic, but represent more of a dissonance of personalities. Patients feel their doctors may be overly confident, or not confident enough; excessively nurturing, or too aloof. Alternatively, they simply may not “click.”

It cuts both ways. Doctors may not like some of their patients.

Years ago, I was asked to care for a prisoner who had just been diagnosed with lung cancer. When I entered his hospital room, he was lying in bed in his prison jump suit, his leg handcuffed to the bed’s footboard, as two guards stood by his side. As I explained his diagnosis and treatment to him, he stared at me, unblinking, with hate in his eyes. Every hair on my body prickled until I left his room. A guard who followed me into the hallway told me why my patient was in jail: He had killed his wife using a hammer.

I did not like that patient. But I put my emotion aside and cared for him, without judgment and to the best of my abilities, because it was both my job, and my duty.

I worry that we are increasingly losing sight of why our patients are seeing us. It is not because they want to, but because they are sick – they are hurting, not us. In their moments of need, we should disregard any feelings of indignation if our patients seek the opinion of another, or our disappointment that they don’t immediately accept our advice. We should support them as they make decisions about their own health – even if those decisions don’t include us.

As I walked into the exam room to meet my new consult, I put on a warm, welcoming smile. I didn’t want her to feel the least bit uncomfortable about the reason for her visit. Because this was about her medical care, and not about anyone’s pride.

Dr. Mikkael Sekeres is director of the leukemia program at theCleveland Clinic.