Ed Finkel

	At least 21 states now have passed or considered bills to protect physicians who choose not to fulfill American Board of Medical Specialties requirements for

 from losing their hospital privileges, insurance eligibility and/or state licensure. As of press date, three states had passed bills this year addressing the requirement to maintain certification for a variety of purposes, in addition to the five that did so in 2016.

	Georgia lawmakers passed a bill in May that prohibits MOC from being used for state licensure, eligibility for health insurance panels, eligibility for malpractice insurance and staff privileges at state-owned hospitals. Texas lawmakers passed a bill that was awaiting the governor’s signature at press time, which addresses licensure and insurance plans, as well as staff privileges at hospitals that are not either academic medical or designated cancer centers. And Tennessee lawmakers passed a bill in May that  addresses licensure. 

	This legislative success pleases Paul Teirstein, MD, president of the National Board of Physicians and Surgeons (NBPAS). Founded as an alternative to the ABMS maintenance of certification process, the group has been monitoring the progress of 19 bills across the nation including the three that passed this spring. 

	“I am very optimistic about the bills currently pending,” he said in an e-mail. “Hopefully, passage of this legislation in many states will inspire other states to create similar legislation. It is inspiring to see so many physicians support this new legislation.” 

	NBPAS formed in 2014 in opposition to MOC programs that some physicians had begun to view as too costly and not useful or relevant to their practices. Teirstein, chief of cardiology at Scripps Clinic in San Diego, asserts MOC has become “onerous, expensive and has no impact on medical care.” 

	Board certification gives patients the comfort level that their physician is up-to-date on the latest procedures and technology, says Lois Margaret Nora, MD, JD, MBA, president and chief executive officer of ABMS. “Legislation being introduced in states across the country increases the potential for patients and families to receive substandard care by either reducing access to board certified medical specialists, or by lowering the standards for specialty medical practice,” Nora told 

	Grant Greenberg, MD, MHSA, medical chairman at Lehigh Valley Health Network in Allentown, Pennsylvania, believes state legislators should steer clear of hospitals’ decisions about staff privileges and leave those to medical administrators. 

	“Board certification is establishing a minimum standard of competency, based on the expertise of physicians practicing in the field, who are knowledgeable about the field, who teach in the field, about what someone should know to be deemed competent in that field,” he says. The anti-MOC movement has come about, in his view, “because there’s a few bitter people who don’t like having to pay money to the board, or take a test or do a quality improvement project.”

	Greenberg also notes that some of the ABMS boards, including the American Board of Internal Medicine and the American Board of Family Medicine, have attempted to address at least a few of the concerns of people who find the testing process onerous. 

	They are doing so “by providing a wider array of easier, more accessible options that still maintain the integrity in terms of minimum standards, and yet make it administratively less difficult or time-consuming,” he adds. “Boards are going in a good direction with respect to that.”

	But until they encountered opposition from NBPAS, the ABMS boards had been aggressively expanding their testing regimes and advocating their use, says Jane Orient, MD, executive director of the American Academy of Physicians and Surgeons (AAPS), and an internist based in Tucson, Arizona.

Maintaining certification: Gold standard or is luster tarnished?

	“Since doctors don’t think their program is that worthwhile, they need to have it forced upon them by state legislation, or by hospitals,” she says, adding that the AAPS favors using state legislation to limit the use of MOC for purposes such as admitting privileges. 

	She adds that when MOC is required by hospitals or insurers, “One day you’re qualified, the next day you missed one too many exam questions and you’re no longer qualified, and patients are left without their doctor.”

	The Georgia bill initially limited all potential  uses of MOC, including for admitting privileges at private hospitals in addition to those at state-owned facilities. However, the limitation on private hospitals was dropped as part of a compromise during the legislative process, says Steven Walsh, MD, an anesthesiologist and president of the Medical Association of Georgia.

