The Right Way to Say Goodbye (continued)
Dealing with managed care
What about dismissing managed care
patients? In this case, the doctor should first review the
managed care contract or physician manual. Some will outline a
process for dismissing a patient. Next, contact the
plan’s medical director and discuss the situation. Some
plans provide mediation services which must be exhausted before
the patient can be dismissed. A specialty physician might find
herself obligated to continue seeing a patient if that
physician is the only member of her specialty participating in
that particular plan in that geographic area.
However the managed
care company requires the situation to be handled, the
physician should forward to the insurance company copies of any
dismissal letter or other related correspondence. Stewart
cautions physicians to be sure the reason for dismissal is
“rock solid tight” and to avoid any appearance of
dismissing a capitated patient simply for overuse of medical
services.
Once a physician has
dismissed a patient, should she continue to see other family
members of that patient? That probably depends on the reason
the patient was fired. “If you’ve discharged them
for non-payment, it’s unlikely other family members will
pay,” Anders points out. “If it’s a case of
the patient not following the treatment protocols or a
personality clash, if the rest of the family chooses to
continue to see the physician, there’s no reason not to
see them.”
If the reason for
discharge is abuse of staff, then continuing to care for the
patient’s minor children, for example, still provides the
patient with opportunity to act out. In this case, discharging
the entire family may be warranted.
Getting back together
Like couples who break up and end up
getting back together, doctors and patients sometimes also
agree to see each other again after a period of time. The
decision of whether to treat a former problem patient again is
individual to the doctor and the patient. Some doctors make a
firm policy that once a patient is dismissed, he is never
welcome in the practice again. “Most of the behaviors
that cause us to dismiss a patient from the practice in the
first place are so ingrained that they aren’t going to go
away,” Stewart says.
Others are more
forgiving. Anders has known physicians to take patients back
who were dismissed for non-payment and have asked for a second
chance. He recommends establishing ground rules with the
patient beforehand, that a certain number of missed payments or
a repeat of certain behavior will result in the patient’s
dismissal again.
The personal cost
While some patients may become angry and
even abusive when fired by their doctors and others will retire
more quietly, the doctor, too, is affected emotionally whenever
she has to ‘give up’ on a difficult patient.
“When I discharged a patient, I felt very sad,”
Stewart says.
Most doctors will feel
some relief as well. “I guess it’s kind of a mixed
feeling,” Sanders says. “Doing orthopaedics, if you
can’t get someone back to the functional level that
you’d hoped to get them back to, it’s always a
disappointment.”
Firing a patient takes
a toll on the physician and staff and can even affect the
practice finances if the patient refuses to pay outstanding
bills. A better approach is to learn to detect potential
problems before they start.
When Stewart was a new
family physician, just starting to see office patients, a man
came in who was clearly seeking drugs. After examining the
patient, Stewart discussed the case with her attending
physician. “I asked his advice and he said ‘Now,
you can give in and give him the drugs. But he’s going to
go out and he’s going to tell everybody he knows and the
next thing you know, your practice is going to fill up with
people who are drug seekers. You’re going to come in
every morning and you’re going to look at the schedule
and your stomach is going to be in knots and you’re going
to hate coming to work. Or, you can take a hard line with the
patient and tell him you don’t practice medicine that
way. That patient will leave and they will never come back.
They will also tell everyone they know not to bother going to
that doctor and pretty soon you won’t have any of those
patients in your practice. You’ll come in and
you’ll look at your schedule and you’ll really like
all the people who are on that schedule.’”
Stewart says she has
tried to follow that advice and feels it has prevented a lot of
problems in her practice.
Likewise, Sanders
feels many problems can be prevented by assessing the
patient’s personality before any physical relationship or
actual treatment begins. “There will be occasions when
somebody comes in the office and you can see that there’s
a chip on their shoulder when they come through the
door,” he says. “You know you’re not really
going to be able to have a good working relationship with this
individual. I think it’s perfectly reasonable in that
situation to say ‘I’d like to help you, but I
don’t really believe that I’m the right one. I
think we need to help you get in to see somebody else.’
It’s not too hard to cut things off at the pass if you do
it before you have really started on an active treatment
program for the patient.
Plan ahead
The decision as to whether to fire a
patient and what behaviors merit dismissal are up to the
individual physician, but it’s important to have a plan
before such a situation arises. “Every practice should
have a policy in place as to the protocol to be followed when a
patient is discharged,” Sanders says. “Then, if you
have to let somebody go, you follow the protocol that
you’ve previously outlined. If the patient becomes
unhappy and there’s a liability situation, you’ve
got something to fall back on.”
And as with every
other interaction with patients, physicians should carefully
document both the patient’s behavior that leads to
dismissal and everything the physician does to try to solve the
problem, as well as all communications and actions related to
the dismissal process.
“Physicians are
very forgiving of their patients,” Anders says.
“Things usually get to a pretty bad impasse before
they’re ready to discharge somebody. I can’t say
they ever pull the trigger too soon. They may make the mistake
of pulling the trigger too late.”
Failure to deal effectively
with problem patients can lead to bigger problems as time goes
by. Following the correct protocol for firing a patient lowers
the physician’s potential for liability, protects staff,
and helps ensure continuity of care for the patient. Firing a
patient can sometimes be the best thing for both the physician
and the patient. g
 |
Discharge Dos and Don’ts
Do
n
Develop a protocol for discharging patients ahead of time.
n
Discuss the problem with patients and attempt to reach a
solution before discharging them.
n
Document all circumstances leading to the decision to discharge
patients.
n Check
managed care contracts for the insurer’s requirements or
policy on discharging a patient.
n
Provide resources for the patient to find another physician.
n Offer
to send copies of medical records to the new physician.
n If the
certified letter is returned as unclaimed, place the unopened
letter in the patient’s chart and send a second letter by
regular mail.
n
Document any interaction/ patient response to the discharge
letter.
n Notify
staff, other physicians in the practice, and the
patient’s insurer of your decision to discharge him or
her.
n Place
a copy of the discharge letter in the patient’s chart.
n Send
of copy of the discharge letter to the patient’s insurer.
n Write
to the patient using certified mail.
n
Provide a grace period (usually 30 days) when you will
continue to provide care.
Don’t
n
Discriminate against a patient on the basis of race, religion,
sexual orientation, or disability.
n
Violate a patient’s privacy. All conversations should be
conducted in private.
n
Discharge a patient who is involved in treatment for an acute
condition.
n Let
anger or other emotions govern your behavior. g
Cindi
Myers is a former medical
office manager and is now a novelist and part-time ski bum who
lives in the mountains of Colorado.
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