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Despite the recent increase in competition in the medical field, there are circumstances when a physician may want to discharge a patient from his or her care. Try as one may to develop rapport and open communication, certain patients may be uncooperative, refuse to comply with treatment, appear to be potentially litigious, are simply difficult to deal with, may not pay their bills, or refuse to sign the arbitration agreement. In those instances, the best choice may be to end the relationship.

A physician is not required to accept all patients who seek treatment unless the situation is an emergency or he or she has given up this right by signing certain managed care contracts. A physician also is not required to continue treatment of a non-managed care patient provided the relationship is terminated properly. In order to discontinue treatment of a patient, the physician must: a) provide for continuity of care, that is, recommend other physicians; b) inform the patient of the risks involved with continuing as well as not continuing treatment; and c) give the patient reasonable notice of intent to discontinue treatment.

If a physician simply withdraws from the case without properly notifying the patient, then he or she can be held liable for abandonment and may be in breach of contract under certain managed care agreements. Here are some basic guidelines on how to discontinue treatment:

1). Medical Review. The patient should be informed of his or her medical history and progress of treatment. If the patient had been uncooperative, the physician should explain how that affected his or her medical condition.

2). Managed Care Issues. If the patient is being seen under a managed care contract, then the physician should contact the managed care organization for its advice and for the procedures to follow in properly transferring the patient's care so that the physician does not breach his contractual obligations to the MCO or violate existing laws governing HMOs. Note that procedures to transfer patients to another physician vary under different MCOs. In general, managed care patients may not be refused to be seen if they refuse to sign an arbitration agreement. But the agreement may be offered to these patients.

3). Recommend. The physician should recommend the best course of treatment for the patient.

4). Warn/Inform. The physician should outline the risks and benefits of continuing and not continuing treatment.

5). Continuity. The physician should offer a list of physicians in the area who are qualified to treat the patient. He or she should offer to consult with and make copies of the patient's medical records available to the subsequent treating physician. The discharging physician should remain available to treat the patient for a reasonable period of time. As a general guideline, 10 days would probably be needed in an urban area and 3 to 4 weeks in a rural area or however long is needed for a patient to find the physician qualified to treat his or her condition.

6). Confirm with Patient. The physician should notify the patient by certified mail with a return receipt of his or her intention to discontinue the relationship and if relevant, the significant risks of the patient not continuing proposed treatment. The return receipt should be retained in the patient's file as evidence that the patient received the letter.

7). Documentation. The physician should document thoroughly that the patient was properly notified, provided with referrals, and advised of the risks and benefits of continuing or not continuing treatment. Correspondence and discussion with the managed care organization should also be documented in the patient's chart. The discharging physician should make copies (never originals!) of the patient's medical record available to the subsequent treating physician or the patient. The physician may charge for these copies up to $0.25 per page or $0.50 per page for microfilm, retrieval and reasonable clerical fees. From a risk management/loss prevention perspective, it may be wise to not charge the patient for copies of their records. A summary of the patient's relevant medical records may also be prepared. However, from a loss prevention perspective, summaries have the downside risk of not disseminating the patient's entire history. Lastly, medical records cannot and should not be "held ransom" until the patient pays any outstanding medical bills.

If a physician has completed treatment for a patient's condition and the patient comes to the physician with another medical problem, the physician has a right to refuse treatment as if the patient were new. If applicable, the physician should refer the patient back to their managed care organization. For example, if an obstetrician delivered the woman's first child, he or she is not obligated to deliver her second child (unless the circumstance is an emergency). When a physician retires or otherwise discontinues practice, he or she should follow the same procedure in making sure that patients are properly notified and have adequate continuing care until the patient is transferred.

Finally, if a patient who requires further medical attention discharges a physician or leaves the hospital against medical advice, the physician should take protective action from being accused of abandonment. The physician should try to obtain a signed statement that the patient is leaving against medical advice. Failing that, the physician should send a registered letter to the patient stating that the discharge was contrary to medical advice. The physician should fully document the patient's refusal and subsequent actions in the patient's chart.

NOTE: In the attached sample letter of discontinuing care, it is wise, but not mandatory, to include the reason why the physician is discontinuing care. This letter may be modified for situations of patient non-compliance, failure to pay bills, or retirement/leaving practice. Physicians need to review and incorporate the policy and procedure for transferring patients who are under managed care contracts. Before you actually discharge the patient from your practice, contact the managed care group provider relations department for their advice on how to proceed. The correspondence between the physician and MCO must be maintained. The attached sample release for medical records is a general release and does not cover release of HIV test results or other highly confidential records for mental health or substance abuse. Separate and specific releases need to be obtained from the patient for these highly confidential materials.

Much of the above information is contained in the "California Physician Legal Handbook," published by the California Medical Association. The CPLH may be ordered by calling (415) 882-3336.

If you have questions regarding this article or other loss prevention/risk management issues, please call CAP/MPT's Risk Management Department at (800) 252-7706.

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