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	“What led to the push is that physicians were just feeling more and more of a burden in time and money placed on them in qualifying and participating in the MOC exams,” he says. “Within our medical community, there are objections to the way that many of the specialty boards implement their MOC process.”

	Cody McClatchey, MD, a board member of the Medical Association of Atlanta and chair of the public policy committee of the Georgia chapter of the American College of Physicians (ACP), says physicians in the state are very pleased with the new law. While there could be “some friction” about the provision regarding staff privileges at private hospitals being stripped from the bill, he hasn’t heard much discontent about that compromise to date.

	McClatchey, an internist in Atlanta, believes doctors in his state are taking a wait-and-see approach to ABMS member boards’ actions to respond to physician concerns. “We’re still in kind of a transitional time for that,” he says. “They’re moving in the right direction, and there seems to be dialogue.”

	Physicians in the state are committed to continuous education, but ABMS testing gets too far into minutiae and covers areas irrelevant to a physician’s practice, says Jacqueline Fincher, MD, a partner at the Center for Primary Care in Thomson, Georgia, and board of regents member for the ACP’s Georgia chapter.

	“This law enables internists here in Georgia not to have to worry about losing their credentials,” she says. “State licensure has certain criteria you have to meet every year in terms of continuing education. Patients want to know their doctor is knowledgeable and treats them well. I’ve never had a patient ask me if I’m board- certified.”

	Fincher says that while she finds it somewhat disappointing that private hospital privileges were excluded from the bill, they might feel pressured to drop the requirement anyway. “The private hospitals, if they choose not to implement this [voluntarily], they risk losing physicians,” she says. “I think that will resolve itself.”

	The Texas bill, cosponsored by two physicians, limits MOC use for licensure, insurance reimbursement and staff privileges at non-academic, non-cancer center hospitals. Others may limit MOC’s use for these purposes, but that decision must be made at the individual hospital level and not corporation-wide for those hospitals that are part of larger groups, says Carlos J. Cardenas, MD, president of the Texas Medical Association.

ABIM touts certification to restore patient trust

	“It empowers each independent medical staff to opt out of the MOC requirement,” says Cardenas, a gastroenterologist at Doctors Hospital at Renaissance in Edinburg, Texas. “It’s the medical staff, rather than a corporate entity, saying what it [the MOC policy] is going to be.” 

	In a state where about two-thirds of physicians are in either sole proprietorships or two-doctor offices, Cardenas thinks that the majority of his colleagues believe that MOC had grown “out of touch with the practice of medicine, in terms of what they were doing in their own specialties,” he says. 

	“The concern on the other side was, ‘What will be the metric?’” But he adds that state licensure and continuing medical education (CME) seemed adequate to most physicians in the state.

	Testifying on behalf of the Texas Medical Association, Kim Monday, MD, a neurologist from Houston, told the Public Health Committee of the state’s House of Representatives that MOC could be compared to attorneys needing to retake the bar exam every 10 years. 

	“Most physicians feel initial board certification is necessary to validate expertise following residency and training programs,” Monday said. “However, we find the continuous maintenance of certification process to be burdensome, expensive and filled with irrelevant curriculum.”

	The Tennessee law enacted in May addresses only licensure, although an earlier version would have prohibited use of MOC to determine hospital privileges or insurance eligibility, says Dave Chaney, vice president of the Tennessee Medical Association.

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	But Chaney suspects those provisions may be revived in the next legislative session. “This is something that has been brewing for a number of years,” he says. “We’ve heard from a lot of our members who incur what they feel is excessive cost and an unnecessary burden to complete the exams and the studies to maintain their specialty board certification.”

	The Tennessee Medical Association believes board certification should be entirely voluntary, “yet [doctors] don’t feel they have a choice when the hospitals and payers say it’s a requirement,” he adds. “Our members are happy we’re taking up the flag and doing something about it. As with any advocacy issue, you don’t always hit a home run on the first swing.”

