Physicians and the medical practice leadership have a fiduciary and ethical obligation to ensure for the continuity of care for their patients.
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Overview
Physicians and the medical practice leadership have a fiduciary and ethical obligation to ensure for the continuity of care for their patients. Care may be voluntarily withdrawn by the patient if they request to leave the care of the provider, or if the patient no longer requires the care of the provider, a specialist, who was to provide only a certain aspect of the needed care.
Like any relationship, the effort to maintain a therapeutic and respectful connection between provider and patient takes effort and time. And like any connection between two parties, the relationship can reach a point of disruption or challenge. Ideally, working through the rough patches is the preferred option. Circumstances may reach a point though where the differences are too far apart, the bond broken and mutual respect lost. All efforts to resolve the matter have been exhausted.
Exceptions
There are exceptions when a patient may not be terminated. These can include the presence of an emergent or acute medical condition, a pregnant patient approaching delivery or a contractual agreement with insurance. To avoid allegations of abandonment or discrimination, patients should be medically stable, no longer in the acute or post-operative stages, or postpartum before a physician withdraws from their medical care.
As a team, the provider should review the patient’s record, discuss the patient’s visit history with the care team and the practice leadership to ensure that there are no state law requirements, mandates through your medical board or contractual arrangement from the patient’s health plan that prohibit the termination.
The primary goal here is to not only protect the practice but also ensure for the patient’s safe discharge from the physician/patient relationship.
It is important to note that the ultimate decision as to whether to terminate the relationship rests with the physician. Other team members should provide supportive documentation and feedback about problematic encounters, but no other team member may terminate the relationship without the direct guidance of the physician.
Many a reason
The termination of the physician/patient relationship may happen for any reason, provided it is not discriminatory. Such discrimination could include gender, limited English proficiency, race, religion, disability, ethnicity, age and national origin.
Caution must also be taken to ensure that the decision is not cause for a charge of patient abandonment. The physician must provide proper notice to the patient. Best practice for the notification process follows.
Reasons for terminating the physician and patient relationship can include:
Treatment non-compliance: The patient has violated the established behavior or pain management contract. Attempts to resolve any barriers that supported non-compliance or non-adherent behaviors have been unsuccessful.
Follow-up noncompliance: The patient repeatedly cancels follow-up visits or is a “no-show.”
Office policy noncompliance: Patient refuses to abide by the office rules and procedures.
Abusive or violent behaviors: Patient is rude or uses threatening, offensive, demeaning, or hostile language, exhibits violent or aggressive behavior, makes threats of physical harm, or uses anger to jeopardize the safety and wellbeing of staff, other patients or visitors.
Chronic abuse or misuse of medications or controlled substances: Patient refuses to seek treatment for substance abuse or to abide by a therapeutic contract; exhibits drug-seeking behavior or obtains controlled substances concurrently from multiple physicians; fraudulently obtains any medication, which includes altering or adulterating a prescription.
Property: Theft or destruction of the practice’s (or staff’s) property or equipment.
Failure to honor agreements: Repeated failure to make a good faith obligation to meet financial obligations; nonpayment of bills.
Demands: Patient makes unreasonable demands on the physician’s time or asks for care/treatment that is beyond the scope of the specialty or plan of care
Legal action: A patient or family has filed legal action against the physician. The provider is under no obligation to continue care. See key points below.
Business changes: Relocation of the medical practice, retirement, or discontinuation with a specific health plan.
Inappropriate contact/improper boundaries: Sexual advances or stalking behavior toward a physician or staff member.
Exceptions: Examples where terminating the relationship may become problematic:
Any patient in an acute phase of care or in follow-up post-hospitalization or surgery
Any termination based on a patient's race, creed, color, national origin, marital status, sex, or sexual orientation
Any time when the physician is the sole available physician specialty for a condition within a reasonable geographical distance, such as a rural setting
Process
Provide a code of conduct early in the relationship with a new patient. When introducing a practice to a new patient, outline for them how they can address their complaints, unrealized expectations, what behaviors are expected in the waiting rooms, how you expect them to speak to your staff, what is considered problematic behavior for your specialty and what to do if they feel they have not been heard.
Recognize that office systems and policies may be at the heart of the patient’s frustration. Service mishaps occur every day, and patients may already be stressed.
The termination process begins long before the final letter is sent. When problems arise use a team approach for problem solving. Seek out resources to avoid termination if you can, such as a team conference, social work interaction, psychiatric referral or a different practitioner in your office.
