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Discharging a Patient: Breaking Up Is Not That Hard to Do

Discharging a Patient: Breaking Up Is Not That Hard to Do

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I receive a number of calls from physicians each year who, for a variety of reasons, want to terminate their relationship with a patient. I commonly get asked: “Do I have to keep treating someone who won’t pay me?”; “Must I continue to schedule appointments for patients that keep cancelling with little notice?”; or “Do I have to tolerate patients who are continually rude to my staff?” My answer is: “No.” A physician can terminate his or her relationship with a patient for these reasons and a host of others, as long as the patient’s health and well-being is protected. 

When terminating a patient from your practice, the most important thing to do is avoid a claim of patient abandonment. A physician should never be in a position, from an ethical or legal perspective, of responding to such a claim. To prevent patient abandonment concerns, consider the following:

1. Document any consistent issues you are having with a patient. I recommend you not terminate a relationship until there is some evidence in the record of a problem, such as mistreatment of physicians or staff, unwillingness to keep appointments, or failure to follow through with treatment or recommended care. Also, provide patients with notice of problem issues and the opportunity to modify their behavior. Sometimes, patients do not realize how much their actions impact on practice operations. Sometimes they do, and they just don’t care.

2. Allow a patient sufficient time to find alternative care. I was talking with a physician once who wanted to immediately terminate his relationship with a patient who failed to keep multiple appointments. While I understood his anger and frustration, we ultimately decided to allow the patient 30 days to find another physician. Keep in mind that reasonable notice may be longer depending upon the patient’s medical condition. For example, I recommended an oncologist not terminate a patient for non-payment of medical bills until the patient had completed her current course of chemotherapy. Also, be mindful of state-specific laws regarding minimum notice periods.

3. Provide patients with written notice of your intent to terminate care. It is not necessary to detail all the reasons why the patient is receiving the letter. Generally, a statement that the physician believes it is imprudent to continue to provide care to the patient will suffice. To the extent a patient insists on specific details, the physician can address this on a case-by-case basis, supported by adequate documentation. Remember not to discuss patient issues with any representative of the patient absent appropriate HIPAA documentation. When in doubt, or if contacted by the patient’s lawyer, make sure you reach out to legal counsel.

4. Patients should be informed in writing of the date they will no longer receive care, how to obtain their medical records and how they can obtain assistance locating a new physician. I often suggest physicians provide patients with contact information for a state medical association or similar organization, which often maintains a database of providers by specialty and location. The physician should arrange to quickly transfer medical records (subject to the physician’s reasonable fee policies).

5. Determine under what circumstances, if any, the patient may continue to be seen by the practice after termination date. I worked with an allergist who provided notice to terminate a treatment relationship after 30 days, except as related to the treatment of one particular allergy condition, which would continue for 120 days. This allowed the allergist to continue to treat a condition for which she knew the patient would have difficulty finding care, while minimizing other interactions with the patient.

Practicing medicine requires a fine balance between caring for patients and running a business. In certain situations it will be necessary to be the caregiver and temporarily look the other way when a patient is being difficult or having financial troubles. This is the benevolent part of being a doctor, even when it makes poor business sense. More often than not, however, decisions to terminate a difficult patient reflect good judgment and will help you maintain a happier and more efficient medical practice.

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