	State Senator Richard Briggs, MD, a cardiothoracic surgeon and sponsor of the bill, says he “absolutely” intends to revive the other aspects of the original bill related to hospital privileges and insurance eligibility. 

	As an adult open heart surgeon, Briggs says he has had to answer questions about everything from heart transplants to pediatric heart surgery on MOC exams. “Why should I take time and money to take courses on those [issues]?” he says. “You’re spending time that has absolutely nothing to do with your practice.”

	At least three other states had bills pending that did not pass in the spring of 2017. A Florida bill that would have prohibited MOC from being used in determining hospital privileges and insurance eligibility made it through a House committee, but not the full House. 

	The Florida bill enjoyed the support of three physician-legislators, including State Rep. Julio Gonzalez, MD, an orthopedic surgeon in Venice, Florida, and the bill’s sponsor. “All three of us were in lockstep in espousing and believing in the virtues of this bill,” he says. “The concept was very straightforward.”

	But the state’s Senate, which does not have any doctors among its members, changed the bill significantly and it did not pass, Gonzalez says. “Number one, they don’t understand the economics and industry dynamics because they don’t have a physician in their chamber,” he says of the Senate. “Number two, pressure was applied by the hospitals and insurance industry, and ABMS hired a lobbyist to lobby against the bill.” He adds that he plans to reintroduce the bill in 2018.

	Rhode Island’s legislature held hearings on a bill but has tabled it for further study. House minority leader Patricia Morgan still hopes it will progress. “[Doctors] don’t think [MOC] improves their skills and knowledge, but it certainly adds a lot of cost and time,” she says. “They say it’s just an added layer of requirements on them.”

	However, Peter Hollmann, MD, vice president of the Rhode Island Medical Society, says he doesn’t think many doctors in his state see the need for legislation limiting the use of MOC, and hopes the legislation doesn’t pass.

	“In general, we support medical staffs being autonomous” to make decisions on what’s needed for hospital privileges, says Hollmann, a geriatric internist and chief medical officer of University Medicine, a medical center affiliated with Brown University. “We’d rather not have legislators telling us what to do.” 

	But Hollmann adds that the feeling isn’t quite unanimous and that a minority of physicians saw the bill as a bulwark against what they view as onerous requirements. “In our community, there are a small number of doctors who are very, very, very concerned about this,” he says.  

Articles

At least 21 states now have passed or considered bills to protect physicians who choose not to fulfill American Board of Medical Specialties requirements for Maintenance of Certification 

MOC-limiting laws spreading to additional states

	Patients who lack health insurance or have high deductibles 

 can avail themselves of numerous options to purchase medications at a discount.

	Doctors whose patients use these services-such as 

-say they provide savings, primarily on generic drugs. But it’s debatable how much help these services truly provide in meeting 

the challenge of high deductibles for prescriptions.

	George G. Ellis Jr., MD, an internist in Youngstown, Ohio, and chief medical adviser for 

 says he provides patients with information regarding one or more online prescription services and encourages them to comparison shop.

	“I’ve got a lot of elderly patients, and I want to make sure they get their meds and are able to afford their meds,” he says. “My concern is taking care of the patients and making sure that patients receive the medications they need at a reasonable cost, so they don’t compromise their health.”

	These online services are addressing a very real need, given the variation in the prices of prescription medications, the result of a dizzying series of negotiations among manufacturers, insurers, distributors and pharmacies, says Darius Lakdawalla, Ph.D., a health economist at the University of Southern California.

	“At the end of that complicated dance, there ends up being a lot of diversity in the price of what seems like an identical drug,” he says. “More information is almost always better, and here, the case is that more information about pricing is definitely better because there’s so much idiosyncratic variation.”

	Leaders of these online prescription services cite national statistics that they say underscore the challenges patients face. GoodRx chief executive officer Doug Hirsch points to figures from the Kaiser Family Foundation that show 29% of consumers were covered by high-deductible plans in 2016, up from 13% in 2010.

