The success of a physician-patient relationship encompasses several important factors, including mutual respect, trust and effective communication. But what can be done when this relationship becomes adversarial and communication breaks down?
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Explore This IssueNovember 2020
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The American Medical Association has historically pointed out that poor physician-patient communication is directly related to malpractice or discrimination lawsuits. When providers end a physician-patient relationship with a difficult patient, it’s critical they understand their legal obligations to mitigate the risk of future claims. Following is an overview of the proper way to terminate a patient relationship.
Difficult Patient Behaviors
Unfortunately, certain patients can be challenging. This can have a negative impact on the physician-patient relationship and make proper medical treatment difficult.
In recent years, patients have taken a more active role in their medical treatment, not only because the medical decision-making model has shifted away from traditional paternalism and toward increased patient autonomy, but also because patients are now afforded additional healthcare rights under federal and state laws. Core patient rights include informed consent, the right to refuse treatment and privacy rights under the Health Insurance Portability and Accountability Act (HIPAA) and its state equivalents.
In addition, many states have adopted laws requiring a patient’s bill of rights that applies to treatment in hospitals and similar facilities. These bills of rights generally explain how patients can expect to be treated, include descriptions of how patients can be involved in their own care and how their privacy will be maintained, as well as information regarding billing and insurance claims. They also contain information on what a patient can expect when a physician-patient relationship ends.
Generally, adverse patient behaviors fall into five main categories:
- Non-adherence: The patient unintentionally deviates from a treatment plan, frequently cancels or reschedules appointments, and/or fails to follow certain practice/office policies;
- Non-compliance: The patient intentionally refuses to attend appointments or follow a treatment plan, fails to obtain ordered testing, and refuses to take prescribed medications and/or follow medical advice regarding lifestyle changes;
- Non-payment: The patient has extensive or repeated unpaid bills and refuses to establish a payment plan;
- Inappropriate or hostile behavior: The patient uses crude or vulgar language with the physician, office personnel, or others, exhibits violent behavior, makes physical or legal threats, is dishonest about their medical history, and/or engages in sexual advances of any kind; and
- Disagreement or dissatisfaction: The patient repeatedly disagrees with and challenges the physician’s recommended treatment course despite a reasonable explanation of health outcomes and risks, desires alternative treatment options or more specialized care that the treating provider doesn’t offer, and/or requests a referral to another provider due to dissatisfaction.
In addition, the COVID-19 public health emergency has increased the complexity of maintaining effective communication in the physician-patient relationship. Patient encounters may be more isolated, and many providers and patients have limited proficiency in telemedicine encounters.
Regardless of whether a relationship was formed virtually or through an in-person encounter, however, terminating a patient relationship may be necessary if the behavior has caused the relationship to break down in an irreparable way that detrimentally affects the patient’s medical treatment. Once a physician-patient relationship has been formed, a provider must follow applicable rules and guidance for terminating physician-patient relationships.
Terminating the Relationship
Termination may occur through a series of carefully articulated steps or through a single termination letter, but should be done with prudence and supported by internal documentation and examples of the patient’s actions sufficient to justify the decision.
Certain states mandate the steps that must be taken, including a notice provision—often a period of 30 days—that identifies the effective date of termination. A provider may first put a patient on notice for violations of specific policies, such as unpaid bills or routinely failing to show up for scheduled appointments, but other behaviors, such as threats of violence, may not merit advance warning of termination.
A patient relationship cannot be easily terminated under all circumstances, however. For example, if a patient is in a legally protected category, such as having a disability under the Americans with Disabilities Act or on the basis of race, color or national origin under the Civil Rights Act, the relationship may not be one that can be terminated without first helping the patient find an appropriate substitute for care. Additionally, if a provider is the only specialty provider within a geographic area and the patient would suffer significant medical hardship without the provider’s services, the relationship may be extremely difficult to terminate, because the patient cannot simply be abandoned.
If a patient is in a vulnerable medical state, including but not limited to postoperative, undergoing chemotherapy or in an acute stage of treatment that poses significantly higher health risks without continuing care, termination may be very difficult unless an appropriate substitute can be found. Even when a substitute is found, the relationship generally cannot be terminated until the new physician-patient relationship begins.
Finally, termination can be complicated if any state laws provide patients additional rights with respect to time for notice of termination, required referral and transfer of care, or if a patient has a health plan that requires the provider to request a patient transfer or requires additional notice beyond the state law’s required time period (60 or 90 days) before the patient can be discharged.
Elements of the Termination Letter
When ending the physician-patient relationship is appropriate, a physician must send a written notice to the patient. The letter should clearly state the relationship is formally being terminated using either generalized or specific language based on the patient’s actions. It must also, as permitted by state law, express that the patient has a responsibility for their own health to continue necessary medical treatment.
In addition, a termination letter should include:
- A grace period for the patient to transition their care to another provider; this period may be based on best practices or applicable state or payer requirements;
- A description of the patient’s rights, including the right to obtain a copy of their medical record;
- Recommended referrals for care and an offer to assist the patient in the transition of that care;
- A clear statement of the effective date on which the physician’s services will conclude, except for emergencies; and
- The physician’s signature and the date of signing, and contact information for the practice.
A release form for the patient to execute that directs the practice to release the patient’s medical record to the patient’s new provider(s) should be included with the letter. The letter and release should be sent via certified mail so they can be tracked, and a copy of the letter and any enclosures should be placed in the patient’s medical record. Once the letter has been sent, office staff should be notified of the termination.
Ending a relationship with a patient should be a last resort, an action taken only after discussing the patient’s behavior and providing an opportunity to correct it. However, this may not always be feasible, leaving termination as the only viable option.
Providers should proactively consult with a healthcare attorney to discuss difficult patient situations and to review relevant state and federal laws, thereby reducing specific risks for future negligence, abandonment, or discrimination claims, and consult with their malpractice carrier to review their policy. Once termination is in process, it would be prudent to engage a healthcare attorney to review or assist in drafting the termination letter.
If your practice doesn’t have a patient termination policy, consider putting one in place now so that, going forward, a reliable process is applied consistently to all patients
Steven M. Harris, Esq., is a nationally recognized healthcare attorney with McDonald Hopkins LLC. Contact him at email@example.com.