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How to Dismiss Problem Patients

How to Dismiss Problem Patients

Are you fed up with patients who fail to pay, who consistently miss appointments, and who refuse to submit to tests or screenings you believe necessary for their good health? Have you been confronted by patients seeking services that you object to for moral or religious reasons? In frustration, do you wish you could just tell certain patients "goodbye?"

You might be able to. Physicians can pull out of a physician-patient relationship under some circumstances, but it's important to understand all the legal implications and background first.

Defining the relationship

Under common law — a body of principles derived from unwritten customs or judicial decree (as opposed to legislative enactment) — the so-called "no-duty rule" means that a physician has the right to refuse treatment to a patient in need of emergency care if there is no prior physician-patient relationship. In order to establish a physician-patient relationship, both parties must voluntarily consent to it, with the physician indicating an intention to treat the patient.

Clearly, a physician-patient relationship is expressly established when the physician actually sees the patient. But it can be implied in other ways; for example, when the patient schedules an appointment with the physician, but does not keep that appointment; or when a primary-care physician refers the patient to a specialist participating in the same health plan and the specialist's office gives the patient an appointment at a designated time and place.

Once a physician-patient relationship is established, the general rule is that a physician has a duty to continue to provide care to the patient until that relationship is terminated by the mutual consent of the physician and patient; the patient dismisses the physician; the services of the physician are no longer needed; or the physician properly withdraws from the physician-patient relationship.

Today, statutory laws — those enacted by legislatures — add several layers of complexity to the common-law rules governing the physician-patient relationship. Laws including those governing emergency treatment provided by hospitals and antidiscrimination, as well as certain ethical constraints, play a significant role in how and when a physician can terminate that relationship. Also, specific laws vary by state.

Statutes that matter

In very broad terms, you can legally extricate yourself from a physician-patient relationship if you:

• give the patient adequate notice in writing preferably by certified mail, return receipt requested (30 days is generally acceptable);

• give the patient a brief explanation why you are terminating the relationship;

• document notification and the reasons for termination in the patient's medical record;

• help the patient find another physician;

• offer to transfer medical records to a newly-designated physician upon signed patient authorization to do so; and

• continue to provide care if the patient remains in need of care.

For physicians practicing under fee-for-service, that may be all that is required. However, if you are under contract to managed-care plans or you treat patients in a hospital setting, it is not quite so simple. In those cases, you are subject to the stipulations of your contracts with payers, and to laws that prohibit "patient dumping."

Regardless of your setting or payment structure, a physician's office is considered a "place of public accommodation," and is therefore subject to state and federal laws. For example, Title III of the Americans with Disabilities Act (ADA) prohibits a place of public accommodation from denying access to healthcare because of disability, unless the disabled individual poses a direct risk to the health and safety of others. The ADA also provides broad protections for those who are considered disabled by virtue of having certain diseases, such as HIV.

In several cases, the courts have addressed the application of the ADA to a healthcare provider's decision to refuse to treat a patient. The best-known of these is probably Bragdon v. Abbott, decided by the Supreme Court in 1998. The case involved a dentist who refused to fill a cavity of an asymptotic HIV patient in his office, although he was willing to treat the patient in a hospital at a higher cost to the patient. The patient sued for violation of the ADA, and the court ruled that asymptotic HIV constitutes a disability. The court's decision speaks to other healthcare providers' legal obligations to treat HIV infected patients as well as patients with other disabilities.

Hospital emergency room physicians are even more restricted in their ability to choose not to treat certain patients. The federal Emergency Medical Treat-ment and Active Labor Act (EMTALA) was enacted by Congress in response to a concern over "patient dumping" by hospitals refusing treatment to individuals who could not afford to pay for medical services.

EMTALA imposes a duty on the hospital and its physicians to provide medical screening exams and stabilization of everyone seeking emergency care, regardless of their ability to pay. Under EMTALA, a patient cannot directly sue a physician for not complying with the act, but physicians may be subject to civil monetary penalties and exclusion from participating in Medicare and Medicaid for flagrant or repeated violations of EMTALA.

A question of beliefs

Certain federal and state laws, including antidiscrimination laws, do allow some exceptions. One exception allows physicians and other healthcare providers (and faith-based health systems) to refuse to provide services, such as abortions and sterilizations, that are morally or religiously objectionable to them. Most states have some form of these "conscience clauses."

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