	And Matthew Chaiken, cofounder and chief operating officer of Blink Health, says figures from the Commonwealth Fund and Kaiser indicate that 70 million patients in the U.S. are either uninsured or underinsured, which he notes can translate to high deductibles and copays. 

	The online services provide greater benefits to those without insurance, says Edward Kaplan, senior vice president and national health practice leader at Segal Consulting. Segal’s employer clients have become more interested in finding discounts on drug prices, given that 40% offer percentage-based (as opposed to fixed-dollar) copays and/or high-deductible plans, yet their interest in services like GoodRx and Blink Health has been tepid. 

	“We bring them up to our clients,” he says. “We say, ‘You’ve got these firms out there, they’re free, you can promote them to [benefit plan] members and maybe they can be better shoppers. We haven’t gotten a huge amount of interest from HR and benefit directors.”

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	To the extent individual policy holders might be using those plans, Kaplan notes that their employers would not necessarily know about it. “It’s an individual going onto a retail site and doing their own thing,” he says. 

Next: Understanding the savings mechanics

	The online prescription services vary in the mechanics of how they provide savings. 

The key to making virtual visits a digital success

	For example, GoodRx negotiates specific prices with pharmacies for each medication and ends up offering a wide range of prices for some medications. Patients must take the GoodRx discount code to their pharmacy to get that price. 

	In contrast, Blink Health negotiates a single price with the manufacturer for each medication and sells them directly to patients. HelpRx provides a third approach, negotiating a specific percentage discount at one of its 17 participating pharmacy chains, a group that includes Walgreens, CVS and Rite Aid. It also offers the discounts to supermarket and mass merchant chains including Walmart and CVS-operated Target pharmacies.

	Ellis believes that, by and large, patients find somewhat cheaper prices using online services than they would by going to a pharmacy. “With the high-deductible plans, patients are struggling,” he says. “I often don’t know how patients are going to be able to buy their meds. They either eat, or they buy their prescriptions.” 

	But the savings on the medications are usually modest, Ellis adds. 

	“It’s really difficult to say that any of these companies are making a dent” in high deductibles, he says. “If you look at drug prices, they’re going through the roof. Even the generics have gone through the roof.”

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	The discounts are not significant, agrees Ashesh D. Patel, MD, a Washington, D.C.-based internist. He adds that the discounts are often advertised as ranging from 10% to 90%, but often they turn out to be at the lower end of that range. 

	Kaplan points out that insured patients must weigh the benefits of whatever discounts the online services provide against the reductions already built into the pricing of their employer health plans. “When you pull [prices] up and compare, sometimes it’s a little cheaper, sometimes it’s a little higher,” he says. “You’ve got to go drug by drug.”

	For the most part, Kaplan adds, the services are not attractive to people with solid prescription insurance through their employers, which means Good Rx, Blink Health and the like “are just getting the low-hanging fruit, people who have out-of-pocket costs and high-deductible plans.”

	Not all doctors are impressed by the online prescription services, however. Jonathan Weiss, MD, who practices internal, pulmonary and critical care medicine in Monticello, New York, says neither he nor his colleagues in his office recommend them to patients. Patients have not been asking about them and he would prefer to support local drugstores, Weiss adds.

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	Lakdawalla has a set of suggestions for Hirsch, Chaiken and owners of other online prescription services: “I think it would be very useful if these services began to provide information about value to providers and patients,” he says. “That is, in addition to price, they could begin to compile information about clinical benefits, side effects, modes of administration and other attributes that help patients understand which drugs are right for them.”

	Kaplan hopes the online prescription services continue to add value in terms of increased transparency. “They protect the individual consumer from individual pharmacy price gouging,” he says. “That’s their main value-you can get some comparisons.”

	Lakdawalla hopes the online prescription companies continue to succeed. 