Include the patient in discussions of problematic behavior or situations and use limit-setting strategies to redirect the behavior. If the patient is willing to work with you and your team members, do so but provide a time frame where each party may check in with the other. The physician should always attempt to discuss the recent problematic situation with the patient or family.
The patient’s medical record must clearly document ongoing efforts throughout the relationship by the physician, clinical staff, and non-clinical staff. Let the documentation support efforts taken to address the concerns.
Authority
The termination process must be led/guided by the patient’s physician. The care team will provide input, but it remains at the discretion of the physician whether to pursue termination.
Key points
The patient should then be advised of the termination either in person by the physician or in writing. Ideally, the letter is signed by the patient’s physician or practice leadership. If the termination is for not just one physician but for the entire practice, the letter should be signed off by the CEO, practice administrator or chief medical officer for the group. If the practice is part of a large healthcare system, risk management and/or patient relations should be made aware of the termination.
Guidance
Should a patient have filed a legal action or a complaint with the physician’s licensing board against a physician, often the physician may terminate the relationship with the patient and is under no obligation to continue with care unless the patient’s status continues to be in the acute stages of care as noted above.
A physician may also consider whether continued care of the terminated patient’s relatives who are also patients should continue. An example of this situation is the minor children who are patients being terminated after the parent has been terminated. Care would likely continue for the patient’s family members who are also patients of the physician practice unless there is a compelling and ethical reason to discontinue the relationship.
Documentation
All instances of the patient’s non-compliance and/or disruptive or acting out behavior should be documented in the medical record at the time of the occurrence/event, including problematic encounters with scheduling personnel and those at the front desk. Ensure that the efforts taken to resolve the issue with the patient are also well documented.
Make certain that the records reflect challenges along the way. The last entry in the chart should describe what transpired in that moment but all prior notations in the medical record should support a pattern of behavioral issues. The exception to this is a violent or threatening encounter. When such a situation arises, immediate termination is warranted, but the staff’s response to the situation, the documentation of such and any other interaction again must be clearly documented.
When patients use profanity, document what was said using quotes.
Prompt documentation is best practice. Better to write a few brief statements, dated and timed notes down on a progress sheet than be struggling to remember details weeks or months down the road.
Terminations should be trended no differently than any other data that is collected. Are more patients being terminated from one physician or one location? What is the reason for most of the terminations?
Patient/legal representative notification
Once the decision has been made to terminate the relationship, the reasons for the decision should be noted in the medical record.
It is important to note (objectively), in the patient’s medical record, all instances of non-compliance, disruptive behavior, etc. that have occurred.
We recommend you meet with or speak with the patient (and family members, if appropriate) to inform them of your decision, explain the reasons for it, and to answer any questions the patient may have. (If you feel that such a meeting would not be safe for you or the staff, a phone call is acceptable).
The patient should be put on written notice that he or she must find another physician.
The written notice signed by the physician should be mailed to the patient by regular and certified mail, return receipt requested.
Keep a copy of the letter and the certified mail receipt in the patient’s medical record.
The practice manager should document termination status in the electronic medical record (EMR) systems in use to ensure a future new appointment is not made following the termination.
The written notice should include:
Reason for termination — Provide a brief, clear and factual summary of the reason(s) for termination, e.g., non-compliance, failure to keep appointments, therapeutic relationship no longer exists.
Effective date — The letter should provide the patient with a reasonable period to establish a relationship with another physician. Thirty working days (unless state law requires a different notification period) from the date of the letter is usually adequate and should allow time for the patient to secure a new physician.
Interim care provisions — Offer interim care as needed.
Continued care provisions — Offer suggestions for continued care through local referral services, such as medical societies or community resources.
Request for medical records — Provide a release of records authorization with the termination letter.
Best practice
In closing, consider having a written policy for termination of the physician and patient relationship using the criteria noted above. Equally important to support that written policy is training staff and providers on not only the termination process but also how to work with patients and their families through difficult situations. Consider adding criteria for how to address situations where the patient is appealing the termination process.
When training staff consider training anyone who is patient-facing, even staff who only speak with the patient by phone. Guide staff on documentation required for such situations — in the patient record and in the event report.
Disclaimer
Willis Towers Watson hopes you found the general information provided in this publication informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, Willis Towers Watson offers insurance products through licensed entities, including Willis Towers Watson Northeast, Inc. (in the United States) and Willis Canada Inc. (in Canada).
