Dropping a Problem Patient 
Sometimes it's best for you and a patient to part company......but you must end the relationship in a legal, ethical manner.
By Jeffrey D. Weinstock, Esq.

Every practice has some patients who are more trouble than others. It's an unfortunate reality of medical practice; difficult patients come with the territory. But there are those few times when you may determine that it's in everyone's best interest for the patient to seek treatment elsewhere.

Although a patient may end his relationship with you at any time and for any reason, you don't have that choice. You have specific responsibilities that you must fulfill when carrying out the process of terminating a patient.

As with any other important decision you make, dropping a patient can involve a number of factors. Acceptable and unacceptable reasons exist for discharging a patient from your practice. Even when dropping a patient is permissible, you must follow defined procedures to reduce the risk of liability. If you don't properly terminate the patient, you may violate American Medical Association (AMA) ethical provisions, as well as state and federal law, and be subject to private legal actions by the patient.

In this article, I'll outline the legal basis for terminating a patient and describe the appropriate steps you should take when dismissing a patient from your care. Follow these rules and you'll reduce the risk of liability and other repercussions.

What's your reason?

You may want to discontinue treating a patient for a number of valid reasons, including:

• failure to pay for treatment
• harassing office staff
• failure to follow medical recommendations
• continually missing appointments
• personal differences.

Depending on the circumstances, it may be appropriate to discharge a patient if you take the proper precautions. However, using a person's race or ethnicity as a reason to stop treating a patient would be totally inappropriate.

The decision to terminate a patient should be reached carefully and should only be made after genuine attempts to effectively render treatment. If a patient doesn't comply with medical advice, it's in your (and the patient's)

In cases of nonpayment, experts advise that prior to dropping a patient you should try to resolve the issue and explore the possible reasons for nonpayment. If these efforts fail, provide notice to the patient and begin the discharge process discussed in more detail below. Even if a patient won't pay, it isn't permissible to simply stop treatment.

Dropping a patient carries with it a whole set of potential problems. You should be aware of the following laws before beginning any termination process:

• Patient abandonment. The AMA's Office of the General Counsel, Division of Health Law, defines patient abandonment as "the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement." Abandonment must happen at a critical time of treatment without justifiable reason or adequate notice and must also involve some injury to the patient. In addition to potential civil liability as a result of abandonment, a proven case of abandonment could raise issues with your state licensing board.
• Anti-discrimination statutes. Avoid any action that could lead to a discrimination charge. Malpractice insurance policies won't protect you in these situations. The AMA says that a physician can't refuse to treat patients because of "sex, color, creed, race, religion, disability, ethnic origin, national origin, sexual orientation, age, or any other basis that would constitute invidious discrimination." Make sure to contact your attorney if these issues may potentially come into play.
• The federal Emergency Medical Treatment and Active Labor Act (EMTALA). This law governs the methods in which patients may be denied treatment or transferred from one hospital to another. EMTALA generally applies to "participating hospitals" and to emergency situations that are beyond the scope of this article, however its requirements must be kept in mind when in a situation that may involve these factors.
  When you're certain that you won't be violating the law or compromising the patient's rights, you may begin the discharge process by taking these steps:
• Contact your malpractice insurance company. Many malpractice insurers will provide you with information that will help you terminate a patient in a manner designed to reduce the risk of litigation. Some insurance companies have sample letters available for their physicians to use in specific situations.
• Check with the patient's managed care company. In addition to ethical and statutory requirements governing terminations, you may also have a contractual duty. Managed care contracts can place specific requirements on physicians regarding the manner in which patients may or may not be terminated, and how termination must take place. In addition to providing notice to the patient, plans often require that you notify them prior to terminating the patient. The plan's response may depend on the reasons you give for the requested discharge. Follow the requirements of the plan in addition to other laws and regulations, not in place of them.
• Notify the patient of your intention to terminate him. You must provide adequate notice to the patient in every instance of termination to make sure the patient's care isn't compromised. In most instances, 30-day notice is sufficient. The patient's care takes priority over his failure to pay or philosophical conflicts with the physician. Since the well-being of the patient is the highest priority, you must ultimately make the determination that the discharge should occur, using medical as well as business judgment. The requirement to furnish notice to a patient prior to termination applies in all cases of termination, not just the ones mentioned here. If the patient requires treatment during the interim, you must treat him, or that patient could claim abandonment. Tell the patient that you'll treat him in the interim and for emergencies that arise. It's important to keep detailed records of the entire process. If a member of your staff spoke to the patient a month ago regarding problem issues such as nonpayment or inappropriate behavior, that information should be noted in the patient's file along with the name of the person who spoke to that patient and the results of the conversation. If the patient orally agreed to pay by a certain date but hasn't, refer to that conversation in the patient's chart.

Make a graceful exit

Deciding on whether to elaborate on reasons for termination in the notice letter can be a sticky issue. On one hand, providing a reason for termination eliminates confusion on the part of the patient. On the other hand, depending on the wording, it may provide fuel for a subsequent lawsuit. Remember to consult with your attorney and insurer to determine appropriate wording. Don't include details that will anger the patient. Be careful to phrase your letter in a way that points out that the end of the relationship is mutually beneficial. Send the notice letter via certified mail, with return receipt requested, to prove that the letter was received. Once you receive a written request from a patient to transfer his records, do so without delay. Keep the original records and send a copy.

Finally, advise the patient to seek care from another physician. If the patient asks for physician suggestions, refer him to his insurer or the local medical society. Depending on the reason for termination, it's advisable not to refer the patient to a specific physician. You don't want problem patients of yours to become problem patients of your colleagues. 

Jeffrey D. Weinstock, Esq. is the Assistant General Counsel of Cyber-Care, Inc. Based in Boynton Beach, Fla., Cyber-Care is a technology-assisted health management company.