Breakups with problem patients require communication, documentation

Key takeaways:

• A “Patient’s Rights and Responsibilities” document can establish expectations.
• Reasons for termination may include disruptive conduct, treatment noncompliance and communication breakdowns.

PARK CITY, Utah — Physicians can sever ties with difficult patients, but these terminations require communication, documentation and justification, according to a presentation here.

It all begins with managing expectations, Kim Stanger, JD, a partner with Holland & Hart LLP, said during his presentation at the Association of PAs in Allergy, Asthma and Immunology Annual Allergy, Asthma & Immunology CME Conference.

Rights and responsibilities

At the beginning of treatment, even as early as registration, Stanger advised physicians to give patients a “Patient’s Rights and Responsibilities” document explaining what is expected of them during their care.

Kim Stanger

“Come up with something that says, ‘Look, essentially, we’re a health care provider. We want to provide effective care. But you are critical for this process, and in order for us to provide effective care, we really need you to do the following,’” Stanger said.

These patient directions can include cooperation in developing the treatment plan, complying with the treatment plan, participating in ongoing communication and engaging in professional, respectful and nondisruptive conduct.

“You set the expectation so that when the patient starts acting in a disruptive [or] unprofessional manner, you can go back to them and say, ‘Look, we told you at the outset, this is what we need you to do,’” Stanger said.

Physicians need to document whenever patients do not comply with these expectations, Stanger continued, to protect themselves later.

“You can document it in a medical record if you want, but if you are going to put it in the medical record, be really, really careful,” Stanger said. “The patient is probably going to be able to access that, and that’s just going to make them more mad.”

Medical records should be objective and professional, keeping in mind that a jury someday may read it, Stanger warned, adding that peer review may be helpful too. Timeliness also is important.

“You want to make sure that you’ve got that document contemporaneously in case you need it down the road, whether it’s to justify why you terminated this person or whatever the case may be,” he said.

When patients do not comply with the rights and responsibilities document, physicians must communicate and emphasize what that document requires from them, explaining how inappropriate conduct interferes with their ability to provide effective care.

Physicians also should advise patients that noncompliance may result in termination of the patient-provider relationship and that the patient is free to seek care elsewhere.

“We will continue your care as long as you act in a professional manner. You participate in the program. You come to your appointments,” Stanger said. “If you don’t, then we’ll have to terminate the relationship.”

Legitimate reasons for termination include an inability to provide needed care, failure or refusal to pay bills, breakdowns in the relationship or in communications, disruptive conduct, noncompliance with treatment and missed appointments. Discrimination is not a valid reason to terminate a relationship.

Stanger advised physicians to try warnings, patient care conferences and behavior contracts to salvage problematic relationships. But if the patient continues to be problematic, physicians cannot simply abandon a patient, Stanger said.

“You provided the care. You’ve tried working it out with the patient, and you decide you just don’t want to deal with that guy anymore,” Stanger said. “Don’t just kick them out of the practice, because if you do, you could be liable for patient abandonment and all sorts of bad things that can come up as a result of that.”

Patients can sue for malpractice and patient abandonment alike, Stanger said, if they can prove that there was an established patient-provider relationship, the patient was abandoned while medical attention was still needed, the patient did not have adequate opportunity to transfer care to another provider, and the patient suffered damage due to the abandonment.

Also, Stanger cautioned, patients might not file a lawsuit, but they might file a complaint with the appropriate board. Civil penalties may be possible under the Emergency Medical Treatment and Labor Act and under Conditions of Participation for third-party payer programs. Licensure actions may be at risk as well.

“You can terminate the patient relationship. You just can’t abandon them,” Stanger said. “You can terminate them for any legitimate reason, or even no reason at all, as long as it’s not an illegal reason.”

Patient notification

When physicians decide it is time to terminate the relationship, they should notify the patient in writing and perhaps verbally as well, Stanger said. Also, physicians should give patients sufficient time to transfer their care to another provider. They must continue to provide care until that next provider begins treatment too, Stanger continued.

“How long do you need to give them? The general rule is maybe 30 days in most states,” he said. “It’s not black and white. It really depends on the patient’s needs.”

For example, Stanger suggested, an oncologist might not be able to terminate care in the middle of a patient’s cancer regimen. But a primary care provider who only sees a patient once a year for a physical probably could take immediate action.

“You have to determine, OK, is the patient going to be harmed if we just terminate this relationship, and how much time do they need to transfer their care to somebody else?” he said.

Immediate termination may be justified when patients present a danger to themselves, to the practice staff or to others or if there has been criminal misconduct. But, even then, terminations without notice still must consider the patient’s needs, availability of alternatives, and statutory and contractual obligations.

“There may be certain circumstances that justify immediate termination,” Stanger said. “Just make sure that it’s going to sound OK to a jury. It’s got to be pretty serious stuff, not simply that they parked in your parking spot.”

Stanger said he prefers sending notices of termination via delivery services such as FedEx. A copy of this letter can be kept with the patient’s chart or file as part of documentation.

“I don’t necessarily send it certified mail because they might not go to the post office and pick it up,” Stanger said. “They never get notice.”

The letter should clearly state that the physician will no longer be able to continue providing care as of a specific date and that the patient should seek another provider, although the physician will continue providing care through that date.

Also, the letter should provide the name and contact information of a local referral service that would be able to help the patient find another provider, along with a reminder that insurance programs, local hospitals or acquaintances may be helpful too.

Physicians should offer to transfer all the patient’s medical records to the new provider as well, once that has been determined, Stanger added.

Some physicians may avoid speaking to the patient directly and rely on the letter alone, but Stanger says this is a bad idea.

“They get frustrated. They don’t know,” he said.

Once the relationship has been terminated, the whole practice needs to know so the relationship does not start again. Records should be flagged to prevent new appointments from being made.

“If the patient calls up and makes another appointment and you didn’t let the staff know they were terminated, suddenly they’re back, and they have to go through the whole process again,” Stanger said.

If care mistakenly resumes, he continued, physicians must respond promptly.

If it becomes necessary to provide care to these patients even after the relationship has been terminated due to emergency or necessary care or on-call obligations, Stanger said physicians must reaffirm the termination of their relationship and make it clear that it is no longer ongoing.

Physician discretion

Stanger noted that the best way to avoid problems is to avoid problematic patients in the first place, adding that physicians generally are not required to accept every patient who walks through their door.

“You’re not a bus. You don’t have to take people on,” he said, noting that civil and contractual requirements may exist.

“Once you do take them on, though, you’ve got certain obligations until you terminate them appropriately,” he said. “You have to give notice and time to transfer their care.”