	“There’s a lot of stuff in healthcare that’s complicated. This isn’t complicated,” he says. “Imagine if you were trying to buy a car, and nobody would tell you what you had to pay. It’s a little bit crazy. That’s the system of healthcare.”  

Online outlets provide savings, but physician buy-in remains varied

A prescription to help  cure high drug costs?

	Gary LeRoy, MD, a primary care physician in Dayton, Ohio, recalls an incident at East Dayton Health Center when a patient with mental health issues became belligerent and tried to grab a front-desk employee through the window.

	“That person was immediately given a verbal notification that he was being discharged from the office,” LeRoy says. “We had our office manager draw up the letter immediately.”

	Although this kind of incident is the exception, not the norm, it does illustrate that sometimes, practices need to dismiss a patient. Most often, patients pose problems like non-adherence to treatment plans or failure to show up for appointments and need to be managed on a regular basis.

	Terminating a patient relationship is “not a first-resort issue because the doctor-patient relationship is really paramount,” says Carrie Horwitch, MD, a Seattle-area internist and chairwoman of the American College of Physicians committee on ethics, professionalism and human rights.

	“It’s very uncommon for doctors to summarily dismiss folks because they’re an annoyance,” LeRoy agrees. “It’s our responsibility to ferret out whether there is something there that can be fixed.”

	While physicians should be circumspect about “firing” patients in most types of cases, they are well within their bounds to dismiss patients who are violent, verbally abusive or use their trusted doctor-patient relationship to feed drug addictions. 

	When a patient becomes violent or physically threatening, Horwitch says, they need to be dismissed. “The cases I am familiar with, where a dismissal became necessary, was where a patient came in with a gun to a clinic and threatened somebody,” she says. “Then it’s a safety issue not only to clinicians and staff but to other patients.” LeRoy cites another type of situation that often warrants dismissal: when patients with drug addictions forge or alter a prescription, or “physician shop” to get prescriptions. 

	“That violates our trusted relationship, where I cannot provide you medical care,” he says. “If they’re at the emergency room for an overdose of a controlled substance that I didn’t give them, [the next time I see them] I ask, ‘Where did you get this?’ That’s grounds for dismissal,” at least potentially, judged case by case.

	If a patient isn’t clearly in violation of the law, LeRoy says, he will sit them down and remind them of the contract that he has ongoing users of opioids and controlled substances sign that says they will not abuse their medications. 

	If they are not forthcoming about their actions, he informs them they have violated their contract and that he will no longer prescribe those medications. In some cases, the patient then elects to leave the practice to find another doctor. 

	If the patient does appear to be in violation of the law, which LeRoy says is very rare in his experience, he is obligated to contact the local office of the Drug Enforcement Administration. 

	Perhaps unsurprisingly, LeRoy says, patients never acknowledge doctor-shopping but will sometimes invent stories about a friend or family member who gave them the pill and pretend not to know its name. Mental health issues also can play into this scenario (see sidebar).

	Whatever the cause, doctors and healthcare attorneys offer several legal guidelines as well as ethical advice regarding what to do-and what not to do-when physicians reach the point where a doctor-patient relationship simply cannot be saved.

	Wakefield notes that each state has specific licensure rules, or at least case law that governs various aspects of how to properly end a doctor-patient relationship. 

	Jodi Laurence, JD, a healthcare attorney with Greenspoon Marder in Fort Lauderdale, Florida, says most states require physicians to provide written notice of about 30 days along with some assistance in finding another physician, and some state statutes include language regarding forwarding of medical records. 

Notify the patient clearly and in writing

	The patient should know why they are being turned away, and they should have been given opportunities in most cases to correct their behavior, says Joel Wakefield, JD, a healthcare attorney with the Nelson Law Group in Phoenix, Arizona.

	He adds that he often finds himself advising clients not to terminate a patient based on a first-time problem. 

	East Dayton provides very clear reasons for terminating a relationship, LeRoy says, adding that he also tries to explain to the patient face to face why the health center finds termination necessary. If that can’t happen, letters from the office manager or another staff member are sent out via certified mail, with a restricted delivery signature, “so we know the person has actually received it,” he says.

