Ethical Concerns Surrounding “Expensive Patients”
By Paul Soloviev, General Practice Training & Consulting
General Practice is built on compassion, accessibility, and continuity of care. Every patient who walks through the door brings their own unique story, their own specific needs, and their own unique challenges. Most patients respect the boundaries of a clinic’s time, resources, and professional obligations. However, there are occasionally patients whose ongoing interactions with the clinic extend well beyond the scope of reasonable care — and the impact on staff, doctors, and clinic operations can be profound.
This article explores the ethical and practical concerns that arise when a small number of patients become disproportionately demanding, either by frequently requesting inappropriate medications (such as benzodiazepines or opioids), or by pressing for documentation that places clinicians in uncomfortable or professionally compromised positions. These situations are further complicated by Medicare billing restrictions, which prevent clinics from charging for most non-face-to-face interactions — even when they are time-consuming and repeated.
These patients are sometimes referred to, informally and quietly, as “expensive patients.” Not because they are charged more — but because they cost the clinic more in unbillable time, staff stress, and ethical strain. They may call frequently, argue, send long emails, or expect repeated justifications or exceptions. They are often challenging to manage and sometimes abusive. But they are still patients — human beings deserving of respect, care, and fairness.
Herein lies the ethical dilemma:
– Where is the line between patient rights and staff safety?
– How can clinics protect their teams and remain financially viable without discriminating or withdrawing care unjustly?
– Is there a way to anticipate and manage these situations before they escalate?
Some have proposed the idea of a “social contract” — an agreement or code of conduct that applies to all patients at the outset of care. But such blanket policies risk alienating new patients and creating an atmosphere of distrust. A statement like “We will not be able to continue care if you behave unreasonably” may be legally sound, but ethically and socially uncomfortable.
At the same time, continuing to support patients who generate significant unbillable work or place the clinic under pressure to act unethically is also untenable. General Practices are small businesses. They are also places of healing. The balance is challenging — and becoming increasingly difficult as patient expectations rise and pressures on healthcare systems intensify.
This article aims to open a conversation — not to judge, but to reflect. We’ll explore what makes a patient “expensive,” what impact this has on clinics, and what ethical approaches could support both staff and patients under challenging scenarios.
Defining “Expensive Patients”
“Expensive patients” are not necessarily frequent attenders or those with complex health needs. Instead, they are patients whose engagement with the practice leads to disproportionate use of staff time, administrative energy, or emotional resources — much of which is not billable under current funding models.
They may:
– Request medications like diazepam, S8s, or antibiotics inappropriately or persistently
– Push for medical certificates or reports that misrepresent the clinical facts
– Call or email repeatedly to argue about decisions or request further clarification
– Become aggressive or manipulative with front desk staff
– Demand outcomes that go beyond the ethical or legal limits of care
They are not always ill-intentioned. Some are distressed. Others lack insight or are dealing with addiction. But the reality is, these interactions drain the system.
Ethical Challenges: The Human Factor
Ethics demand that we treat all patients with dignity and fairness. Yet ethics also require that healthcare workers are not exploited, endangered, or overburdened. Staff burnout and moral distress often come from navigating the grey area where professional duties collide with patient demands.
Turning away a patient can feel cruel. But continuing care without boundaries can be harmful — to the clinic, the staff, and sometimes even to the patient themselves, particularly when care turns into appeasement rather than evidence-based practice.
The question becomes: can a clinic still be ethical while placing limits on unreasonable engagement?
Systemic Constraints: Medicare and Billing
Under the current Medicare structure in Australia, GPs cannot bill for time spent:
– Reading or responding to patient emails
– Handling phone calls when the patient is not present
– Dealing with administration related to unreasonable requests
– Providing clarifications or justifications outside a formal consultation
This means that the more demanding a patient is outside of consults, the greater the burden becomes — and the clinic receives no compensation. Some practices absorb the cost. Others burn out.
The government’s rigid billing framework assumes patients use services fairly and within structured appointments. In reality, modern clinics face a flood of informal interactions.
What Are Clinics Doing Now?
Some General Practices manage these patients on a case-by-case basis, recognising that every patient deserves fairness — but also that care must be safe, ethical, and sustainable. However, clinics cannot simply discontinue care without proper grounds. Ethical guidelines and professional codes of conduct require that the termination of a doctor–patient relationship be justified, carefully documented, and managed in a way that does not abandon the patient.
Appropriate reasons to end care may include:
– Repeated abusive or aggressive behaviour toward staff or clinicians
– A breakdown of trust or inability to maintain a productive therapeutic relationship
– Inappropriate demands that place clinicians in conflict with their legal or ethical obligations
In such situations, clinics may:
– Document the specific behaviours or patterns that led to the decision
– Notify the patient in writing and suggest alternative providers
– Ensure any urgent or ongoing medical issues are not left unmanaged during the transition
Some clinics also use internal flags or alerts in the patient management system to guide future interactions or caution staff. Others rely on strict administrative protocols and templated responses to manage requests that fall outside of standard care.
However, few practices have formal frameworks for managing this category of patients. Often, the burden falls on individual GPs and practice managers to make difficult judgment calls — without training, support, or policy backing.
The Case for (or Against) a Social Contract
Would it help if every patient received a clear, respectful outline of clinic expectations?
A “social contract” might say:
“We are committed to providing high-quality, respectful healthcare. In return, we ask that patients engage respectfully and use services in a way that is appropriate and fair to all.”
It could outline that:
– Prescription requests must occur during consults
– Medical certificates must reflect clinical findings
– Excessive administrative requests may not be accommodated
Such a document could guide patient behaviour gently — without threat. But there is a risk. If poorly worded, it could appear elitist or dismissive. Some vulnerable patients may misinterpret it as exclusion.
This is the challenge: can a clinic set expectations without setting off alarm bells?
Conclusion: Towards a Fair and Sustainable Solution
The problem of “expensive patients” is not new — but it is becoming more visible. With mounting pressures on General Practice and tighter funding rules, every minute counts.
Yet we must remain human.
Solutions need to balance fairness to staff with compassion for patients. Perhaps that balance lies in:
– Early, non-confrontational communication
– Clinically guided boundaries, not emotionally reactive ones
– Professional support for staff experiencing repeat difficulties
– Advocacy for more flexible billing models that recognise the realities of modern General Practice
We must protect the soul of General Practice — the trusting relationship between doctor and patient. But we must also protect the system that sustains it.
This conversation isn’t about blame. It’s about balance.
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