Monday, February 27, 2012

Costs of Care...and Coercion?

The following anecdote is written by Dr. John Schumann, Associate Professor of Medicine at the University of Oklahoma. His story was a finalist in the 2011 Costs of Care Contest, and will be featured on American Public Media's Marketplace.

[All names and identifying features of characters in this story have been changed.]

Nora, a third year medical student, came to me in moral distress.

Ms. DiFazio, one of the hospitalized patients on her Internal Medicine rotation, was frightened to undergo an invasive (and expensive) medical procedure: cardiac catheterization.

The first year doctor [‘intern’] with whom Nora was paired, Dr. White, vented to her:

“These patients come to us seeking our help and then refuse what we have to offer them,” Dr. White steamed.

At the bedside, the intern demanded to know why Ms. DiFazio refused the procedure. When no reason beyond “I don’t want to” was offered, Dr. White told Ms. DiFazio that there was no longer cause for her to stay in the hospital.

By declining the procedure, Dr. White informed Ms. DiFazio that she would have to sign out ‘against medical advice’ (AMA). To signify this she would have to acknowledge that leaving AMA could result in serious harm or death. In addition, Ms. DiFazio would bear responsibility for any and all hospital charges incurred and not reimbursed by her insurance due to such a decision.

“The threat of a huge hospital bill got Ms. DiFazio to stay and take the test,” Nora related. “It just seems so wrong to bludgeon a patient this way. Can it possibly be true?”

I’d been out of medical school myself for eight years at that point; until then I’d never heard that patients who sign out against medical advice risk bearing the costs of their hospitalization. What about a patient’s freedom of choice, or as we like to call it in medicine, their autonomy?

I told Nora I didn’t know, but was determined to find out. Ethically, the notion that patients in the hospital must do our bidding or pay the price seemed dubious. Yet in a world of co-pays, deductibles, and ‘preexisting conditions,’ a mere grain of plausibility made this idea seem vaguely credible.

I asked around. To my surprise, many fellow attending physicians told me they had been taught the very same thing. My colleagues had trained at teaching institutions around the country, so I began to see this as a pervasive and widely-held belief.

I straw polled some of our residents, and like Dr. White, found that they almost unanimously believed that AMA discharges incurred financial penalties. Where did they learn this?

From their attendings.

From the nurses.

From the AMA form itself, with language stating that the patient, by signing, acknowledges financial risk.

We needed to find the truth.

Colleagues helped us sift through nearly ten years of AMA discharges from our teaching hospital. And though the results are in press at a medical journal, I can say that out of hundreds of cases of AMA discharges over a decade, in only a handful was the bill was not paid—and that was invariably due to ‘administrative issues,’ not because of the AMA discharge.

I also thought it important to go to the source: I called the insurance companies themselves. I talked with VPs and media relations people from several of the nation’s largest private insurance carriers.

Each of them told me that the idea of a patient leaving AMA and having to foot their bill is bunk: nothing more than a medical urban legend.

They were glad to tell me so, as this was a rare occasion of insurance companies looking magnanimous. One director went so far as to poll his company’s own medical directors—a half dozen of them--and found that several of them had been taught and believed the canard about AMA discharge and financial responsibility. He was happy to set the record straight.

So patients and doctors beware: The next time you or your loved one has decided that it’s time to leave the hospital, don’t let us doctors coerce you into staying by threatening you with the bill.

It simply isn’t true that leaving against medical advice makes it fall entirely upon your pocketbook.

Future Noras should feel empowered to set the record straight with their interns and residents. Most of all, the Ms. DiFazios of the world won’t have to submit to procedures that they don’t wish to undergo.


  1. Thank you for getting to the bottom of this. I hear this used by nurses at least once a week. It doesn't stop those who are not paying the bill, but it does stop those who are. No one should be coerced into a procedure. Some patients need to find a drink, a smoke or a fix and they storm off.

  2. Actually, I checked out AMA when I had my baby and was held responsible for ALL charges. So, it does happen. :)

  3. I just talked to a friend who left AMA, and her insurance tried to hold her responsible for the charges, but she was able to appeal. Her insurance eventually paid for her care.

  4. I signed out AMA when I was pregnant with my daughter and the insurance company paid, no problem. I have also threatened to leave AMA in another instance and was never told that I would be responsible for the bill. This is the first I've heard of this! It's outrageous the lengths that medical personnel will go to so as impose their will on a patient. Maybe I'm agressive enough about taking ownership of my own body that they didn't dare tell me some balderdash like this?

    Watch out for a "sedation" drug called Versed! It will force you to be very compliant. All these people have to do is give you an armful of this drug and you will go along with pretty much anything. You will probably not even remember it, as along with the compliance issue, it also causes amnesia. Just another way for medical workers to coerce patients into accepting more treatment than they want.

  5. David Ackman, MD, MPHMarch 17, 2012 at 12:42 PM

    As a medical director for a Medicaid plan, I can aver that the discharge status does not determine payment. The only time "AMA" comes up is when a patient walks out of the emergency room AMA and the hospital submits a claim that he or she was admitted and should be paid as a full DRG admission. While we do not hold the hospital responsible for a patient's decision to walk out, we do look carefully at cases where the patient was well enough to walk out. As far as the patient goes, they are never billed in the Medicaid program, which is one reason Medicaid is about the best insurance available.

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