	Medical practices should inform patients in writing what types of behavior could lead to their dismissal and then again in writing when they are dismissed, Horwitch says. And Lewis urges providers to try to reach patients who haven’t paid to find out why they’re having difficulty. “We are given the responsibility and faith of our patients,” she says. “On the other hand, if you’re running a business, you have to pay your staff and keep the lights on.”

Give adequate notice, going beyond legal standards when medically justified

	The state might require 30 days, but “in some specialties, I will tell clients to give them more time,” Wakefield says. “If they can’t get in to see another endocrinologist because everybody is booked for 60 days, I can’t just cut them off.”

	This timeframe can vary based on the specific standard of care, Laurence says. For example, an OB/GYN obviously would not want to end a relationship with a woman in the third trimester of her pregnancy. And in general, “If you’re treating a patient during an active episode of care, you would have to be very careful about how you transition,” she says.

	LeRoy describes this as a “critically important” aspect of the process. “You do have to provide them advance notice and provide them medical care until they’re established with another professional,” he says. “You need to help them as much as you can” in making the transition.

	“You want to make sure you facilitate getting the new doctor the medical record, so the patient is continuing to receive care appropriately and is not put at risk of harm,” Laurence says.

	LeRoy warns against holding a patient’s medical records hostage because they haven’t paid their bills unless the medical practice is sure it’s on solid legal ground. He recalls one recent anecdote in which a father was laid off from his job, the family got behind on medical bills, their doctor dismissed them and then refused to forward their records. 

	“Therefore the kids couldn’t start school because they didn’t have the medical records to verify immunizations,” he says. “If they are going to withhold medical records, they have to say so, and if it’s legal in your state, you should put that in your letter.”

Clearly explain to the patient his or her lingering medical problems upon departure

	Mark Glassman, JD, of the law firm Glassman Lane in Plantation, Florida, says physicians need to make specific recommendations in the form of a treatment plan and ask patients to sign off on them. “Having the patient sign their chart is one of the best things you can do to protect yourself,” he says. “It sounds daunting, and it sounds very legal, but if you’re already in the process of parting ways with a patient … it protects the doctor.”

	This is especially important for receptionists and other employees who might encounter a patient who doesn’t go away quietly, Wakefield says. 

	“You owe it to those people to let them know what’s going on, without any malice or vitriol, and give them a script for how to deal with it,” he says.

	Otherwise, patients can get their foot back in the door, LeRoy says. If a doctor dismisses a patient but does not inform a colleague, who then treats that patient, “inadvertently, if we’re in practice together, that reestablishes the patient-physician relationship,” he says. “That can get sticky, legally.”

Don’t cut them loose without a lifeline

	“The key is to avoid patient abandonment,” Laurence says. “It will be easy-if God forbid they say you abandoned them-if you have a policy that shows you didn’t.”

	LeRoy suggests having an attorney look over the practice’s standard termination letter. “It’s very important for the patient being dismissed to understand the circumstances that led to that, and what their obligations are,” he says.

	Horwitch says that if the physician hasn’t yet found a referral source, he or she is obligated under most circumstances, when a patient has an acute issue, to continue providing care. “There always needs to be respect for a patient’s best interests, and the overall health and well-being of that patient,” she says.

	“You can’t leave patients high and dry,” Wakefield says. “That is the first thing I’m telling my clients.”

Don’t respond in kind to the patient’s behavior

	Sometimes that’s tempting to do when doctors and staff are frustrated, but remaining professional lessens the chances of a patient sending a letter to a licensure board-or filing a lawsuit, Wakefield says. 

	Doctors sometimes want to respond to a rude patient in similarly vitriolic language, but “I’m usually trying to talk them down off of that,” he says. 

	More measured tones will soothe not only the patient but also family members and others “who will help the patient understand what happened, and [encourage them to] move on.” And if the patient contacts the licensure board, “I want [board members] to see a reasonable and helpful letter” and not an angry rant, he adds.

Don’t say or do anything discriminatory

	“You don’t want to [terminate care] if it would be discriminatory, or violate any laws or rules around race, gender, disability, nationality, etc.,” Laurence says.

Don’t send them to usual referral sources

	“This gets really tricky,” Wakefield says. “You don’t want to say, ‘Go see my good friend Jim,’ because then Jim won’t talk to you anymore.” 

	He frequently counsels his clients to send the patient to a medical board or medical association website, which he says “is a bit of a cop out, but I always want to send them someplace.”  

While physicians should be circumspect about “firing” patients in most types of cases, they are well within their bounds to dismiss patients who are violent, verbally abusive or use their trusted doctor-patient relationship to feed drug addictions. 

The right and wrong ways to dismiss patients

	While medical offices typically have good cause to dismiss patients who are violent or abusive, doctors and healthcare attorneys say they should be (and generally are) more circumspect in other types of frustrating but ultimately resolvable situations.

	Joel Wakefield, JD, a healthcare attorney with the Nelson Law Group in Phoenix, Arizona, says noncompliance with medication or other aspects of physician care is probably the most common situation his physician clients face, and part of their concern is that they could still be liable if a patient’s health worsens. 

	“They’re trying to take care of the patient, but they see the patient not being involved,” he says. “It is a combination of some people simply saying, ‘No, I’m not going to do that,’ especially if the treatment is uncomfortable or makes them feel weird, but it can blend into passive-aggressiveness, as well.”

	This happens most often with patients who have multiple medical problems, or chronic mental health problems such as schizophrenia that interfere with their ability to comprehend their physician’s instructions or to properly care for themselves, says Gary LeRoy, MD, a primary care physician with East Dayton Health Center in Dayton, Ohio.  

	But sometimes, a patient simply has a different agenda than his or her doctor, LeRoy says, based on an honest difference in priorities. “I might want to get their diabetes controlled, and talk to them about their labs. Their agenda might be that ‘my back hurts, and I want to get Vicodin.’”

	Sandra Lewis, MD, a cardiologist in Portland, Oregon, and chairwoman of the American College of Cardiology’s ethics and discipline committee, recalls a patient with heart disease who wanted naturopathic treatment, which the physician did not provide. “I said, ‘You need to find a different cardiologist.’ Other than that, I really can’t remember ever firing a patient,” Lewis recalls.

	Carrie Horwitch, MD, a Seattle-area internist, believes noncompliance should rarely lead to dismissal. “Those scenarios need to be taken on a case-by-case basis,” she says. 

	Collection issues can also lead to patient dismissal, although this is uncommon. Doctors in larger practices seldom even know when a patient falls behind on their bills, LeRoy says, and billing offices in those practices need to ensure that physicians are brought into the loop. As a Federally Qualified Health Center, East Dayton Health tries not to dismiss people for financial reasons, he says.

	“We don’t ever send a letter out [to the patient] without informing the physician that this is something being considered,” he says. 

	The center sends out two or three warning letters before discharge, which gives the doctor a chance to better understand their situation, LeRoy says. “Sometimes, you start connecting the dots when you start talking to the grandmother, the husband, the children. It makes it more clear why they’re having difficulties,” he says.

	In smaller practices, where a doctor would be more aware of collections issues, LeRoy figures they probably also have more one-on-one contact with the patient and can try to work something out with them. “The key to that is communication, communication, communication,” he says. “You’re $2,000 behind, what do you want to do? … You still have to have a standard for triggering that discharge, so it’s not arbitrary. 

While medical offices typically have good cause to dismiss patients who are violent or abusive, doctors and healthcare attorneys say they should be (and generally are) more circumspect in other types of frustrating but ultimately resolvable situations.

Author | Ed Finkel

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